Multisystem Inflammatory Syndrome in Adults

A Case Report and Review of the Literature

Fardad Behzadi; Nicolas A. Ulloa; Mauricio Danckers


J Med Case Reports. 2022;16(102) 

In This Article

Case Description

A 22-year-old overweight African American female, with a body mass index (BMI) of 29.1 kg/m2, presented to the emergency department (ED) with 3 days of fever, sore throat, right-sided neck pain, and swelling. She denied any respiratory symptoms. She had tested positive for SARS-CoV-2 by polymerase chain reaction (PCR) 4 weeks prior, complaining of fever, chills, cough, headache, and diarrhea for 1 week. At that time, she had visited the ED and had been discharged with acetaminophen. Per the patient, she was not discharged with steroids or antibiotics.

During her initial ED visit, her blood pressure was stable at 110/57 mmHg, temperature of 39.4 °C, and heart rate of 150 beats per minute (BPM). While in the ED, she received broad spectrum antibiotics (vancomycin and ceftriaxone), 30 cc/kg bolus of normal saline, and blood cultures were obtained. Computed tomography (CT) of the neck with intravenous contrast revealed bilateral reactive lymphadenopathy with enlarged adenoids and mildly enlarged tonsillar pillars without abscesses. Initial chest X-ray was negative, without signs of pleural effusions or consolidations. Her electrocardiogram showed sinus tachycardia. She was admitted for persistent tachycardia and otolaryngology evaluation. Originally, the patient was admitted to a telemetry floor. The following night, a rapid response code was called due to hypotension. At that time, her blood pressure was 80/57 mmHg, heart rate was 125 BPM, respiratory rate of 25, and temperature of 103 F. She appeared comfortable, without signs of respiratory distress. She exhibited mild bilateral periorbital and lower extremities edema. Neck examination was notable for bilateral posterior lymphadenopathy with mild decreased range of motion. Her pulmonary and cardiac examinations were unremarkable other than tachycardia. Additionally, the rapid response team noted bilateral conjunctivitis as well as small strawberry rash diffusely. Another electrocardiogram was performed, which showed low voltage and sinus tachycardia. A point of care ultrasound (POCUS) was performed that was negative for pericardial effusion, right ventricular dilation, or signs of obstructive shock. She was fluid resuscitated with an additional 2 L of normal saline, with transient/negligible improvement of blood pressure. She was bolused another liter of lactated Ringer's, initiated norepinephrine infusion, and admitted to the intensive care unit (ICU) for the management of distributive shock.

Her follow-up studies showed a peak D-dimer of 3557 ng/mL, C-reactive protein (CRP) of 47 mg/dL, and ferritin of 344 ng/mL. Fibrinogen was 460 mg/dL and remained within normal limits. She has a nadir hemoglobin of 10.6 g/dL, 24-hour urinary protein of 560 mg with preserved glomerular filtration rate through her entire hospital admission. Initial white blood cell count was 7000 cells/mm3 and only increased slightly after corticosteroid use. She exhibited a mild elevation of aspartate transaminase (AST) to 46 U/L, alanine transaminase (ALT) of 49 U/L, and alkaline phosphate (ALP) of 51 U/L. Her pro-B-type natriuretic peptide (BNP) was 3590 pg/mL on hospital day 2 and her troponin I peaked at 0.257 ng/m on day 3.

Official transthoracic echocardiography revealed a mild systolic dysfunction, grade 2 diastolic dysfunction and an ejection fraction of 40–45%, and a concentric small pericardial effusion. Coronary angiography revealed normal coronaries without evidence of obstruction or aneurysms. CT angiogram of the chest was negative for pulmonary embolism but notable for moderate-sized pleural effusions bilaterally. Cardiac magnetic resonance imaging (MRI) was not performed.

The patient received supportive treatment with dynamic hemodynamic-driven preload resuscitation and vasopressor support with norepinephrine. Her maximum dose of norepinephrine was 5 mcg/minute. Infectious disease was consulted on hospital day 3, who broadened antibiotic coverage with 3.375 mg piperacillin/tazobactam every 8 hours (q8) for 1 week. Broad infectious and immunologic workup was ordered and is summarized in Table 1. She tested negative for immunoglobulin (Ig)M and positive for IgG SARS-CoV-2 antibody. Dexamethasone 4 mg was initiated in the ED and continued q12 hours until hospital day 5 when it was changed by infectious disease team to hydrocortisone 50 mg q6 hours. Full-dose aspirin was initiated on hospital day 4 and continued until discharge. Intravenous immunoglobulin (IVIG) infusion was initiated and completed on hospital day 5, when she received 80 g over 16 hours. She was weaned off vasopressors by hospital day 6. An MRI of the neck without contrast on day 6 revealed resolution of her prevertebral soft tissue swelling and persistent nonspecific cervical lymphadenopathy bilaterally without any fluid collection. She received intravenous furosemide and albumin 25% intermittently with improvement in her interstitial edema. Blood and urine cultures remained negative during her hospitalization. She was discharged home on day 11.