We read with great interest the article by Pouletty et al reporting 16 paediatric patients presenting with Kawa-COVID-19, an inflammatory syndrome similar to Kawasaki disease (KD) associated with SARS-CoV-2 infection. 1 All 16 patients met criteria for complete or incomplete KD. Severe cases in children involving systemic inflammation and multiorgan involvement related to COVID-19 are increasingly being reported. These cases, named multisystem inflammatory syndrome in children (MIS-C) in the USA and pediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 in the UK, share features of both KD and macrophage activation syndrome. 2-6 In contrast to children, few adults with KD-like cases have been reported. 7 8 Herein, we describe an adult who presented with KD-like illness similar to children in the Kawa-COVID-19 cohort 4 weeks following a documented SARS-CoV-2 infection. A 38-year-old Hispanic woman developed fever, dyspnoea, cough, anosmia, myalgias and polyarthralgias of the hands, wrists, elbows and knees 4 weeks prior to admission. At that time, nasopharyngeal SARS-CoV-2 PCR was positive. Her symptoms completely resolved within 2 weeks. Five days prior to admission, she developed fevers up to 39.4°C, dyspnoea and polyarthralgias. Additionally, she described occipital headaches, conjunctival injection, lip peeling, odynophagia, vomiting and a maculopapular rash on her chest and arms (figure 1A). The conjunctival injection and rash resolved within a week, but arthralgias, dyspnoea and fevers persisted. On admission, vitals showed temperature 39.1°C, pulse 114 beats/min, blood pressure 114/67 mm Hg and 97% oxygen saturation. Physical examination revealed clear conjunctiva, erythematous tongue, lip peeling, clear lung fields and a normal cardiac

Patient: Male, 47 Final Diagnosis: Acute disseminated encephalomyelitis (ADEM) Symptoms: Spastic paresis Medication: Methylprednisolone Clinical Procedure: — Specialty: General and Internel Medicine Objective: Rare disease Background: Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease that usually presents in pediatric patients, usually following a viral or bacterial infection. The clinical findings in ADEM include acute neurologic decline that typically presents with encephalopathy, with some cases progressing to multiple sclerosis. An atypical case of ADEM is reported that presented in a middle-aged adult. Case Report: A 46-year-old Caucasian man, who had recently emigrated to the US from Ukraine, presented with gait abnormalities that began four days after he developed abdominal cramps. Magnetic resonance imaging (MRI) of the brain with contrast, fluid-attenuated inversion recovery (FLAIR), and T2-weighting showed contrast-enhancing, patchy, diffuse lesions in both cerebral hemispheres. Cerebrospinal fluid (CSF) was negative for oligoclonal bands. On hospital admission, the patient was treated with intravenous (IV) methylprednisolone, 500 mg twice daily. He responded well and was discharged from hospital after a week, with resolution of his presenting symptoms and signs. Conclusions: This report is of an atypical presentation of ADEM in a middle-aged patient who presented with spastic paresis. Although there are no set guidelines for the diagnosis of ADEM in adults, this diagnosis should be considered in patients with acute onset of demyelinating lesions in cerebral MRI. As this case has shown, first-line treatment is with high-dose steroids, which can be rapidly effective.

Patient: Female, 57Final Diagnosis: Disseminated nocardiosisSymptoms: Chills • cough • fever • shortness of breathMedication: InfliximabClinical Procedure: —Specialty: Infectious DiseasesObjective:Rare diseaseBackground:Opportunistic infections may occur when patients with inflammatory bowel disease (IBD) are treated with tumor necrosis factor (TNF)-alpha inhibitors. With the increasing use of new immunosuppressant drugs, the incidence of opportunistic or atypical infections is also increasing, including with Nocardia spp. A high level of awareness of atypical infections is warranted in immunosuppressed patients.Case Report:A 57-year-old female African American, with a past medical history of ulcerative colitis (UC) and arthritis, was treated with infliximab and prednisone. She presented to the emergency department with acute onset of chest pain, shortness of breath, and a two-week history of a productive cough. Examination showed hypoxia, tachypnea, decreased and coarse bilateral breath sounds, and fluctuant, tender, erythematous masses on her trunk and groin. Laboratory investigations showed a leukocytosis with a left shift. She was initially treated for presumed community-acquired pneumonia (CAP). However, blood cultures grew Nocardia farcinica and treatment with trimethoprim-sulfamethoxazole (TMP-SMX) was begun, which was complicated by severe symptomatic hyponatremia. Following recovery from infection and resolution of the hyponatremia, the patient was discharged to a senior care facility, but with continued treatment with TMP-SMX.Conclusions:To our knowledge, this is the first case of disseminated nocardiosis associated with infliximab treatment in a patient with ulcerative colitis. As with other forms of immunosuppressive therapy, patients who are treated with infliximab should be followed closely due to the increased risk of atypical infections. When initiating antibiotic therapy, careful monitoring of possible side effects should be done.