From 13% to 60%: A Rare Case of Multisystem Inflammatory Syndrome in Adults 4 Weeks Following COVID-19 Infection

INTRODUCTION: Multisystem inflammatory syndrome in adults (MIS-A) is a rare but serious entity implicated with COVID-19 infection. Improved diagnosis and treatment of MIS-A may mitigate morbidity and mortality attributed to COVID-19 infection. CASE REPORT: Our patient is a 24-year-old male with no known past medical history except for COVID-19 infection diagnosed 4 weeks prior. He presented with a 5-day history of intractable nausea, vomiting, and abdominal pain. He was febrile. COVID-19 test was negative. The patient became hypotensive, tachycardic and was aggressively resuscitated (5L crystalloid) with no improvement. He was transferred to ICU, intubated for worsening acute hypoxic respiratory failure, and started on vasopressors. TTE showed EF of 13% with severe global LV hypokinesis and RV enlargement with severe global hypokinesis. He underwent urgent coronary angiogram which showed normal coronaries. His clinical course was consistent with the working definition of MIS-A as specified by the CDC. As the patient was in cardiogenic shock with severe biventricular dysfunction, left femoral Impella CP and right femoral Impella RP were placed. Given his severe hemodynamic compromise leading to persistent shock and multiorgan failure, he was eventually placed on venoarterial ECMO. The patient was being treated with methylprednisolone, IVIg and anakinra. Over the following days, he continued to improve, and his vasopressors were weaned off. His Impella CP was successfully removed with stable LV pulsatility on arterial line. His LV function improved on TTE and the patient was decannulated 5 days after initiation of VA ECMO. TEE done 6 days after initial echocardiogram showed LVEF of 60% and normal RV systolic function. The patient was extubated and continued to improve clinically. SUMMARY: MIS-A is a serious hyperinflammatory condition that presents with multiorgan dysfunction approximately 4 weeks after onset of COVID-19 infection. Aggressive supportive care in the ICU, utilization of advanced heart failure devices, and immunomodulatory therapeutics should be utilized during management. More studies are needed to elaborate on treatment modalities and clinical predictors.