Pediatrics & Therapeutics
Open Access

Post COVID Multisystem Inflammatory Syndrome with Progressive Aneurysm Involving Multiple Vessels

Kiran B. Bhaisare^*, Shivprasad Mundada, Nitin Yelikar and Jessica Tellis ^*Correspondence: Kiran B. Bhaisare, Department of Pediatrics, VDGIMS Latur Maharashtra, India, Tel: +91- 9503122186, Email:

Author info »

Introduction

Three clinical patterns of MIS-C presentation have been proposed

1. shock and cardiac involvement

2. fever and elevated inflammatory markers

3. features like Kawasaki dieses [1-3]

This is a rare case of patient who had overlapping features of Kawasaki disease and MIS-C with severe presentation as giant coronary aneurysm and organized thrombus which progresses to brachial aneurysm and thrombus.

Case Description

18 month male was referred to our institute for non-responding fever and raised inflammatory markers since 1 month. He was apparently alright 1 month back, developed loose motions, one episode of convulsion. Admitted and treated as febrile convulsion with diarrhea.

Fever recurred on 5th day, Investigations suggestive of raised total leukocyte count with altered Neutrophil: lymphocyte ratio, thrombocytosis and raised inflammatory markers. Rapid antigen for COVID negative. No family history of COVID contact/ history of COVID vaccination.

Patient was treated as MIS-C received pcv transfusion, steroids Aspirin, Heparin and Antibiotics, discharged on oral Antibiotics, Prednisolone and Aspirin on day 14th. On follow up day 20, Parents had intermittent fever and raised Inflammatory markers, he was referred us.

On admission, patient was febrile, spo2 96% with Normal blood pressure, mild pallor and genital macular rash (Figure 1). On Systemic examination, persistent tachycardia disproportionate to fever with grade 1 murmur, normal heart sounds and mild hepatomegaly.

Figure 1: Genital rash

Investigations suggestive, of raised WBC, thrombocytosis with markedly raised Inflammatory markers, sr,. Albumin. Liver enzymes deranged. ECG suggestive of sinus tachycardia with mild cardiomegaly on Xray Chest (Table 1).

2D-echo (Figure 2) showed pericarditis with mild pericardial effusion with giant coronary aneurysm involving major arteries LMCA 4.7 mm (Z score 8.4), proximal LAD 5.6 mm (Z score+13), RCA 7.5 mm (Z score+17) and thrombus in left circumflex (7 mm), borderline left ventricular systolic function EF: 51%.

Figure 2: Dilatation of coronary arteries

RTPCR negative, as COVID-19 IgG was positive; we put diagnosis MIS-C stable Kawasaki type with giant coronary aneurysm. Treated with methylprednisolone pulse dose for 5 days and IV immunoglobulin. LMWH, high dose Aspirin both started as thrombocytosis. Empirical Antibiotics and Lasix given due to pericardial effusion. 2D echo rafter 48 hr s/o reduced thrombus size (5 mm), LVEF increased to 55% with effusion.

Inflammatory markers reduced and leucocyte count became normal. The LMWH dose was adjusted accordingly to INR and shifted to warfarin after 2 weeks.

In follow up, patient developed right axillary swelling, CT angiography suggestive right and left brachial artery aneurysm (Figure 3). Propranolol, anticoagulant and Clopidogrel started, Coronary thrombus disappeared.

Figure 3: bilateral axillary artery aneurysm

Discussion

MIS-C and KD differ in several clinical features. Gastrointestinal complications, shock and coagulopathy are more common in patients with MIS-C, unusual in classic KD. Classic KD is common in North East Asian countries, whereas MIS-C in Africans, Hispanic or Latino ethnicity. KD is common below 5 years with male predominance whereas MIS-C common in older children [1-6].

Our patient had overlapping features, Asian male infant without shock like classic Kawasaki. While he presented with gastrointestinal symptoms like MIS-C.

Symptomatic myocarditis reported in 40%–80% of patients with MIS-C in contrast to 5% with KD [1]. MIS-C likely to exhibit cardiac dysfunction and hypotension, as opposed to coronary abnormalities [4].

Our patient was stable with coronary aneurysm like classic KD. Cardiac biomarkers were normal in contrast with MIS-C.

Majority of patients with MIS have lower number of leucocytes, lymphocytes, monocytes and platelets while thrombocytosis is common with classic KD [2].

Our patient had thrombocytosis, raised WBC and monocytes like classic KD And lymphopenia, altered Neutrophil lymphocyte ratio with markedly raised D-dimer, CRP and COVID IgG antibody like Kawa COVID.

Conclusion

1) There are overlapping clinical features between MIS-C and Classic KD though there are many differences in demography, symptoms, age of presentation, laboratory markers and extent of coronary involvement.

2) Early 2decho to diagnose coronary involvement and Immunoglobulin therapy plus steroid and anticoagulation can prevent long term complications.

Early cardiac complications should be ruled out by vigorous Investigation in MIS-C irrespective of its type to give proper treatment and prevent long term complications.

Conflict of Interest

The authors declare no conflict of interest.

Financial Disclosure or Funding

No funding.

Informed Consent

Written informed consent from parents taken.

References

1. Jayakanthan K, Rakesh Kumar P, Reena K, Sathish Kumar T, Debashish D, Surjit S. Severe COVID 19, multisystem inflammatory syndrome in children and Kawasaki disease: Immunological mechanisms, clinical manifestations and management. Rheumatol Int. 2021; 41(1):19â??32
2. Marco C, Sara Della P, Fiammetta Z, Claudia B, Manuela G, Lucio V, et al. Defining Kawasaki disease and paediatric inflammatory multisystem syndrome temporally associated to SARS-CoV-2 infection during SARS-CoV-2 epidemic in Italy: Results from a national, multicentre survey. Pediatr Rheumatol Online J. 2021; 19(1): 29
3. Shreepal J, Supratim S, Srinivas L, Prashant B, Sumitra V, Soonu U, et al. Multisystem Inflammatory Syndrome in Children With COVID-19 in Mumbai, India. Indian Pediatr. 2020; 57(11): 1015-1019
4. Natasha AN, Dean AB, Angel HG, Satyan L. Multi-System Inflammatory Syndrome in Children (MIS-C) Following SARS-CoV-2 Infection: Review of clinical presentation, hypothetical pathogenesis, and proposed management. Children (Basel). 2020; 7(7): 69
5. Megan SR, Hannah B, Jake PJ, Jennifer L, Snejana N, Susan A, et al. Multisystem inflammatory syndrome in children (MIS-C) and the coronavirus pandemic: Current knowledge and implications for public health. J Infect Public Health. 2021; 14(4): 484-494
6. Mariana C, Bárbara RR, Virmondes R. Case report: Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 with Coronary Involvement: Arch Clin Biomed Res. 2020; 4(6): 760-765