Multisystem Inflammatory Syndrome in Children After SARS-CoV-2 Vaccination

Eisha Jain; Jeffrey R. Donowitz; Elizabeth Aarons; Beth C. Marshall; Michael P. Miller


Emerging Infectious Diseases. 2022;28(5):990-993. 

In This Article

The Study

Patient 1 was a 15-year-old girl with asthma who received her first dose of BNT162b2 6 days before seeking care. She had low-grade fever and myalgia, which resolved within 2 days of vaccination. Four days later, she experienced 102°F fevers, headaches, nonbilious emesis, myalgias, chest pain, and a rash. Emergency department (ED) examination identified pharyngeal erythema, bilateral conjunctivitis, and a diffuse blanching rash. She had no respiratory or cardiovascular symptoms. At admission, laboratory test results showed leukocytosis with polymorphonuclear cell predominance and elevated CRP, fibrinogen, prothrombin time, brain natriuretic peptide (BNP), and D-dimer (Table). Urinalysis revealed trace protein, large blood, moderate leukocyte esterase, 10–20 leukocytes per high-powered field, and 1+ bacteria. Results of nasopharyngeal SARS-CoV-2 reverse transcription PCR were negative. Further tests included chest radiograph, chest computed tomography angiography, electrocardiogram, and echocardiogram; all results were unremarkable. She was admitted to the pediatric intensive care unit (ICU) and given 2 g/kg intravenous immune globulin (IVIG) for suspected of MIS-C. Symptoms rapidly improved. Leukocyte level decreased to 11.0 K/uL and D-dimer to 2.5 mg/L within 48 hours. The patient remained hemodynamically stable throughout admission and was afebrile with improved symptoms when she was discharged 3 days after admission. SARS-CoV-2 antibody test results at discharge were positive for nucleocapsid but negative for spike. Two days after discharge, the patient returned to the ED for throbbing headaches, nausea, and fatigue. CRP had downtrended since discharge to 2.71 mg/L. Magnetic resonance venography results were normal and she was discharged on antimigraine medication.

Patient 2 was a previously healthy female 17-year-old who received her first dose of BNT162b2 vaccination 7 days before seeking care. Three days after vaccination, she experienced fevers, headaches, abdominal pain, fatigue, and myalgias. Her primary care provider noted leukocytosis to 20 K/uL and referred her to the ED. She had a 103.1°F fever, diffuse abdominal tenderness, and costovertebral angle tenderness. She had no respiratory symptoms. At admission, laboratory test results showed leukocytosis with polymorphonuclear cell predominance and elevated CRP, erythrocyte sedimentation rate, lactate dehydrogenase, BNP, troponin, D-dimer, creatinine, aspartate aminotransferase, and alkaline phosphate (Table). Urinalysis revealed 100 mg/dL protein, moderate blood, moderate leukocyte esterase, 10–20 leukocytes per high-powered field, 5–10 red blood cells per high powered field, and no bacteria. Urine culture was positive for 10,000 CFU/mL of Escherichia coli. Blood culture results were negative. Electrocardiogram showed sinus tachycardia and nonspecific T-wave abnormalities. Abdomen and pelvis computed tomography showed diffuse left renal enlargement without hypoattenuation or hyperattenuation and possible polycystic ovaries. Results of chest radiograph and echocardiogram were normal. Nasopharyngeal SARS-CoV-2 RT-PCR was negative. Results of SARS-CoV-2 spike antibody testing were positive; nucleocapsid antibody testing was not performed. She started 3 days of intravenous methylprednisolone (30 mg 2×/d) and 1 day IVIG (2 g/kg) for MIS-C. Troponin decreased to <0.05 within 24 hours and CRP to 16.2 within 48 hours. BNP rose to 2,024 on hospital day 2. Repeat echocardiogram showed mild right coronary artery ectasia, and she was started on 325 mg of aspirin daily. On hospital day 3, repeat echocardiogram results were normal, and she was afebrile. Aspirin was decreased to 81 mg daily. She was discharged on hospital day 4 with no fevers for 60 hours and downtrending inflammatory markers including CRP to 8.49 mg/dL. She was also treated for a possible UTI.