Presentation
Patient's family members tested positive for COVID-19 six weeks prior (patient was not tested). Mild abdominal pain in last few days. Now presents to tertiary pediatric hospital for severe diffuse abdominal pain, vomiting, hypotension and tachycardia. Noted to have lip and eye erythema.
Patient Data
US in emergency department...
US in emergency department "shock room"
First two images show inflammatory fat in right lower quadrant with significantly enlarged lymph nodes. Third image shows mild periportal edema.
Chest X-ray on admission
Normal chest X-ray.
Abdo CT at D1 after admission
Markedly enlarged lymph nodes in the right iliac fossa mesentery with surrounding fat stranding, larger than expected for the relatively mild short-segment thickening of the terminal ileum. No clear signs of appendicitis. Mild free intra- and retro-peritoneal free fluid.
Chest X-ray 2 days later
New moderate pulmonary edema.
Chest X-ray 5 days later
X-ray in seated position. Resolved pulmonary edema. Right PICC.
Case Discussion
Overweight 7-year-old male patient with no significant prior medical history presented to tertiary pediatric center emergency department with severe diffuse abdominal pain, vomiting and signs of shock. His family had tested positive for COVID-19 six weeks prior, but he hadn't been tested. He was initially clinically suspected to have septic shock and treated with antibiotics, but extensive viral and bacterial work-up revealed no pathogen.
Inflammatory markers were highly elevated, with white blood cell count up to 49 x 10^9/L, ferritin up to 3925 mcg/L and CRP up to 241 mg/L. He had moderate to severe anemia and thrombocytopenia on admission, attributed to inflammatory status since the rest of the workup was negative. Liver and pancreatic enzymes were also elevated. Patient developed acute kidney injury and pulmonary edema. Three echocardiograms were normal.
After a 4-day course in the pediatric intensive care unit receiving intravenous immunoglobulins and corticosteroids, patient improved rapidly on a clinical, laboratory and imaging basis. There were no clinical criteria for Kawasaki disease or signs of an infectious cause. Final diagnosis by multidisciplinary consensus was pediatric inflammatory multisystem syndrome (PIMS) / multisystem inflammatory syndrome in children (MIS-C). Patient was subsequently discharged with planned follow-up by pediatric immunology team.
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