¹Giovanni Brambilla, ¹Zuhair Yousif, ¹Amel Ginawi, ¹Mahmoud Marashi

¹Mediclinic City Hospital

Background:

There is still much to understand about COVID–19, especially in regards to the long term effects and the clinical syndromes that follow the acute primary infection. A serious multisystem inflammatory syndrome was described initially in children 1 and then in adults as well.Multisystem inflammatory syndrome in adults (MIS–A) is a severe illness requiring admission in patients ≥21 years old, with severe extra pulmonary involvement, raised inflammatory markers and evidence of previous COVID–19 infection within 12 weeks.

Material(s) and Method(s):

A 22-year-old male was admitted after few days of neck pain, swollen lymph nodes, headache and temperature, followed by vomiting, diarrhea, and abdominal pain. Three weeks before the onset of symptoms he was diagnosed with mild COVID–19 infection. The medical and family history were unremarkable. On admission he was hemodynamically stable and apyrexial. Some cervical lymph nodes were palpated, otherwise no other abnormality was detected. A CXR was normal. During admission CT chest chest–abdo–pelvis and CT pulmonary angiogram were normal. Within 24 hours the patient developed severe cardiogenic shock and was transferred to ICU where inotropes were started. An echocardiogram showed global hypokinesia, EF 30–35%, no chamber dilatation, and stunned myocardium. Given the history of COVID–19 infection with negative Polymerase chain reaction and positive serology, deranged LFTs, pancytopenia, raised troponin and inflammatory markers, a diagnosis of MIS–A was made and confirmed when all the other etiology tests returned negative. Methylprednisolone, IVIG, Tocilizumab, and prophylactic enoxaparin were administered.

Results:

The patient improved within 24 hours. The inotropes were discontinued within 72 hours. The cardiac ejection fraction improved to 55% on day 6. The patient was discharged asymptomatic after 12 days on Prednisolone 60 mg.

Conclusion:

MIS-A is likely to become a common presentation and it is important to bring it to the attention of our colleagues working in primary and secondary care. The MIS-A can be severe even in patients with previous oligo symptomatic COVID–19 infection. The quick deterioration observed in our case suggests that prompt recognition and treatment are critical to achieve complete resolution. In patients presenting with acute febrile illness MIS–A should be routinely included in the differential diagnosis. The MIS-A is ultimately a diagnosis of exclusion and therefore a thorough diagnostic workup is required. The combination of supportive management and multidrug anti-inflammatory treatment was effective in our case but robust evidence is needed.