(18 - Saturday) Severe acute mitral valve regurgitation in a pediatric patient with Multisystem Inflammatory Syndrome Associated with COVID-19 Infection: a case report.

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Abstract: Introduction
Pediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS-TS), which is also referred to as multisystem inflammatory syndrome in children (MIS-C) in the literature is a new disease entity evolved during the COVID-19 pandemic. Cardiac involvement may include rhythm disturbance, depressed myocardial function, valvar regurgitation, and coronary artery inflammation. The pathophysiological mechanisms underlying acute myocardial injury are not well understood. Theories on endothelial cell infection across vascular beds may explain the broad variety of clinical manifestations of COVID-19. They include hypercoagulability, cytokine storm, stroke, myocarditis, acute renal failure, and chilblains (COVID-19 toes) among others. Treatment involves intravenous immunoglobulins (IVIG), systemic corticosteroids, acetylsalicic acid and in severe cases immunomodulatory treatment (biologic drugs).
Case Description
We describe the case of a 9-year- old girl with a history of documented COVID-19 infection with mild symptoms 1 month prior to presentation. Routine checkup revealed a heart murmur, she was referred to the pediatric cardiology who found mild mitral regurgitation. One week later she presented with abdominal pain and vomiting. She was admitted to our emergency department with acute respiratory distress syndrome requiring intubation. On physical examination the patient was febrile (38.3 ◦C) with tachycardia (heart rate 140 beats per minute) and hypotension (blood pressure 84/46 mm Hg), oxygen saturation 99%. She appeared tired and toxic and moderately dehydrated, and progressively became somnolent and lethargic. Transthoracic echocardiogram found severe mitral regurgitation with rupture of the anterior mitral valve leaflet. She initially received two doses of intravenous immunoglobulin (2g/kg each) and methylprednisolone (30mg/kg/dose). On the fifth day of admission the patient underwent emergent surgical mitral valve replacement with a 21-mm Carbomedics mitral valve, she was found to have thickened leaflets and ruptured chordae of the anterior mitral leaflet. Her clinical condition improved after surgery, and she was extubated on hospital day 7. On the twelfth day, she had a sudden deterioration in level of consciousness together with a tonic–clonic seizure. She was intubated. The patient received an additional dose of intravenous immunoglobulin and Tocilizumab was initiated. MRI brain showed bilateral occipital, parietal, frontal cortex and subcortical white matter T2/Fluid-attenuated inversion recovery hyperintensities, suggestive of Posterior reversible encephalopathy syndrome (PRES). The patient improved after management with intravenous antiepileptics and antihypertensive, monitoring of blood pressure. She was successfully discharged home on the forty days of admission.
Discussion
Multisystem inflammatory syndrome is a novel disease in paediatrics linked to SARS-CoV-2 that has high mortality. Cardiac involvement is common in children with MIS associated with the Covid-19 pandemic. Acute mitral regurgitation may radiographically resemble acute respiratory distress syndrome, therefore the differential diagnosis of respiratory failure in COVID-19 infections should include acute mitral valve insufficiency.