Fatal Multisystem Inflamatory Syndrome in Adult After SARS-CoV-2 Natural Infection and COVID-19 Vaccination

Heather N. Grome; Michael Threlkeld; Steve Threlkeld; Charles Newman; Roosecelis Brasil Martines; Sarah Reagan-Steiner; Michael A. Whitt; Maria Gomes-Solecki; Nisha Nair; Mary-Margaret Fill; Timothy F. Jones; William Schaffner; John Dunn

Disclosures

Emerging Infectious Diseases. 2021;27(11):2914-2918.

Abstract and Introduction

Abstract

We describe a fatal case of multisystem inflammatory syndrome in an adult with onset 22 days after a second dose of mRNA coronavirus disease vaccine. Serologic and clinical findings indicated severe acute respiratory syndrome coronavirus 2 infection occurred before vaccination. The immunopathology of this syndrome, regardless of vaccination status, remains poorly understood.

Introduction

A multisystem inflammatory syndrome in children (MIS-C) and adults (MIS-A) occurring after coronavirus disease (COVID-19) has been identified; onset is ≈4–6 weeks after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.^[1–3] A case definition for MIS-A has been developed by the Centers for Disease Control and Prevention (CDC);^[4] MIS-A after vaccination is rare and remains of great clinical and public health interest.^[5] We report a case study and histopathologic findings from a fatal MIS-A case after SARS-CoV-2 infection and subsequent complete COVID-19 vaccination.

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Abstract and Introduction
The Patient
Conclusions
References

Table. Results of pertinent laboratory testing completed during the 4-day hospitalization of a patient with fatal multisystem inflammatory syndrome in adult, Tennessee, USA, 2021*
Variable	Hospital day				Reference range
Variable	Day 1	Day 2	Day 3†	Day 4†	Reference range
Hematologic testing
Peripheral leukocyte count, 1,000/μL	11.0	14.4	28.1	8.8	4.2–10.2
Hemoglobin, g/dL	13.7	11.7	10.8	9.5	12.8–16.4
Hematocrit, %	39.6	33.8	34.3	27.7	38.8–48.1
Platelets, 1,000/μL	110.0	86.0	45.0	17.0	150–400
Absolute neutrophils, 1,000/μL	10.5	13.7	23.9		1.8–7.1
Absolute lymphocytes, 1,000/μL	0.4	0.4	5.0		1.3–5.9
Segmented neutrophil, %	95.3	95.3	76.6		40.0–76.0
Lymphocytes, %	3.8	2.8	15.9		14.0–46.0
Monocytes, %	1.9	0.9	0.9		4.0–12.0
Chemical testing
Creatinine, mg/dL	1.2	1.3	3.4	1.9	0.70–1.30
AST, U/L		78.0	5,938.0	8,861.0	15–37
ALT, U/L		61.0	3,386.0	3,421.0	16–61
Total bilirubin, mg/dL	1.9	1.4	1.6		0.2–1.0
Alkaline phosphatase, U/L	76.0	74.0	295.0	202.0	45–117
Ferritin, serum, mg/dL		1434.9	>40,000.0		26.0–388.0
Coagulation
aPTT, s	29.3		54.2	80.9	23.2–34.1
PT, s	13.9		39.6		11.7–14.5
INR	1.1		4.2	3.6	0.9–1.0
Fibrinogen, mg/dL	642.0		750.0		208–475
D-Dimer, μg FEU/mL	5.2	4.3	12.2		0.0–0.44
Cardiac
Troponin-I, ng/mL		18.0	15.5		0.0–0.045
Immunochemical testing
ESR, mm/h	40.0				0–15
C-reactive protein, mg/L		284.0	174.0		<3.0
Procalcitonin level, ng/mL		4.9			0.50–2.0
Microbiologic testing
SARS-CoV-2 RT-PCR, index value	Negative				Negative
SARS-CoV-2 IgG antibody,‡ index value	4.96				<1.39
Adenovirus DNA PCR, qualitative	Not detected				Not detected
CMV PCR, quantitative	Negative				Negative
Mononucleosis screen	Negative				Negative
Ehrlichia chaffeensis DNA PCR	Not detected				Not detected
HIV-1 p24 Ag	Nonreactive				Nonreactive
Peripheral blood culture, 2 sets	No growth	No growth	No growth	No growth	No growth

*Laboratory values represent pertinent laboratory results during the patient's hospitalization. Not all laboratory studies completed during hospitalization are represented in this table. Blank cells indicate test not done. ALT, alanine aminotransferase; AST, aspartate aminotransferase; aPTT, activated partial thromboplastin time; CMV, cytomegalovirus; ESR, erythrocyte sedimentation rate; FEU, fibrinogen equivalent units; INR, international normalized ratio; PT: prothrombin time; RT-PCR, reverse transcription PCR; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.
†Laboratory values indicate studies after cardiac arrest, which occurred at ≈3 a.m. on hospital day 3. Note patient was initiated on extracorporeal membrane oxygenation shortly after return of spontaneous circulation; anticoagulation treatments affect laboratory values.
‡SARS-CoV-2 IgG test specific for nucleocapsid protein antibody.