Beware of the ambiguous enemy of multisystem inflammatory syndrome in adult (MIS‐A) following Covid‐19 infection or vaccination

Abstract

Multisystem Inflammatory Syndrome is a rare and novel clinical presentation described during the evolving COVID‐19 pandemic. The condition is usually presenting as a sepsis‐like syndrome leading to secondary multi‐organ dysfunction post–COVID‐19 infection. Although the syndrome has been mainly described in children, rare adults' form has been similarly described. We are describing a 37‐year‐old female patient presented with fever and neck pain after 1 month of a mild SARS‐CoV‐2 infection course and 10 days post her second COVID‐19 vaccine. Examination demonstrated fever, hypotension, and hypoxemia, in addition to multiple tender cervical lymph nodes. Initial laboratory workup showed evidence of significant inflammation with raised markers, including C‐reactive protein, ferritin, and interleukin‐6. Extensive evaluation to rule out active infection was done, and all return negative, including repeat SARS‐CoV‐2 test. Furthermore, cardiac evaluation showed moderately reduced systolic ventricular function. Despite all negative test and supportive measures, the patient continued to deteriorate requiring critical care admission for ionotropic support, non‐invasive ventilation in addition to presumptive broad‐spectrum antimicrobial management. There was no significant improvement with supportive care until the presentation of multisystem involvement on in the context of a recent history of COVID 19 and negative infective screen was raised. The diagnosis of multisystem inflammatory syndrome‐adult form (MIS‐A) was embraced, and the patient was commenced on methylprednisolone leading to a dramatic resolution of symptoms both clinically and biochemically with stabilization of vital functions allowing for safe outcomes.

Case of adult-onset Kawasaki disease and multisystem inflammatory syndrome following SARS-CoV-2 vaccination

“…Most of these patients had prior SARS-CoV-2 infections and develop symptoms shortly after vaccination. Few among these patients experienced minor erythematous rashes on their torso or extremities; however, they did not demonstrate additional features of KD 13 15–18…”

“…Prior to the COVID-19 pandemic KD was observed following vaccination, and although multiple investigations failed to establish a causal link, a temporal relationship between vaccination and KD persisted 6 27. Recent reports describe MIS-V in adult patients after receiving SARS-CoV-2 vaccines, many of whom experienced multiorgan failure and responded to high-dose steroids or IVIg 13 15–18. Most of these patients had prior SARS-CoV-2 infections and develop symptoms shortly after vaccination.…”

“…The SARS-CoV-2 spike protein is known to be highly immunogenic, particularly via mechanisms that activate innate inflammatory responses 12. To date, most reported cases of SARS-CoV-2-associated KD and MIS have resulted from infection with native SARS-CoV-2, though cases of MIS in children and adults have been reported following delivery of spike protein-based SARS-CoV-2 vaccines 13–18. Termed MIS associated with vaccination (MIS-V), most of these reported patients were previously infected with SARS-CoV-2 and developed fever, rash, elevated inflammatory markers and multiorgan dysfunction shortly after receiving a vaccine dose.…”

Multisystem Inflammatory Syndrome (MIS) following SARS-CoV-2 vaccinations; a systematic review

“…COV2. S vaccine (Johnson &Johnson/Janssen) 1 Chai et al [ 25 ] Denmark 17 M Pfizer-BioNTech 1 Poussaint et al [ 26 ] USA 12 M Pfizer-BioNTech 1 Lee et al [ 27 ] United States 13 M Pfizer/BioNTech vaccine (BNT162b2) 1 Al Bishawi et al [ 28 ] Qatar 37 F Modern mRNA vaccine 1 Park et al [ 29 ] Korea 67 M AstraZeneca vaccine / ChAdOx1 nCoV-19 1 Buchhorn et al [ 30 ] Germany 18 M Pfizer/BionTech (BNT162b2) 1 Grome et al [ 41 ] USA in 30 s M Pfizer/BioNTech mRNA COVID-19 vaccine 0 Nune et al [ 15 ] UK 44 F Pfizer-BioNTech mRNA vaccine 1 Uwaydah et al [ 31 ] …”

Multisystem inflammatory syndrome in adults: Characteristics, treatment, and outcomes

“…[15][16][17]19,25,26 Many countries, including the United States, the UK, Italy, Israel, India, Canada, Japan, Pakistan, the United Arab Emirates, Croatia, Norway, France, Spain, Belgium, Portugal, South Africa, Lebanon, Switzerland, Thailand, Turkey, Austria, Cyprus, Sweden, Qatar, Oman, Brazil, South Korea, Germany, Uruguay, Mexico, Ireland, Malaysia, Australia, and Taiwan had reported the occurrence of MIS-A (Figure 1). 16,[27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] To help understand this rare but fatal complication, this review was conducted to provide updated and comprehensive information on MIS-A.…”