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Table 2 MIS-A published case reports

From: Multisystem inflammatory syndrome in adults: a case report and review of the literature

Authors Age, sex, ethnicity Past medical history Signs and symptoms at presentation Previous COVID-19 infection Initial COVID-19 testing ICU stay Laboratory findings Imaging studies Treatments Outcome
Kofman, 2020 [4] 25, female None Fever, dyspnea, sore throat, diarrhea, vomiting, cough, and adenopathy No PCR (+)
IgG (+)
Yes Increased neutrophils, ESR, CRP, d-dimer, ferritin, Tn, and creatinine; lymphopenia Chest X-ray and CT: No detected abnormalities
CT angiography: dilated main pulmonary artery
CT abdomen/pelvis: acute uncomplicated pancreatitis
Echo: dilated IVC then right ventricular dysfunction
Aspirin, IVIG Recovery
Fox, 2020 [9] 31, female, African-American HTN, DM, and obesity (BMI 36.1 kg/m2) Fever, tachycardia, left-sided neck pain, nausea, vomiting, and parotitis by examination Yes, 12 days prior PCR (−) NR Elevated d-dimer, lactic acid, CRP, and creatinine CT neck: bilateral parotid enlargement and swelling of the posterior nasopharynx to the oropharynx
CT chest: bilateral basal GGO plus anterior mediastinal lymphadenopathy
NR Deceased
Shaigany, 2020 [8] 45, male, Hispanic No PMH
BMI of 26.6 kg/m2
Fever, diarrhea, sore throat, painful lower extremities, diffuse exanthema, conjunctivitis, periorbital edema, left neck swelling with lymphadenopathy, plaques and papules diffuse, hypotension, tachycardia, and atrial fibrillation No PCR (+) No Increased neutrophils, low lymphopenia, ESR, CRP, d-dimer, ferritin, Tn, AST, ALT, PCT (3179 ng/mL), IL-6 (117 pg/mL) Chest X-ray: diffuse interstitial haziness
CT neck with contrast: inflamed edematous lower eyelids and preseptal spaces, reactive lymphadenopathy
ECG: anterolateral ST segment elevation
PCI: normal coronary
TTE: global hypokinesia of the left ventricle with reduced EF of 40
Slit-lamp examination: conjunctivitis and uveitis
Full dose enoxaparin, IVIG (2 g/kg over 2 days), and single dose of IL-6 inhibitor (tocilizumab) Recovery
Ahsan, 2020 [13] 28, male Thalassemia minor. BMI of 28.48 kg/m2 High-grade fever (40.6 °C), anorexia, vomiting, nausea, lower limb pain, generalized weakness, red eye, difficult urination, and constipation. Bilateral facial nerve palsy, optic neuritis Yes, 2 weeks before Ab (+), PCR (−) Not done NR Anemia hypoalbuminemia leukocytosis with neutrophilia
Elevated ESR, ferritin, and CRP
ECG: normal
Chest X-ray: normal
MRI brain and orbit: normal
Ceftriaxone 2 g daily and prednisolone 1 mg/kg/day orally for 6 weeks Recovery
Bettach, 2021 [14] 54, female None Fever, septic shock, GI symptoms, skin rash, heart failure, bilateral acute anterior uveitis No PCR (−)
IgG (+)
Yes NR Slit-lamp examination: bilateral corneal edema with Descemet’s membrane and keratin precipitates
Fundus examination: small localized intracranial bleed
Fluorescein angiography: no vascular abnormalities
Antibiotics, corticosteroids, and vasopressors. After 2 weeks, topical dexamethasone Recovery
