Did we understand the total picture of the COVID-19? Is there something more to unfold in the coming months?
Multisystem inflammatory syndrome in children (MIS-C) is a
newly described condition associated with severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) exposure that is reminiscent of both Kawasaki
disease and toxic shock syndrome. There is recent surge in this disease. It has
prompted us to increase the awareness of MIS-C.
The number of reported cases continues to increase. Kawasaki-like
multisystem inflammatory condition is a possibility in adults. The first case
is reported in USA.
A constellation of signs 1)fever for more than 5 days,
2)erythema multiforme-like rash, 3)bilateral non-exudative conjunctivitis, 4)erythema
or cracking of the lips, 5)unilateral cervical lymphadenopathy measuring more
than 1·5 cm in diameter), the American Heart Association (AHA) criteria for
Kawasaki disease were noted in a man. So, based on these criteria he was
diagnosed with Kawasaki-like multisystem inflammatory syndrome associated with
COVID-19. It
was notable that he did not experience the hypoxic respiratory failure most
frequently associated with moderate to severe COVID-19, despite his abnormal
chest x-ray findings. He exhibited many MIS-C-related features such as a
predominance of gastrointestinal symptoms, generalised extremity pain, and
prominent cardiac dysfunction, and his cardiac findings (elevated cardiac
enzymes and left ventricular hypokinesis with a reduction in ejection fraction)
resemble findings of myocarditis recently described in MIS-C. This patient's
palmar lesions are distinct from the acral erythema and swelling with
subsequent desquamation typically seen in Kawasaki disease, and his diffuse
conjunctivitis was not limbic-sparing. Biochemically, he demonstrated markedly
elevated C-reactive protein, neutrophilia, and lymphopenia, which are more
consistent with MIS-C than with classic Kawasaki disease. Emerging reports
depict the phenotype of MIS-C as a combination of Kawasaki disease, toxic shock
syndrome, and macrophage activation syndrome (or haemophagocytic
lymphohistiocytosis), these are all syndromes of dysregulated immune
responses. Diagnostic distinction from classic Kawasaki disease might have
meaningful implications: whereas treatments targeting IL-6 are currently being
investigated among therapeutic options for COVID-19-associated
hyperinflammation, the IL-6 inhibitor tocilizumab might provoke the development
of coronary artery aneurysms in patients with classic Kawasaki disease. Though this
is a rare presentation of one case in association with COVID19, we should be aware
of such can be associated and we vigilant in the future.
