Multisystem inflammatory syndrome in children (MIS-C) is one of the many challenges thrown by the ongoing SARS CoV-2 pandemic. A high index of suspicion is warranted for the diagnosis of MIS-C as presenting features overlap with Kawasaki disease and toxic shock syndrome. The treatment guidance is empirical with consideration of intravenous immunoglobulin (IVIG) and glucocorticoids. However, treatment of refractory MIS-C remains eluded. We describe here a 7-year-old boy with MIS-C refractory to IVIG and pulse methylprednisolone who responded to interleukin-6 inhibition using tocilizumab.

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A persistent left superior vena cava (PLSVC) draining into the left atrial appendage can exist as an unidentified right-to-left shunt often with no demonstrable evidence of hypoxia on history but predisposing to life-threatening clinical implications. We present a 7-year-old boy with a brain abscess who was incidentally noted to have features of hypoxia on examination. His evaluation revealed the presence of a PLSVC on computed tomography pulmonary angiogram, draining into the left atrium, thereby acting as a right-to-left shunt explaining the brain abscess. He underwent a craniotomy with a course of intravenous antibiotics, remained well on follow-up, and was referred for definitive surgery for PLSVC. Children with unidentified right-to-left shunts may present with brain abscesses in the event of which both intracardiac and extracardiac shunts have to be ruled out with the help of history, a focused clinical assessment, and more advanced imaging.

Takayasu's arteritis (TA) is a rare primary vasculitis, typically affecting the aorta and its main branches causing progressive vessel wall inflammation with concentric wall thickening and stenosis producing a variety of ischemic symptoms or aneurysms. Although etiopathogenesis of this disease remains poorly understood, an autoimmune basis is widely suggested in addition to genetic and environmental factors, among which evidence implicating Mycobacterium tuberculosis (MT) has been provided. We discuss hereby a 12-year-old boy brought with refractory renovascular hypertension secondary to aortoarteritis as found on ultrasound Doppler and computed tomography angiogram, who, apart from fulfilling criteria for TA, was also found to have latent tuberculosis. He was managed with multiple antihypertensives, immunosuppressants, and antitubercular therapy, despite which he developed hypertensive crises. A renal angioplasty proved beneficial as hypertension was better controlled allowing a gradual taper of all antihypertensives over an 8-week period and improved renal blood flow and renal function.