Razavi, 2020 [15] 23, male, African-American BMI of 35.4 kg/m2 Fever, fatigue, myalgia, dyspnea, orthopnea, watery diarrhea, and temporal headache. Hypotension, bilateral scleral, and conjunctival injection Yes, 1 month prior PCR (−)
IgG (+)
NR Leukocytosis, lymphocytopenia, high Tn I and BNP (NSTEMI)
High CRP, d-dimer, ferritin, and fibrinogen
Echo: global hypokinesia with reduced EF (40–45%)
Chest X-ray: no focal consolidations
CT chest with contrast: no abnormalities
Cardiac MRI: pericardial effusion and borderline EF (54%)
Antibiotics, IVIG, methylprednisolone, aspirin, enoxaparin Recovery
Gulersen, 2021 [18] 31, female Obesity, asthma, pregnant (28 weeks) Fever, left-sided pleuritic chest pain, shortness of breath. Late-onset hypotension and tachypnea Yes, 4 weeks prior. PCR (+) PCR (−)
IgG (+)
Yes Leukocytosis. Elevated CRP, normal lactate, ferritin, PCT, late-onset increased in cardiac enzymes and inflammatory markers CT angiography of the chest: normal with no pulmonary embolism or lung pathology detected
TTE: On admission, EF 65–70% with a hyperdynamic left side, rim pericardial effusion, and well-functioning right ventricle. On day 4: global dysfunction of the right and left ventricles with rim pericardial effusion
Non-stress test: reactive fetus
Intravenous heparin, IVIG, dexamethasone (10 mg every 6 hours), mechanical ventilation, inotrope and vasopressor Extubated on day 8, elective delivery, and discharged home on day 15
Malangu, 2020 [19] 46, male History of pneumonia Fever (39.1 °C), atrial fibrillation, mild hypoxia (SatO2 91% on room air), bilateral exudative conjunctival injection, oral mucositis, bilateral cervical lymphadenopathy, and macular skin rash No PCR (−)
IgG (+)
NR Leukocytosis and thrombocytopenia. Elevated d-dimer, CRP, ferritin, LDH fibrinogen. Mildly elevated ALT, AST, kidney injury with hematuria, and proteinuria CT angiography of the chest: bilateral apical patchy consolidations
Chest X-ray: basal and middle lobe opacities
TTE: left ventricular dysfunction with EF 31% and eccentric hypertrophy
Cardiac MRI: perihilar lymph nodes with no infiltrative lesions
Bronchoscopy: no malignant cells
Antibiotics and apixaban Recovery
Othenin-Girard, 2020 [20] 22, male, East African None Five days of chills, myalgia, asthenia, diarrhea, and abdominal pain. Three weeks of loss of taste and smell sensations, and 1 day of dry cough, odynophagia, and rash (over trunk, extremities, palms) Yes, 3 weeks prior. IgG (+) PCR (+)
IgG (+)
Yes Leukocytosis, elevated CRP (275 mg/L), fibrinogen (8.5 g/L), d-dimer (3322 ng/mL), and creatinine (1.5 mg/dL)
Autoimmune workup: negative ANA, ANCA, and rheumatoid factor
CT abdomen and chest: normal lung parenchyma with pulmonary embolism and inflamed mesenteric lymph nodes
TTE: biventricular dysfunction/endomyocardial biopsy: myocarditis with necrotic foci
Nerve conduction study: mononeuritis multiplex
IVIG, tocilizumab, rituximab, corticosteroids, and cyclophosphamide. Mechanical ventilation and extracorporeal membrane oxygenation (ECMO) Recovery
Moghadam, 2020 [16] 21, male, Caucasian None Seven days of fever (40 °C), watery non-bloody diarrhea, chest tightness, vasoplegic shock, rash, tachypnea, bilateral conjunctivitis, and truncal and palmar rash No PCR (−)
