SARS-CoV-2 causes inflammatory syndrome in adults that resembles MIS-C
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Multisystem inflammatory syndrome, a severe complication of SARS-CoV-2 infection seen predominantly in children, has been identified in adults and often has fatal outcomes, according to a new report in MMWR.
Researchers said case findings suggest that adult patients with a previous or current SARS-CoV-2 infection can potentially develop a hyperinflammatory syndrome similar to multisystem inflammatory syndrome in children (MIS-C). The authors of the MMWR report called the adult condition MIS-A.
“Clinical suspicion and indicated SARS-CoV-2 testing, including antibody testing, might be needed to recognize and treat adults with MIS-A,” Sapna Bamrah Morris, MD, of the CDC’s COVID-19 response team, and colleagues wrote. “Further research is needed to understand the pathogenesis and long-term effects of this condition. Ultimately, the recognition of MIS-A reinforces the need for prevention efforts to limit spread of SARS-CoV-2.”
Morris and colleagues examined case data related to 27 patients who had gastrointestinal, dermatologic and neurologic symptoms without the presence of severe respiratory illness and who had a positive SARS-CoV-2 test — traits indicative of MIS-A. They excluded patients that had alternative diagnoses, such as bacterial sepsis, that could account for their symptoms. Of the cases, seven were from case reports, nine were reported to CDC and 11 were pulled from findings in peer-reviewed journals.
The researchers wrote that the patients included had “minimal respiratory symptoms, hypoxemia or radiologic abnormalities” and that only eight patients had respiratory symptoms before MIS-A onset.
“As with children, it is important that multidisciplinary care be considered to ensure optimal treatment,” the authors wrote. “In the process of learning more from MIS-A cases, the working case definition might need to be revised in order to systematically conduct a call for cases.”
Perspective
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David Cennimo, MD
I am reminded of a patient who was recently presented in our department of medicine's clinical case conference who had what was termed a severe COVID-19 infection. I remarked, at that time, that if this were a child, we would be calling the presentation MIS-C and speculated that there will be cases of adults with the syndrome. We did not write up this case as far as I know.
This is a very timely report and draws attention to the possibility of adults of a wide range of ages experiencing a hyperinflammatory syndrome associated with COVID-19. It is difficult to generalize too much because this is a convenience sample, but men and women aged 21 to 50 years were similarly infected. We must also recognize this disproportionate burden of COVID-19 on communities of color. All but one of the patients in this series were members of minority groups. The level of inflammation as evidenced by labs (CRP, ferritin, etc.) and organ dysfunction is striking and on par with reports of MIS-C. The authors excluded patients with significant respiratory compromise, so these effects are not attributable to hypoxia and seem distinct from a "bad case of COVID-19." The fact that all patients had evidence of cardiac involvement should be a notice to clinicians to be wary of this potentially life-threatening complication.
I hope that this report spurs others to publish case series to better delineate MIS-A. The overlap of MIS-C and MIS-A should afford us the opportunity to research the cause (or causes) of this hyperinflammatory response and better delineate treatments. In this series, intravenous immunoglobulin, steroids and tocilizumab were all used to varying degrees, reflecting the currently available evidence for COVID-19 treatment.
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