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Case of the Month - October 2020

What is the differential diagnosis?
Differential diagnosis

  • Viral exanthema (Measles, Adenovirus, EBV, Coxsackievirus)
  • Sepsis
  • Kawasaki disease
  • Multi-inflammatory syndrome in children associated with COVID 19 (MIS-C)

Management and progress
The patient was initially investigated for sepsis and viral infections. He commenced on Ceftriaxone and Clindamycin to cover for bacterial sepsis. Given the inadequate response to antibiotics and paracetamol and the evolving clinical picture with worsening mucosal involvement, Kawasaki and MIS-C were thought to be the likely diagnosis.

Mention investigations that would support the diagnosis of MIS-C?
Further workup for hyper inflammation was in keeping with MIS-C. Intravenous immunoglobulin (IVIG) was given at a dose of 1g/kg a day two days after admission and repeated on Day 3. The ECG showed tachycardia without features of myocarditis, and a normal cardiac echocardiogram. His cardiovascular status remained normal. Given the persistent fever, pulsed Methylprednisolone at 10mg/kg was commenced intravenously, which was weaned slowly when the patient started improving clinically. Proton pump inhibitor for gastric protection was commenced, and Heparin at an infusion rate of 10 iu/kg/hr was initiated based on a thromboelastogram and D-dimer in keeping with a hypercoagulable state. Heparin was substituted with low dose aspirin on Day 7. Blood cultures were negative. Urine had protein 2+ and leucocytes 3+ but no growth in the absence of antimicrobials. Viral studies, including measles, were negative. Defervescence was only noted on Day 7 of admission, and the patient was changed to oral prednisone. Inflammatory markers normalised by Day 11 of admission. Antibiotics were stopped by Day 10 though no cultures were positive. The stomatitis and oedema also resolved by Day 11. Abdominal pain and discomfort settled with inflammatory markers though ascites took a week longer to resolve. The patient was subsequently weaned off prednisone over two weeks. Final Diagnosis was MIS-C with a Kawasaki like phenotype. The patient was discharged a week later.

Final Diagnosis
Multi-inflammatory syndrome in children associated with COVID-19

Table 1. Laboratory investigations and management

Additional investigations

CXR Normal
ECG No myocarditis
Cardiac ECHO No coronary artery involvement
Ultrasound abdomen Ascites
Thromboelastogram Hypercoagulable state
Urine MCS No growth
Blood culture No growth
Viruses (Adeno, EBV, HSV, Measles) Negative