IgG (+)
Yes Leukocytosis, CRP (365 mg/L), PCT (3.4 ng/mL), ferritin (1.282 mg/L), high lactate, Tn (55n ng/L) Skin biopsy: inflammatory infiltrates
TTE: hyperkinetic left ventricle with preserved EF
CT scan chest and abdomen: compatible with congestive heart failure
Fluid resuscitation, noradrenaline, antibiotics (amikacin and ceftriaxone) Recovery
Lidder, 2020 [5] 45, male None Five days of fever, red eyes, diarrhea, sore throat, eyelids edematous rash, nonexudative conjunctivitis, and abnormal perioral mucosa No PCR (+) NR Lymphopenia, elevated CRP, ESR, ferritin, d-dimer, and elevated Tn TTE: global hypokinesia with reduced EF (40%)
CT neck: unilateral lymphadenopathy
Eye-lubricating medications, topical prednisolone acetate 1%, IVIG, tocilizumab, and triamcinolone ointment for the rash Recovery
Tung-Chen, 2021, Spain [6] 25, male None One-day history of nausea and abdominal pain. One week of fever (38 °C), sore throat, fatigue, anosmia, and orthopnea. Shock at presentation No PCR (−)
IgM (+)
IgG (+)
Yes Lymphopenia (0.43 × 109/L), elevated fibrinogen (> 1200 mg/dL), CRP (337.1 mg/L), TnT I, and BNP TTE: global hypokinesia with severely impaired left ventricular function (EF 29.7%) and rim pericardial effusion. EF improved after 8 days
CT chest: no abnormalities
Chest X-ray: no abnormalities
ECG: sinus tachycardia with no other abnormalities
Antibiotics, ganciclovir, norepinephrine, milrinone, and diuretics Recovery
Uwaydah, 2021 [7] 22, male None Four days of fever (39 °C), sore throat, diarrhea, nausea, vomiting, myalgia, headache, fatigue, erythematous rash involving the torso, tachycardia, hypotension, edema, and proteinuria Yes, 40 days prior PCR (+) PCR (−)
IgG (+)
Yes Leukocytosis, elevated creatinine, AST (53 U/L), ALT (81 U/L), direct bilirubin, CRP (249 mg/L), ferritin (4357 ng/mL), d-dimer (14 mg/mL), PCT (9 ng/mL), IL-6 (90 pg/mL), low platelets (122) and albumin (16 g/L) TTE: severe tricuspid regurgitation, pulmonary HTN (46 mmHg), left ventricle dysfunction (EF 45%), and rim pericardial effusion. Normal echo after recovery
CT chest: bilateral moderate pleural effusion and basilar atelectasis
Antibiotics, intravenous hydrocortisone Recovery
Ahmad, 2021 [21] 26, male, Caucasian None Fever, abdominal pain, loose stool, nausea, reduced urine output, hypotension tachypnea (38 breath/minute) and hand/feet rash PCR (+) PCR (+)
Abs (+)
Yes Leukocytosis. Elevated lactic acid (9.7 mg/dL), CRP (246 mg/L), PCT (105.12 ng/mL), d-dimer (2.03), LDH (236 U/L), creatinine (4.66 mg/dL), and urea (38 mg/dL) Lower limb doppler: left peroneal DVT
Chest X-ray: peribronchial thickening
Noncontrast CT abdomen: perinephric edema and mesenteric lymphadenopathy
TTE: severely impaired left ventricular function (EF 15–20%) as well as right ventricular dysfunction. EF increased to 60% after 10 days
Vasopressors, IVIG, methylprednisolone (250 mg/6 hours), aspirin, anakinra (IL-1 receptor antagonist), mechanical ventilation, and CRRT Recovery
Li, 2021 [10] 28, male None Five days of right-sided neck pain and swelling, enlarged tonsils, tenderness of the right submandibular fever, malaise, tachycardia, pruritic rash 4 weeks prior, PCR (+) PCR (−)
