key: cord-0872129-lmmjxpka
authors: Guice, Kenneth Cory; Gerrity, Rebecca; Skinner, Ashley; Thomas, Caitlin; Bharani, Yashubhrika; VanLandingham, Alex; Al-Bedour, Arwa; Risquez, Cristobal; Romero-Legro, Ivan; Muddassir, Khawaja; Animalu, Chinelo; Raza, Syed; Wells, Daniel
title: Multisystem Inflammatory Syndrome post-SARS-CoV-2 Infection: A Case Series
date: 2022-04-21
journal: Am J Med Sci
DOI: 10.1016/j.amjms.2022.04.020
sha: 35ad72eb78ae9189a0540a4c11f098c3614e2e2e
doc_id: 872129
cord_uid: lmmjxpka

nan

Multisystem inflammatory syndrome (MIS) is a hyperinflammatory condition that can happen weeks after a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection hallmarked by a hyperinflammatory state, cardiac injury, and/or shock. As cases of SARS-CoV-2 continue to persist it is imperative for clinicians to be aware of short-and long-term sequelae of these infections. MIS was first identified in children (MIS-C) in Spring of 2020 and adults (MIS-A) in early 2021. After this, the Centers for Disease Control (CDC) published a case series along with a way to report cases of MIS directly. 1 Our cases were not submitted to the CDC and thus have not been included in the current literature. Very little is known about the pathologic mechanism of this condition and literature regarding MIS-A remains sparse despite numerous studies on MIS-C. MIS-A shares many of the same characteristics as MIS-C, and if not recognized and treated promptly, it can lead to severe complications.

We identified four patients who were treated for MIS between December 2020 and March 2021 at two academic tertiary care hospitals. Three patients met the CDC Case Definition for MIS-A, and one met criterion for MIS-C. 2, 3 Analysis of each patient's hospitalization was conducted examining laboratory results, diagnostics, and clinical indicators of disease severity including vasopressor requirement and length of ICU stay.

The demographics, comorbidities, and clinical outcomes are described in Table 1 . All patients were Black, aged between 20 -42 years, three were male and two were obese. All 1, 6 , which was again demonstrated in our case series. This concept could be explored further as more cases develop to adequately assess any genetic or social predispositions.

MIS is a unique condition, and more studies need to be done to further link or differentiate MIS-A and MIS-C. Fortunately, MIS appears to respond well to anti-inflammatory treatments and immune modulation resulting in a relatively low mortality rate highlighting the possibility of immune mediated injury as an underlying mechanism for MIS-A. 3 The American Additionally, all our patients exhibited cardiac dysfunction which has occurred in an estimated 60% of patients with MIS-A according to a recent systematic review. 6 It is also important to note that MIS-A can be difficult to differentiate from primary SARS-CoV-2 as evidenced by the fact that both conditions usually produce a hyperinflammatory state. However, MIS-A typically involves extrapulmonary symptoms and is heralded by a past SARS-CoV-2 infection with MIS-A symptoms starting around four weeks after the initial infection. 6 We also recognize that the number of cases of MIS that we observed were disproportionately high considering the rarity of the condition. This could be attributed to the high number of SARS-CoV-2 cases we saw in our region and the subsequent surge in cases during that time. Our hospital also has a high proportion of physicians who concurrently care for hospitalized children, so familiarity with MIS-C may have contributed to earlier recognition.

In response to this, we did develop hospital guidelines for recognition, diagnosis, and treatment in April 2021 which were approved by hospital administration and disseminated to the medical staff.

These cases emphasize the need for recognition and diagnosis of MIS-A, especially in the absence of alternative diagnoses. All patients had negative blood cultures, no source for their severe sepsis, and progressive clinical deterioration. This study demonstrates that more work Multisystem Inflammatory Syndrome: A Case Series 6 needs to be done to further examine MIS-A/C, develop treatment algorithms for adult hospitals, and explore its short-and long-term effects in all patient outcomes.

Link to CDC reporting page: https://www.cdc.gov/mis-c/pdfs/hcp/mis-c-formfillable.pdfpdf icon Multisystem Inflammatory Syndrome: A Case Series 7

We declare no competing interests.

We have no financial disclosures.

Institutional Review Board approval was obtained prior to our study. 

Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection -United Kingdom and United States

Multisystem inflammatory syndrome in adults (mis-A) case definition information for healthcare providers

American College of Rheumatology Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 and Hyperinflammation in COVID-19. Version 1

Cardiogenic Shock and Hyperinflammatory Syndrome in Young Males With COVID-19

Coronavirus Disease 2019 Acute Myocarditis and Multisystem Inflammatory Syndrome in Adult Intensive and Cardiac Care Units

Multisystem Inflammatory Syndrome: A Case Series 9

Clinical Characteristics of Multisystem Inflammatory Syndrome in Adults: A Systematic Review

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