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 (+) Abs(+) | 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 |