IgG (+)
NR Leukocytosis (13,800/mm3), anemia (10.7 g/dL). Elevated hs-Tn I (11,908 ng/L), BNP (1661 pg/mL), CRP (304.2 mg/L), and ferritin (1588 mg/L) CT neck: cervical lymphadenopathy, more on the right side
TTE: mildly impaired left ventricular function (EF 45–55%)
Cardiac MRI: rim pericardial effusion and slightly impaired right ventricular function
Broad-spectrum antibiotics, fluid resuscitation, beta-blocker, ACE inhibitor Recovery
Veyseh, 2021 [23] 43, female None Fever, hypotension, tachycardia, erythematous rash, diarrhea, and cramping abdominal pain No PCR (−) Yes High WBCs, CRP, ferritin, d-dimer, fibrinogen, LDH, AST, and ALT TTE: reduced EF (toxic cardiomyopathy), EF improved after IVIG and steroids Antibiotics, vasopressors, IVIG, and intravenous solumedrol Recovery
Diakite, 2021, [17] 33, male HTN Fever, diarrhea, chest pain, dyspnea, conjunctivitis, and cheilitis. Hypotension, tachycardia, and elevated hepatojugular reflux Possible 6 weeks prior PCR (−)
IgG (+)
NR Leukocytosis (21,000/mm3), anemia (10.7 g/dL), high AST, ALT, creatinine, CRP, d-dimer, BNP, and Tn TTE: global hypokinesia, reduced EF (20%), and dilated IVC. Cardiac MRI revealed improved cardiac function after a week of treatment
Coronary CT: aneurysms involving the right coronary, interventricular artery, and the left circumflex
Dobutamine, norepinephrine, IVIG, aspirin, prednisolone Recovery
Bastug, 2021, Turkey [24] 40, male, Caucasian None Fever (39 °C), tachycardia, tachypnea, abdominal pain, diarrhea, and skin rash 23 days prior PCR (−)
IgM (+)
IgG (+)
NR Lymphopenia, leukocytosis as well as high liver function tests, ferritin, d-dimer, troponin, BNP, CRP, fibrinogen, PCL, and IL-6 CT abdomen: inflamed intestine and mesentery, mesenteric lymphadenopathy, and effusion
TTE: global hypokinesia, reduced left ventricle function (EF 45%), and mild pericardial effusion. EF increased to 60% and the effusion resolved after treatment
Antibiotics, methylprednisolone, IVIG, full-dose enoxaparin Recovery
Sokolovsky, 2021, [31] 36, female, Hispanic None Fever, vomiting, abdominal pain, diarrhea, arthralgia, rash hypotension, and tachycardia No PCR (+)
NR Elevated liver enzymes, direct bilirubin, albumin, CRP, ferritin, d-dimer, ESR, and hyponatremia (115 mmol/L) TTE: normal EF (65%) and moderate tricuspid regurgitation
CTA coronaries: normal with rim pericardial effusion
CT chest: trace pleural effusion
Steroids, acetylcysteine, IVIG, aspirin Recovery
Julius, 2021, [11] 59, female, Caucasian HTN and dyslipidemia Fever, right cervical lymph node swelling, odynophagia, hypotension, and rash (neck and chest) 20 days prior, PCR (+) PCR (+) Yes Slightly elevated AST, ALT; high Tn, CRP, and ferritin CT neck: enlarged right nodes with one exhibiting liquefaction
EKG: ST elevation in V1 and V2
Antibiotics, steroids, norepinephrine, epinephrine, terlipressin mechanical ventilation Deceased
Parpas, 2021 [32] 67, male HTN, cirrhosis Dyspnea weakness, weight loss, anorexia, nausea, extremities edema, tachycardia, and cognitive impairment 68 days prior PCR (−)
Abs (+)
