A 7-Year-Old Boy and a 14-Year-Old Girl Initially Diagnosed with Toxic Shock Syndrome and Tested Positive for SARS-CoV-2 Infection, Supporting a Diagnosis of Multisystem Inflammatory Syndrome in Children (MIS-C)

Abstract

Case series Patients: Male, 7-year-old • Female, 14-year-old Final Diagnosis: Multisystem inflammatory syndrome in children (MIS-C) Symptoms: Muscular weakness • shock Medication: — Clinical Procedure: — Specialty: Critical Care Medicine • Infectious Diseases • Pediatrics and Neonatology • Rheumatology Objective: Unusual clinical course Background: Multisystem inflammatory syndrome in children (MIS-C) has recently been described in children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This report describes 2 children with MIS-C who were initially diagnosed with toxic shock syndrome but who tested positive for SARS-CoV-2 infection on reverse transcription-polymerase chain reaction, supporting the diagnosis of MIS-C. Case Reports: Case 1. A 7-year-old boy with fever, cough, and dyspnea was treated with oxygen, intravenous immunoglobulin (IVIG) infusion, and methylprednisolone and showed a worsening of clinical conditions, persistent fever, hypotension, and hematological parameters compatible with macrophage activation syndrome (MAS). Three intravenous boluses of methylprednisolone (30 mg/kg/day) were followed by a progressive resolution. Case 2. A 14-year-old girl with syncope, fever, diarrhea, oliguria, and increased creatinine levels required fluid infusion and correction of electrolyte imbalance. The increase of creatine phosphokinase ( CPK), myoglobin, troponin, and creatine kinase-MB (CK-MB) was associated with grade I atrioventricular block and pericardial effusion. The patient showed myositis and severe muscular weakness, with hematological parameters compatible with MIS-C. She started IVIG and 3 intravenous boluses of methylprednisolone. However, bradycardia, tachypnea, severe hypotension, loss of consciousness, oliguria, bilateral ground-glass pneumonia, bilateral pleural, and peritoneal effusion, in the absence of thromboembolism, required treatment with furosemide, albumin, and enoxaparin, and was followed by a prompt resolution. Conclusions: These 2 pediatric cases highlight the importance of SARS-CoV-2 testing in all patients with acute symptoms and signs of infection during the COVID-19 pandemic. As new variants of SARS-CoV-2 emerge, cases of MIS-C can become more prevalent, and pediatricians should be aware of diagnostic and management guidelines.

Skeletal muscles and Covid-19: a systematic review of rhabdomyolysis and myositis in SARS-CoV-2 infection

“…Several articles report cases of virally induced myositis or myopathy (89)(90)(91)(92)(93)(94)(95)(107)(108)(109). Some describe various (98).…”

Prevalence of Myositis-Specific Autoantibodies and Myositis-Associated Autoantibodies in COVID-19 Patients: A Pilot Study and Literature Review

“…Myositis is a rare complication of SARS-CoV-2. A review of the literature has identified 31 case studies describing a total of 40 cases of COVID-19-associated myositis [7,12,14,15,30,[36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54]. Case reports were selected for review if they described virally-induced cases with associated idiopathic inflammatory myopathy or myositis correlating with recent exposure to COVID-19.…”

“…No cases of patients with prior autoimmune history were included. Patients with history of myositis concurrent with or developed postinfection comprised 31 (78%) of these cases [7,12,[40][41][42][43][44][45][46][47][48][49][50][51][52][53][54], while myositis developed in the setting of vaccination comprised nine (22%) of the cases [14,15,30,[36][37][38][39]. In regard to MSA/MAA testing, 18 of the cases did not mention testing, two cases reported other specialized testing without MSAs/MAAs, and one case reported "negative immunologic tests" without definitive results.…”

A Comprehensive Review of Neuromuscular Manifestations of COVID-19 and Management of Pre-Existing Neuromuscular Disorders in Children

“…In some cases, rhabdomyolysis was the presenting symptom [26,29]. Both myositis and rhabdomyolysis may occur as a part of MIS-C [22,30]. There have been several reports of acute benign childhood myositis in the pandemic period, attributed to influenza or COVID-19 [31].…”