Case Presentation: A 28-year-old male patient was admitted to an outside hospital due to dyspnea on exertion. Further inspection displayed signs of transaminitis, leukocytosis, and a blanchable diffuse body rash. An echocardiogram demonstrated new-onset non-ischemic cardiomyopathy with left ventricular ejection fraction of 30-35%. The patient also had a recent positive COVID-19 diagnosis one month prior. Transfer to a tertiary center was recommended as myocarditis related to COVID-19 was suspected. Vancomycin 1500mg and Cefepime 2000mg were initiated. Upon transfer, the patient was worked up for leukemoid reaction and concern for possible multisystem inflammatory syndrome. The leukemoid reaction presented as erythematous patches on the bilateral axilla, hips, and lateral portion of the upper legs; biopsy was consistent with viral exanthem and suspected inflammatory response resulting from leukocytosis. Mild hepatic steatosis is also seen. He denied any chest pain, abdominal pain, loss of taste or smell, but did acknowledge feelings of nausea. Dermatology and infectious disease were consulted. Lab examinations revealed elevated levels of ferritin (1558 ng/mL); procalcitonin (3.49ng/mL); D-dimer (1.44 mg/L); high sensitivity troponin (182 ng/ml); ALT (122 unit/L); CRP (10.3mg/dL). CBC indicated WBC count of 21,400. Additionally, SARS-COV-2 antibody was reactive, disqualifying this patient from convalescent plasma therapy and remdesivir administration. Vancomycin 1500mg and cefepime 2000mg administration yielded improvement. Cardiac MRI displayed diminished left and right ventricular systolic function, with left more acutely impacted, small pericardial and pleural effusion, and consolidation in the left lower lobe, likely due to pneumonia. CTPE was negative for PE and without pulmonary edema. ECG indicated sinus tachycardia. Patient improved throughout the course of their care resulting in discontinuation of antibiotic therapy and discharge on day 3 post-transfer. Patient was prescribed Lisinopril and Toprol for management of cardiovascular condition.
Discussion: Multisystem Inflammatory Syndrome (MIS-A) is a rare complication in adults involving systemic inflammation manifesting in symptoms encompassing a variety of organ systems. Since 2020, there has been a greater frequency of clinical cases highlighting the association of MIS-A within the COVID-19 pandemic. COVID-19 is often thought to be relatively asymptomatic amongst pediatric patients, however amongst the adult population, the symptomatic nature of a COVID-19 infection can cloak the advancement of other related ailments. MIS-A in adults typically has been seen to present with fever, hypotension, cardiac dysfunction, and shortness of breath. Most patients had elevated D-Dimer levels, and markers of inflammation. Reportedly, 98% of patients with MIS-A were diagnosed with COVID-19 prior to the onset of symptoms. Clinicians should consider a diagnosis of MIS-A among people with hyperinflammatory disease and multiorgan dysfunction happening within 2 to 5 weeks of prior COVID-19 diagnosis
Conclusions: This case report highlights the varying manifestations of MIS-A and highlights the difficulties associated with diagnosis for even the most experienced clinicians. Clinicians should maintain a high index of clinical suspicion and anticipate multisystem involvement in a timely manner.