NR Low sodium (109 mEq/L) and albumin (3 g/dL), leukocytosis (35,000/mm3). High d-dimer, LDH, and PCL Chest X-ray: bilateral basal infiltrative lesions
CT chest: lung atelectasis/collapse
TTE: Pulmonary HTN, and grade I diastolic dysfunction
Duplex of lower limbs: no DVT
Renal biopsy: moderate to severe acute tubular necrosis
Antibiotics, unfractionated heparin, dexamethasone, and hemodialysis Recovery
Pérez, 2021, [25] 88, male HTN, dyslipidemia, essential tremors Hypoxia (saturation 87%), dyspnea, and peripheral edema 54 days prior
PCR (+)
Abs (+)
PCR (−)
IgM (+)
IgG (+)
NR Creatinine (2.14 mg/dL), proteinuria (> 600 mg/dL), and low albumin 3 g/dL
High LDL, CRP, and d-dimer
Chest X-ray: typical COVID-19 picture and pleural effusion
Renal biopsy: findings suggesting acute IgA-dominant infection-associated glomerulonephritis
Intravenous furosemide, intravenous methylprednisolone Recovery
Balan, 2021, [33] 46, male Obesity (BMI 42 kg/m2) Hypotension, hypoxia tachypnea, right hemiparesis, ataxia, and left hemianesthesia 60 days prior PCR (−)
Abs (+)
Yes Elevated ferritin, CRP, LDH, PCT, high creatinine (4.1 mg/dL) and Tn TTE: normal EF and elevated right ventricular pressures
CT chest: bilateral apical and basal as well as right middle ground-glass opacities
Norepinephrine, antibiotics unfractionated heparin, dexamethasone, tocilizumab, hemodialysis Deceased
Mieczkowska, 2021, [22] 32, male None Fever, tachycardia, right-sided swollen groin lymph nodes, diarrhea, and palms and soles rash Two months prior PCR (−)
IgG (+)
No Elevated AST, ALT, and direct bilirubin. Elevated inflammatory markers (CRP, ferritin, PCL, IL-6, ESR, and d-dimer) TTE: EF 55% and pericardial effusion
CT: lymphadenopathy of the right groin
Enoxaparin and intravenous methylprednisolone Recovery
Mieczkowska, 2021, [22] 43, female None Fever, myalgia, headache, cough, and skin rash. Hypotension, cardiomyopathy, and acute kidney injury No PCR (−)
Serology (+)
NR Leukocytosis (21,500/mm3).
Elevated ESR, CRP, ferritin, and d-dimer. Elevated AST, ALT, and ALP
Chest X-ray: right basal pneumonia
Abdominal ultrasound: pericholecystic fluid, hepatomegaly, and steatosis
TTE: EF 40%
Vasopressors, antibiotics, intravenous heparin, methylprednisolone Recovery
Hékimian, 2021 [12] 40, male DM (BMI 26 kg/m2) Apyretic, dyspnea, severe asthenia No PCR (+)
IgG (−)
Yes Elevated PCT, CRP, ferritin
Elevated AST, ALT, and ALP
Elevated LDH, CPK
Peak troponin 439 ng/L
Peak BNP 6025 pg/mL
Chest CT: severe multifocal PNA
TTE: EF 45%
Mechanical ventilation, dobutamine, norepinephrine, ECMO Recovery
Hékimian, 2021 [12] 19, female None (BMI 24 kg/m2) Fever, dyspnea, cough No PCR (−)
IgG (+)
Yes Elevated CRP, ferritin, LDH
Peak troponin 10,652 ng/L
Peak BNP 2585 pg/mL
Chest CT: mild infiltrates
TTE: EF 30%
Mechanical ventilation, dobutamine, norepinephrine, ECMO Recovery
Hékimian, 2021 [12] 22, male DM, asthma (BMI 38 kg/m2) Fever, dyspnea, cough, severe asthenia No PCR (−)
IgG (−)
Yes Elevated CRP, ferritin, LDH
Peak troponin 166 ng/L
Chest CT: severe infiltrates
TTE: EF 30%
Mechanical ventilation, ECMO Recovery
Hékimian, 2021 [12] 19, male None (BMI 22 kg/m2) Fever, headache, diarrhea, dyspnea, severe asthenia No PCR (−)
IgG (+)
