MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN AND ADOLESCENTS (MIS-C) IN A YOUNG ADULT WITH RECENT VACCINATION

Bangash, Bilal; Pitcher, Joseph; Makki, Issa

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: MIS-C is described as a clinical syndrome developing secondary to Coronavirus disease 2019 (COVID-19) in children and adolescents. The presentation is similar to Kawasaki syndrome, hemophagocytic lymphohistiocytosis (HLH) and toxic shock syndrome. We present a case of MIS-C in a young adult two weeks after receiving vaccination for COVID-19. CASE PRESENTATION: 21 year old female with a past medical history of asthma who presented to the emergency department (ED) with fevers, chills and photophobia since receiving the J&J COVID-19 vaccine 2 weeks prior. On evaluation, COVID test was negative. Labs were notable for leukopenia, elevated liver enzymes. She as admitted to the medical floor. Her course was complicated by worsening transaminases >2000 IU/L with progressive encephalopathy. She had witnessed seizure activity requiring intubation and transfer to the Intensive Care Unit (ICU). Computed Tomography (CT) abdomen was unremarkable. Head CT showed no acute abnormalities. Brain Magnetic Resonance Imaging (MRI) showed diffuse nonspecific white matter signal abnormalities. Additional labwork revealed ferritin of 937 mcg/L, and CRP of 47.3 mg/L and an elevated NT-proBNP. Film array and hepatitis panel was negative. COVID spike and nucleocapsid antibodies were both positive. She underwent a liver biopsy which was consistent with acute hepatitis and bone marrow biopsy which was negative for HLH. Lumbar puncture with elevated opening pressure of 27 cm H20. Extensive infectious workup for bacterial, fungal and viral etiologies were negative. She met criteria for MIS-C/A. She received high dose Intravenous Dexamethasone, Intravenous Immunoglobulin (IVIG) and anakinra infusion. Her labwork and encephalopathy improved and she was discharged home. DISCUSSION: MISC-C/A is seen in patients presenting 3 to 5 days after an asymptomatic or mild COVID infection. It is unclear whether the inflammatory response seen in our patient was secondary to a recent asymptomatic COVID infection, her vaccination or both. Cases have been mostly reported in children and patients under 21 years of age. Presentation is usually associated with gastrointestinal symptoms, evidence of mucocutaneous inflammation (rash, conjunctivitis, oromucosal changes), lymphopenia, and high levels of circulating inflammation. The goals of treatment for MIS-C are to decrease systemic inflammation and restore organ function, with use of high dose steroids, IVIG or anakinra. CONCLUSIONS: It is currently unknown if MIS-C/A might follow CVOID immunization, but a need exists to define this potential entity for monitoring as a potential adverse event. It is also important to maintain an index of suspicion for this disorder in the adult post-covid population. REFERENCE #1: Chao J.Y., Derespina K.R., Herold B.C., Goldman D.L., Aldrich M., Weingarten J. Clinical characteristics and outcomes of hospitalized and critically ill children and adolescents with coronavirus disease 2019 (COVID-19) at a tertiary care medical center in New York City. J Pediatr. 2020;223:14–19.e2 REFERENCE #2: CDC COVID-19 Response Team. Coronavirus disease 2019 in children—United States, February 12–April 2, 2020. Morb. Mortal. Wkly. Rep. 2020, 69, 422–426. DISCLOSURES: No relevant relationships by Bilal Bangash, source=Web Response No relevant relationships by Issa Makki, source=Web Response No relevant relationships by Joseph Pitcher, source=Web Response