INTRODUCTION: Since April 2020, multiple reports emerged from Europe and later from New York City of a presentation of a multi-system inflammatory syndrome in children (MIS-C) with different clinical patterns that occurs 1-6 weeks following SARS-CoV2 infection MIS-C is associated with variable degrees of cardiac involvement The median age of affected children is 8 5-10 years METHODS: A previously healthy 16-month-old patient who presented with febrile seizure, diarrhea and generalized skin rash Twelve hours later, patient had persistent fever (41C), skin rash and diarrhea with prominent physical findings of periorbital edema, hepatomegaly, skin rash and inguinal lymphadenopathy Shortly after admission, patient developed vasoplegic shock and was therefore intubated and vasopressor support was initiated Broad spectrum antibiotics were started The diagnosis of MIS-C was established with high inflammatory markers, anemia, thrombocytopenia, markedly elevated ferritin level, coagulopathy with significantly elevated D-dimers and positive anti-SARS-CoV-2 IgG BNP was also elevated Troponin level was within normal limit Electrocardiography showed nonspecific T-wave changes and cardiac echocardiography showed mild atrioventricular (AV) valves' regurgitation that had no clinical significance and ultimately resolved Patient received methylprednisolone with a maximum dose of 30mg/kg/day, anakinra with a maximum dose of 12m/kg/day, 2 doses of 1g/kg of intravenous immunoglobulins (IVIG) and Low molecular weight heparin Patient remained intubated, mechanically ventilated and on vasopressors support for 3 days after which signs of hemodynamic stability were established and was subsequently extubated RESULTS: We successfully treated this patient who presented with shock and reversible AV valves regurgitation secondary to MIS-C in an uncommon age group compared to the recent reports Our management approach was parallel to most institutions with IVIG, glucocorticoids, and interleukins receptor antagonists The good outcome of this patient with MIS-C highlights the importance of early recognition of shock state, proper and judicious fluid resuscitation, early establishment of invasive monitoring, intubation and mechanical ventilation, and appropriate initiation of inotropes and vasopressors
Vasoplegic shock in a young pediatric patient with multisystem inflammatory syndrome (MIS-C)