Yes Elevated CRP, ferritin, LDH
Peak troponin 806 ng/L
Peak BNP 26,956 pg/mL
Chest CT: negative
TTE: EF 15%
Dobutamine, norepinephrine Recovery
Hékimian, 2021 [12] 16, male None (BMI 18 kg/m2) Fever, anosmia, abdominal pain, rash to hands and feet, conjunctivitis, strawberry tongue, adenopathy, severe asthenia, chest pain No PCR (+)
IgG (+)
Yes Elevated CRP, ferritin, LDH
Peak Troponin 2545n ng/L
Chest CT: mild infiltrates
TTE: EF 20%
Mechanical ventilation, dobutamine, norepinephrine, IVIG Recovery
Hékimian, 2021 [12] 16, female None (BMI 24 kg/m2) Fever, headache, abdominal pain, rash to hands and feet, dyspnea, severe asthenia Yes, anosmia and cough 1 month prior PCR (−)
IgG (+)
Yes Elevate CRP, ferritin, and LDH
Peak troponin 64 ng/L
Peak BNP 1689 pg/mL
Chest CT: negative
TTE: EF 45%
None Recovery
Hékimian, 2021 [12] 17, male Moderate aortic regurgitation (BMI 32 kg/m2) Fever, headache, abdominal pain, diarrhea, dyspnea, severe asthenia, conjunctivitis No PCR (+)
IgG (+)
Yes Elevated ferritin and LDH
Peak troponin 138 ng/L
Peak BNP 35,000 pg/mL
Chest CT: mild pulmonary edema
TTE: EF 20%
Mechanical ventilation, dobutamine, norepinephrine, IVIG, corticosteroids 2 mg/kg/day Recovery
Hékimian, 2021 [12] 25, female None (BMI 23 kg/m2) Fever, headache, abdominal pain, dyspnea, severe asthenia, myalgias, arthralgias, adenopathy No PCR (−)
IgG (+)
Yes Elevated CRP, ferritin, LDH
Peak troponin 2542 ng/L
Peak BNP 24,540 pg/mL
Chest CT: negative
TTE: EF 50%
Nasal cannula Recovery
Hékimian, 2021 [12] 17, female None (BMI 18 kg/m2) Chest pain, dyspnea No PCR (+)
IgG (+)
Yes Elevated CRP, ferritin, LDH
Peak troponin 4905 ng/L
Peak BNP 3362 pg/mL
Chest CT: pulmonary edema
TTE: 20%
Mechanical ventilation, dobutamine, norepinephrine, ECMO, IVIG, corticosteroids 2 mg/kg/day Deceased
Hékimian, 2021 [12] 37, male HTN (BMI 35 kg/m2) Fever, headache, diarrhea, severe asthenia No PCR (−)
IgG (+)
Yes Elevated ferritin, LDH
Peak troponin 1164 ng/L
Peak BNP 35,000 pg/mL
Chest CT: Negative
TTE: EF 45%
IVIG, corticosteroids 2 mg/kg/day Recovery
Hékimian, 2021 [12] 29, female None (BMI 22 kg/m2) Fever, abdominal pain, diarrhea, rash, conjunctivitis, severe asthenia Yes, 1 month earlier PCR (−)
IgG (+)
Yes Elevated CRP, ferritin, LDH
Peak troponin 200 ng/L
Peak BNP 21,298 pg/mL
Chest CT: negative
TEE: EF 50%
IVIG Recovery
  1. PMH past medical history, HTN hypertension, BMI body mass index, BPM beats per minute, MIS-A multisystem inflammatory syndrome in adults, PCT procalcitonin, AST aspartate transaminase, ALT alanine transaminase, ALP alkaline phosphatase, CRP C-reactive protein, ESR erythrocyte sedimentation rate, LDH lactate dehydrogenase, EKG electrocardiogram, CAP community-acquired pneumonia, PNA pneumonia, HD hospital day, ANA antinuclear antibodies, ANCA antineutrophil cytoplasmic antibodies, OD once daily, Tn troponin, BNP brain natriuretic peptide, DVT deep vein thrombosis, TTE transthoracic echocardiogram, EF ejection fraction, MRI magnetic resonance imaging, MV mechanical ventilation, CRRT continuous renal replacement therapy, IVIG intravenous immunoglobulins, LMWH low molecular weight heparin, Abs antibodies, SatO2 saturation of O2