Multisystem Inflammatory Syndrome With Complete Kawasaki Disease Features Associated With SARS-CoV-2 Infection in a Young Adult. A Case Report

Abstract

A severe multisystem inflammatory syndrome associated with Kawasaki disease manifestations (MIS-C) has been recently reported in children with signs of recent infection with SARS-CoV-2. We here reported the case of a young adult woman who presented the complete manifestations of Kawasaki disease associated with a severe myocarditis, acute respiratory distress syndrome and hemodynamic instability a few weeks after a transient anosmia. The detection of specific antibodies to SARS-CoV-2 in the absence of detection of the virus suggested that the syndrome was the result of a delayed immune response to a recent COVID-19 infection. A combined treatment with colchicine, tocilizumab, high dose immunoglobulins, and methylprednisolone allowed to control the inflammatory process and to limit the development of coronary aneurysm. The patient recovered without sequelae. This case emphasized the importance of SARS-CoV-2 serology for the diagnosis of delayed immune complications of COVID-19. Clinicians caring for adult patients must be aware that not only children but also young adults can be affected by a multisystem inflammatory syndrome with KD features associated with COVID-19.

Multisystem inflammatory syndrome in children related to COVID-19: a systematic review

“…A quarter of patients (130/557; 23.3%) fulfilled criteria for complete KD [ 12 , 13 , 15 , 30 , 35 , 37 , 41 , 45 , 46 , 50 , 53 , 56 , 59 , 61 , 63 , 64 , 68 , 69 , 72 , 73 , 77 , 79 , 81 , 83 , 85 , 86 ] (criteria in Supplementary information 1 ). A similar proportion (99/411; 24.1%) fulfilled 2 or 3 of the KD criteria in combination with prolonged fever, resembling incomplete KD [ 11 – 13 , 32 , 36 , 39 , 44 , 47 , 48 , 52 , 54 , 57 , 61 – 63 , 65 – 69 , 77 , 79 , 81 , 83 ].…”

“…Polymorphous exanthema (466/849; 54.9%) and non-purulent conjunctivitis (423/849; 49.8%) occurred the most. Although shock was frequently reported in single cases (103/138; 74.6%), shock only presented in half of single cases with complete KD (11/24; 45.8%) [ 12 , 30 , 35 , 41 , 45 , 46 , 53 , 68 , 69 , 72 , 77 ].…”

“…Although white blood cell counts were frequently increased (12,800/μl [9150–20,075]), lymphocytopenia was common (831.5/μl [510–1157.5]) [ 12 , 24 , 30 – 36 , 39 – 41 , 43 – 46 , 48 – 50 , 52 – 57 , 60 , 62 , 67 – 73 , 75 , 77 , 80 , 84 ], contrasting with historical KD cohorts [ 15 , 64 ] (median lymphocytes 2800–3080/μl) or non-PIMS-TS/MIS(-C) (median 2100/μl) [ 23 ]. Most PIMS-TS/MIS(-C) presented reduced to normal thrombocytes (platelets below 150,000/μl in 44/104; 42.3%) [ 11 , 12 , 24 , 30 , 32 – 36 , 38 , 40 , 41 , 43 – 46 , 48 , 50 , 52 – 56 , 62 , 66 – 68 , 70 , 71 , 77 , 80 , 84 ]. Thrombocytosis (platelets above 450,000/μl), a typical KD sign and a laboratory criterium for incomplete KD [ 87 ], occurred in only 5/104 (4.8%).…”

“…Besides inflammatory parameters, coagulation markers were substantially upregulated, including d -dimers (3750 ng/ml [1946–6896]) and fibrinogen (640 mg/dl [504–800]) [ 11 , 12 , 31 – 35 , 38 , 40 , 43 – 47 , 49 , 51 , 55 – 57 , 60 , 62 , 66 – 68 , 70 , 71 , 75 – 77 , 80 , 84 ]. Furthermore, myocardial injury markers such as troponins (188 ng/l [60–614]) and brain natriuretic peptide (BNP) (median 1619 pg/ml [424–3325]) were often elevated [ 11 , 12 , 30 , 32 – 36 , 39 , 40 , 46 – 49 , 54 – 57 , 60 , 62 , 66 – 71 , 75 , 77 , 80 , 84 , 87 , 88 ]. Hyponatremia (130 mmol/l [128–133]) [ 12 , 24 , 30 , 32 , 35 , 37 , 41 , 44 – 46 , 48 – 50 , 52 , 54 , 55 , 62 , 67 , 69 , 76 , 84 ] was frequent, contrasting with KD controls (135 mmol/l [134–137]) [ 64 ] or non-PIMS-TS/MIS(-C) COVID-19 (137 mmo...…”

“…Furthermore, myocardial injury markers such as troponins (188 ng/l [60–614]) and brain natriuretic peptide (BNP) (median 1619 pg/ml [424–3325]) were often elevated [ 11 , 12 , 30 , 32 – 36 , 39 , 40 , 46 – 49 , 54 – 57 , 60 , 62 , 66 – 71 , 75 , 77 , 80 , 84 , 87 , 88 ]. Hyponatremia (130 mmol/l [128–133]) [ 12 , 24 , 30 , 32 , 35 , 37 , 41 , 44 – 46 , 48 – 50 , 52 , 54 , 55 , 62 , 67 , 69 , 76 , 84 ] was frequent, contrasting with KD controls (135 mmol/l [134–137]) [ 64 ] or non-PIMS-TS/MIS(-C) COVID-19 (137 mmol/l [136–139]) [ 23 ].…”