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Rare but serious cases of a multisystemic inflammatory syndrome in children (MIS-C) associated with COVID-19 have been reported worldwide. Now, a study published late last week in Weekly morbidity and mortality report describes a similar syndrome in 27 adults with coronavirus.
Led by researchers from the U.S. Centers for Disease Control and Prevention (CDC), the study involved the identification of suspected cases of the syndrome from medical and public health reports, published case reports, and series of cases of the United States and the United Kingdom.
The patients were not seriously ill with COVID-19, but had cardiovascular, gastrointestinal, dermatological, and neurological signs and symptoms and elevated biomarkers of inflammation and abnormal blood clotting consistent with multi-system inflammatory syndrome in adults (MIS-A). They had tested positive for coronavirus on polymerase chain reaction (PCR) or antibody tests, indicating a current or recent infection.
Similarly, common signs and symptoms in children diagnosed with MIS-C are shock, heart dysfunction, stomach pain, and elevated levels of C-reactive protein (CRP), ferritin, and interleukin-6, all indicative of inflammation and D-dimer. , a sign of abnormal clotting.
Cardiac dysfunction, inflammation, mucositis.
Sixteen MIS-A patients described in case reports and CDC data showed that they all had evidence of syndrome-related heart problems, such as abnormal rhythms, elevated troponin levels, or left or right ventricular dysfunction.
Thirteen patients had gastrointestinal symptoms on admission to hospital and five had dermatologic abnormalities, three of them with mucositis, painful inflammation, and ulceration of the digestive tract lining that is usually the result of chemotherapy or radiation for cancer.
Ten of the 16 patients (63%) had lung abnormalities on chest imaging and 12 (75%) had a fever of 100.4 ° F or higher for at least 24 hours. All had elevated levels of CRP, ferritin, and D-dimer. Ten patients also had low levels of lymphocytes, which may indicate an infection.
Four of the six patients who tested negative for COVID-19 at initial evaluation (67%) had antibodies to the virus. Ten of the 16 patients (63%) required intensive care, three required mechanical ventilation (19%) and two (13%) died.
The patients, who were between 21 and 50 years old, were of Asian (one patient), Hispanic (five) and black (10) ethnicity. Otherwise, nine patients were healthy, while six were obese, one had uncontrolled type 2 diabetes, two had high blood pressure, and one had obstructive sleep apnea. Eight patients had respiratory symptoms before developing MIS-A, while the rest did not.
Large vessel strokes, vascular abnormalities
A case series involving seven men ages 20 to 42 who experienced shock, had elevated levels of inflammatory markers, and tested positive for coronavirus antibodies; four tested negative for COVID-19 on PCR. Three required medications to regulate their heart and blood pressure, and three required the insertion of an intra-aortic balloon pump.
Two patients were black, two were Hispanic, two were from the Middle East, and one was white. They all recovered.
Another case series described two patients aged 21 and 50 who sought medical care after suffering large vessel strokes related to coronavirus, possibly associated with abnormal clotting and non-obstructive coronary artery disease. Although they had few respiratory symptoms, they showed high concentrations of inflammatory markers.
A third case series involved two COVID-19 patients with vascular abnormalities, heart dysfunction, gastrointestinal signs and symptoms, and a rash. One, who had an underlying illness, died within hours of seeking care; the other recovered.
Importance of antibody tests
The authors said the findings show that adults of all ages with current or previous COVID-19 infection can develop MIS-A. What distinguishes this subset of patients from other coronavirus patients with hyperinflammation and multi-organ dysfunction is that they did not have severe symptoms such as respiratory failure.
While the cause of MIS-A and MIS-C is unknown, the authors noted that 8 of the 27 adults in the study (30%) and 45% of 440 children with MIS-C reported to the CDC by February 29. Julio were PCR negative for COVID-19 but antibody test positive, suggesting a post-infectious syndrome or persistent infection outside the upper respiratory tract.
Because eight MIS-A patients reported no prior respiratory symptoms, it was difficult to estimate when they were infected with COVID-19, but those who reported prior coronavirus symptoms developed MIS-A 2 to 5 weeks later.
Clinicians should consider diagnosing MIS-A in adults with associated signs and symptoms, even if they don’t test positive on PCR, and follow up with antibody tests, the researchers said. Laboratory tests to detect markers of inflammation, abnormal clotting, and organ damage may also be indicated.
“As with children, it is important that multidisciplinary care is considered to ensure optimal treatment,” the authors wrote. “In the process of learning more from MIS-A cases, it may be necessary to revise the working case definition to conduct a systematic case call. More research is needed to understand the pathogenesis and long-term effects of this newly described condition.. “
