Multisystemic Inflammatory Syndrome in Children in a Pregnant Pediatric Patient

Introduction: Multisystemic inflammatory syndrome in children (MIS-C) is a rare complication of infection by SARS-CoV-19 thought to be due to hyperinflammation adversely affecting multiple organ systems. Most commonly, the gastrointestinal, cardiovascular, hematologic, respiratory and integumentary systems are affected. Patients presenting with this syndrome often require hospitalization given the potential for rapid deterioration. We present a case of MIS-C and associated shock in a pregnant pediatric patient requiring ICU level care.

Case Description: A 16-year-old G1P0 female presented to the ED at 25 weeks gestation with complaints of fever, headache, myalgias, cough and congestion. She denied prior COVID-19 exposure and vaccination, and COVID-19 PCR testing returned negative. She was diagnosed with a viral syndrome. She further reported decreased fetal movement. OB performed a biophysical profile that was overall reassuring, and she was discharged. Due to persistent symptoms and new onset chest pain and dyspnea, she returned to the ED six days after her initial presentation. Bedside ultrasound demonstrated fetal tachycardia. Laboratory work up revealed leukocytosis, anemia, hyponatremia and hypokalemia with markedly elevated inflammatory markers concerning for MIS-C. She was treated empirically with ceftriaxone and vancomycin. She developed fluid refractory shock and ultimately required vasoactive support with norepinephrine necessitating admission to the PICU with OB consultation. Infectious evaluation including respiratory viral panel with COVID-19 PCR and blood and urine cultures were negative. SARS-CoV-2 IgG antibody returned positive, confirming the diagnosis of MIS-C associated with COVID-19. She was treated with IVIG and corticosteroids resulting in quick resolution of her shock and clinical improvement with down trending inflammatory markers. Continuous fetal monitors demonstrated normalization of fetal heart rate. She was transferred to the high risk OB floor on hospital day 3. During her stay, she developed a mild transaminitis thought to be associated with MIS-C given her otherwise negative workup. She was discharged home on hospital day 12 on a prednisone taper and oral iron.

Discussion: Pregnancy complications associated with COVID-19 are still not well understood, but include preeclampsia, intrauterine growth restriction and premature birth. Although rare, cases of vertical transmission and fetal demise have been reported, as well. Given the profound effects that both pregnancy and MIS-C have on the body, understanding the potential risks of MIS-C in pregnancy is imperative to ensure favorable outcomes. Our current understanding of the effects of maternal MIS-C on a fetus can only be extrapolated from studies on adult women infected during pregnancy and a single reported case of MIS-A in a pregnant adult.

Conclusion: We report a case of a pregnant pediatric patient who presented to the ED with shock secondary to MIS-C and associated fetal tachycardia that was successfully treated with vasopressors, IVIG and steroids to enhance knowledge for this presentation and treatment of this condition in a vulnerable population.