Multisystem inflammatory syndrome with particular cutaneous lesions related to COVID 19 in a young adult

Abstract

To the Editor: A previously healthy 21-year-old Caucasian man was admitted for vasoplegic shock. He denied any drug intake, did not smoke tobacco or use illicit drugs. He presented fever (39°C) with chest tightness, non-bloody watery diarrhea lasting for 7 days and a rash that had developed for 3 days. On clinical examination, he was febrile (40°C), blood pressure was 80/40 mm Hg, respiratory rate 38/mn, and oxygen saturation 97% in ambient air. An asymptomatic rash was present over the trunk and palms, consisting of erythematous round-shapped macules with a darker and raised rim, 1-3 cm in diameter, along with bilateral conjunctivitis (Figure 1 ). The white cell count was 16,000/mm3, with lymphocytes of 900/mm3. C-reactive protein level was of 365 mg/L, procalcitonine 3.4 ng/ml, ferritin 1,282 µg/l (normal<30), lactate 2.4 mmol/l (normal<1.6). Renal and liver function tests were within normal range, troponin level was 550 ng/l (normal<34). Cutaneous biopsy showed a slightly inflammatory infiltrate in upper dermis and direct cutaneous immunofluorescence was negative. Reverse transcription–polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 was negative on nasopharyngeal swab, saliva, stool specimen, and skin biopsy. Extensive infectious enquiry and search for antinuclear antibodies were negative. Electrocardiogram showed diffuse negative T waves, echocardiography displayed hyperkinetic left ventricle with normal ejection fraction, normal right cavities, and dilated noncompressible inferior vena cava. Thoraco-abdominal CT scan did not demonstrate pulmonary embolism or lung infection, but signs of congestive heart failure with bilateral pleural effusion, and wall thickening of the right colon with normal rectosigmoidoscopy. Treatment with volume resuscitation, noradrenaline and antibiotics (ceftriaxone and amikacin), then high flow nasal oxygenation because of respiratory function deterioration. Progressive clinical and biological features normalization, and the patient left the intensive care unit at day 8, while COVID-19 serology returned highly positive with IgG (ELISA SARS-CoV-2 Ig G Euroimmun). At four-weeks follow up he was healthy, heart CT scan and cardiac magnetic resonance imaging were normal with no sign of myocarditis or coronary aneurysms. Figure 1 Annular lesions over the trunk Figure 1 We report here a young adult multisystem inflammatory syndrome (MIS) due to COVID-19 virus who presented with vasoplegic shock and rash. Indeed, severe forms of COVID-19 infections affect mainly old people with underlying conditions. However, severe and systemic infections have been recently reported in children and teenagers close to atypical Kawasaki disease or toxic shock syndrome.1, 2, 3 This syndrome was described initially and termed MIS by Riphagen, 2 in a series of 8 children and teenagers with vasoplegic shock who experienced fever (8/8), rash (4/8), conjunctivitis (4/8), and gastrointestinal symptoms such as non-bloody diarrhea, vomiting and abdominal pain (7/8). None had significant respiratory involvement. One patient had a giant coronary aneurysm, another one died from cerebrovascular infarct. Diagnosis of covid-19 infection relied on RT-PCR testing on bronchoalveolar lavage or nasopharyngeal aspirate (2/8) and serology (8/8). Early treatment with intravenous immunoglobulins was given to all patients, and then 6 of them received aspirin. All children were discharged from the intensive care unit within 4-6 days. Preliminary diagnostic criteria have been subsequently proposed by the WHO in patients under 19 years old. 3 Our patient fulfilled the WHO diagnostic criteria of MIS. However, diagnosis of SARS-CoV2 was established late on the detection of serum SARS-CoV-2 antibodies and therefore no specific treatment was given. Cutaneous lesions associated with COVID-19 are present in up to 20% of patients including maculopapular rash, urticarial lesions, petechiae, and chilblains-like lesions. 4 The annular rash in our patient was particular and diagnosis of erythema multiforma and subacute lupus erythematosus were easily ruled out.