Nurse Practitioner Baylor College of Medicine/Texas Children's Hospital Houston, Texas, United States
Abstract:
Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a hyperinflammatory response observed in children following acute SARS-CoV-2 infection One of the most severe complications of MIS-C is limb ischemia due to thromboembolism. In this case series we present two patients with MIS-C and limb ischemia requiring amputation. Case 1: A previously healthy15-year-old female presented with a 1-week history of fever and diarrhea. SARS-CoV-2 PCR was negative but antibodies were positive. On admission she had elevated inflammatory markers. Due to severely diminished cardiac output she was placed on VA ECMO. She remained on therapeutic bivalirudin for coagulation. Despite anakinra and steroids she continued to have elevated inflammatory markers. On day 7 her CK was noted to be 30,635 and she began to complain of right calf pain. A full body CT showed no thrombi. Given elevated compartment pressures emergent right leg fasciotomies were performed. Repeat wound debridement procedures showed evidence of worsening muscle architecture. 4 days after the initial procedure there was extensive non-survivable muscle of the right lower extremity requiring an above the knee amputation. Following amputation inflammatory markers all improved and over the next 2 months the patient returned to baseline cardiac and renal function. Case 2: A previously healthy 13-year-old male presented with bilateral lower extremity weakness. SARS-CoV-2 was negative but antibodies were positive. On admission bilateral lower extremities were noted to be pulseless and he had elevated inflammatory markers. A CTA showed a large saddle thrombus at aortoiliac bifurcation with extension through multiple arteries of the right leg, and non-occlusive arterial thrombus of the left leg. Echo showed mildly decreased biventricular function with thrombus in the LV. He was taken emergently for aortic thrombectomy, LV thrombus evacuation, bilateral iliac thrombectomy with right lower extremity thrombectomy and right leg fasciotomies. Bilateral muscle necrosis was noted during surgery. Immediately he was started on therapeutic bivalrudin for anticoagulation and steroids. By day 7 of hospitalization he had right leg necrosis with sepsis requiring an above the knee amputation. And by day 10 he required left leg below the knee amputation due to left leg necrosis. Within 1 day of amputation his CK level was detectable again and inflammatory markers were downtrending. Discussion & Implications: Although these cases represent extreme MIS-C complications, thromboembolism rates are higher in MIS-C than acute covid infections in children. Furthermore our experience shows that thromboembolism can occur despite therapeutic anticoagulation. Micro and macro vascular changes including impaired fibrinolysis can be seen with MIS-C and may result in muscle necrosis even after surgical embolectomy with need for amputation. Our overall takeaway is even on therapeutic anticoagulation we as providers must be on high alert for subtle clinical and laboratory findings suggestive of thrombosis as muscle necrosis necessitating amputation can occur quickly in patients with MIS-C.
