Fatal SARS-CoV-2 Inflammatory Syndrome and Myocarditis in an Adolescent: A Case Report

Abstract

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), an entity in children initially characterized by milder case presentations and better prognoses as compared with adults. Recent reports, however, raise concern for a new hyperinflammatory entity in a subset of pediatric COVID-19 patients.

Methods: We report a fatal case of confirmed COVID-19 with hyperinflammatory features concerning for both multi-inflammatory syndrome in children (MIS-C) and primary COVID-19.

Results: This case highlights the ambiguity in distinguishing between these two entities in a subset of pediatric patients with COVID-19-related disease and the rapid decompensation these patients may experience.

Conclusions: Appropriate clinical suspicion is necessary for both acute disease and MIS-C. SARS-CoV-2 serologic tests obtained early in the diagnostic process may help to narrow down the differential but does not distinguish between acute COVID-19 and MIS-C. Better understanding of the hyperinflammatory changes associated with MIS-C and acute COVID-19 in children will help delineate the roles for therapies, particularly if there is a hybrid phenotype occurring in adolescents.

FIGURE 1.

Imaging at hospital admission (A and B) and at PICU admission (C and D). Axial chest CT showed normal lungs (A) with coronal IV contrast-enhanced abdominal CT (B) showing enlarged mesenteric and retroperitoneal nodes (arrows) and normal bowel. On HD 4, repeat chest CT (C) showed bilateral lower lobe consolidation without pulmonary embolism and coronal IV contrast-enhanced abdominal CT (D) demonstrated new wall thickening of the distal transverse colon, gallbladder wall edema and mesenteric stranding (arrows). Both chest and abdominal CT at that time showed prominent diffuse supraclavicular, hilar, mediastinal, abdominal and retroperitoneal lymphadenopathy (C and D). PICU, pediatric intensive care unit.

FIGURE 2.

Biventricular cross-section of heart (A) with areas of pallor. Cardiac myocytes with interstitial lymphoplasmacytic infiltrate (B, H&E stain, 100x). Mixed inflammation surrounding and involving a cardiac vessel (C, H&E stain, 100x). Focal area of myocyte damage in the right ventricle (D, H&E stain, 100x).