Severe Post-SARS-CoV2 Multisystem Inflammatory Syndrome Mimicking Kawasaki Disease Shock Syndrome in a Young Adult

Abstract

Introduction: Long term sequelae of SARS-CoV2 infections are currently being investigated. Previously described long term sequelae include cerebral vascular accidents, liver and kidney disease, and psychological disease, albeit without a consistent pattern of presentation. Recently, several cases have been published regarding multisystem inflammatory syndrome in children following known SARS-CoV2 infection. There has been one reported case of post-infectious Kawasaki-like illness in an adult. We present a patient with a similar multisystem inflammatory reaction, giving support for a Kawasaki-like disease in adults post-SARS-CoV2. Case description: A 27-year-old male with history of mild SARS-CoV2 infection one month prior without respiratory distress presented with fevers, abdominal pain, vomiting, and headache. Physical exam revealed injected bilateral conjunctiva, cheilitis, cervical lymphadenopathy, nuchal rigidity, a morbilliform rash on chest and hands, bilateral hand edema, and suprapubic tenderness. An abdominal CT scan suggested pyelonephritis and prostatitis. Hepatocellular and cholestatic markers were elevated without serological evidence of viral hepatitis. ESR, CRP, ferritin, LDH, d-dimer, and IL-6 were all elevated. SARS-CoV2 PCR was negative but IgG was positive. Blood, urine, and lumbar puncture studies were negative for bacterial, fungal, viral, and tick-borne evidence of infection. Rheumatologic workup was unremarkable. He developed hypotension requiring vasopressor support. ECG was notable for new-onset atrial fibrillation and echocardiogram showed systolic dysfunction with global hypokinesis with an ejection fraction of 45-50%. Cardiac MRI did not show evidence of myocarditis or infiltrative disease. Morning cortisol was low consistent with adrenal insufficiency and started on hydrocortisone. All his symptoms began to resolve with steroid therapy. One month after discharge, he was found to be in normal sinus rhythm. He experienced full resolution of his symptoms other than visual field disturbances with occasional floaters deemed to be of unknown etiology following complete neurologic and ophthalmologic workup. Repeat echocardiogram continued to show global systolic dysfunction with an ejection fraction of 40-45%. The patient continued on goal directed medical therapy and hydrocortisone therapy. Discussion: Post inflammatory conditions secondary to SARS-CoV2 have not been well described in adults. We present a patient whose post SARS-CoV2 inflammatory syndrome mimics the known pediatric post-inflammatory state, including characteristic timing, exam and laboratory findings, and resolution with steroid therapy. Further description of similar presentations is needed to better gauge the incidence of this inflammatory syndrome in young adults.