What’s Your Diagnosis? COVID-19, MIS-C, and Long COVID in Pediatric Patients

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Acute Epistaxis: A Comprehensive Overview in the Acute Care Setting right.

Case Presentation: COVID-19, MIS-C, and Long COVID in Pediatric Patients: An Update  

A 14-year-old boy with no pre-existing medical conditions presents with fever, diarrhea, and abdominal pain for 4 days…

• A diffuse maculopapular rash started 2 days ago, and bilateral eye redness started today. The boy is reporting weakness and looks mildly dehydrated
• The boy’s vital signs are: temperature, 38.6°C; heart rate, 134 beats/min; blood pressure, 100/45 mm Hg; respiratory rate, 20 breaths/min; and pulse oximetry, 98%. He has not traveled out of the country. He reports a diagnosis of COVID-19 3.5 weeks ago, along with other members of his family.
• What is your initial management of this patient? Is the COVID-19 history relevant?

Case Conclusion
Based on this patient’s vital signs, a sepsis huddle was triggered. The tachycardia was concerning to the team, but the attending was concerned about the widened pulse pressure as well. The patient was immediately placed into a room, and laboratory studies were drawn. The attending stated that bacteremia was certainly on the differential, so IV antibiotics were ordered as well as a rapid 2-mL/kg normal saline IV bolus to be given over 10 minutes. The team also raised the concern for MIS-C, considering the patient was 3 to 4 weeks post–COVID-19. Tier 1 laboratory studies (CBC and CRP) were ordered.

Before the patient’s laboratory results came back, but after he received the first IV fluid bolus, his blood pressure was 84/39 mm Hg. At this point, he looked fatigued and was tachypneic to 30 breaths/min. The patient was given another IV normal saline bolus of 20 mL/kg, but with blood pressures this low, he was started on a norepinephrine infusion, and a call was made to the PICU for admission. A point-of-care ultrasound cardiac examination was performed, and there was no pericardial effusion, and the cardiac squeeze seemed normal. The laboratory studies returned with a normal CBC, except for a low absolute lymphocyte count of 800 cells/mcL and a CRP of 210 mg/L.

Tier 2 laboratory studies were sent because your concern for MIS-C was now extremely high. The results of the CMP were a sodium of 132 mmol/L, BUN of 53 mg/dL, creatinine of 5.1 mg/dL, and high normal LFTs (ALT- 48 U/L, AST-53 U/L).The pro-BNP came back at an astonishing 10,020 pg/mL, but the troponins were normal. Procalcitonin was elevated to 12 mcg/L.

With the diagnosis of MIS-C nearly certain at this point (awaiting blood culture results), you added IV dexamethasone and ordered IVIG. Two days later, after being on norepinephrine for 22 hours, and dramatically improved laboratory results, the patient was transferred to the floor. He was ultimately discharged 2 days later with no symptoms and no laboratory defects. 

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Last Updated on September 10, 2024