A Case of Cardiogenic Shock in a Young Adult with COVID-19-Induced Multisystem Inflammatory Syndrome

INTRODUCTION: Multisystem inflammatory syndrome (MIS-C) is associated with the novel coronavirus (COVID-19). Children and young adults with MIS-C typically present with fever, abdominal pain, nausea, vomiting, and occasionally, respiratory symptoms. Myocardial dysfunction (as measured by TTE, elevated troponin, or elevated brain natriuretic peptide [BNP]) has been reported in 51-90% of these patients. CASE REPORT: An 18-year-old male without significant medical history was transferred to the Cardiovascular Intensive Care Unit with cardiogenic shock after presenting with headache, myalgias, sore throat, nausea, and vomiting. Initial workup revealed hypotension, tachycardia, and positive SARS-CoV-2 IgG antibodies. Transthoracic echocardiogram (TTE) showed severe biventricular failure with left ventricular ejection fraction (LVEF) of 26%. Vasopressors were started for blood pressure support. Right heart catheterization (RHC) was consistent with cardiogenic shock. Impella CP percutaneous left ventricular assist device was placed. The patient developed hypoxemia and tachypnea. He was intubated and underwent cannulation for veno-arterial extracorporeal membrane oxygenation (VA ECMO). He was also started on continuous renal replacement therapy (CRRT) for acute anuric renal failure. Endomyocardial biopsy revealed benign myocardium. Vasopressors were weaned and repeat TTE on day 3 revealed LVEF of 34%; subsequent TTE on day 5 showed recovery up to 53%. The Impella device was removed, VA ECMO was decannulated, and the patient was extubated. He improved clinically over the next weeks with normalizing vital signs, inflammatory markers, respiratory status, and renal function. The patient was discharged on day 28, about six weeks after symptom onset. TTE prior to discharge revealed mild LV hypertrophy and normal systolic function. SUMMARY: As illustrated in this case, timely recognition of cardiogenic shock is critical. This patient developed acute-onset cardiogenic shock, which required early escalation to temporary mechanical circulatory support. Additionally, this patient's care was complex and the case highlights the importance of early coordination between teams. Meetings were held nearly daily, with collaboration contributing to a multidisciplinary workup and treatment plan that ultimately led to the full recovery of this young patient.