Case Series of Multisystem Inflammatory Syndrome in Adults Associated With SARS-CoV-2 Infection

United Kingdom and United States, March-August 2020

Sapna Bamrah Morris, MD; Noah G. Schwartz, MD; Pragna Patel, MD; Lilian Abbo, MD; Laura Beauchamps, MD; Shuba Balan, MD; Ellen H. Lee, MD; Rachel Paneth-Pollak, MD; Anita Geevarughese, MD; Maura K. Lash, MPH; Marie S. Dorsinville, MPH; Vennus Ballen, MD; Daniel P. Eiras, MD; Christopher Newton-Cheh, MD; Emer Smith, MPH; Sara Robinson, MPH; Patricia Stogsdill, MD; Sarah Lim, MBBCh; Sharon E. Fox, MD, PhD; Gillian Richardson, MPH; Julie Hand, MSPH; Nora T. Oliver, MD; Aaron Kofman, MD; Bobbi Bryant, MPH; Zachary Ende, PhD; Deblina Datta, MD; Ermias Belay, MD; Shana Godfred-Cato, DO

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(49):1450-1456. 

In This Article

Abstract and Introduction

Introduction

During the course of the coronavirus disease 2019 (COVID-19) pandemic, reports of a new multisystem inflammatory syndrome in children (MIS-C) have been increasing in Europe and the United States.[1–3] Clinical features in children have varied but predominantly include shock, cardiac dysfunction, abdominal pain, and elevated inflammatory markers, including C-reactive protein (CRP), ferritin, D-dimer, and interleukin-6.[1] Since June 2020, several case reports have described a similar syndrome in adults; this review describes in detail nine patients reported to CDC, seven from published case reports, and summarizes the findings in 11 patients described in three case series in peer-reviewed journals.[4–6] These 27 patients had cardiovascular, gastrointestinal, dermatologic, and neurologic symptoms without severe respiratory illness and concurrently received positive test results for SARS-CoV-2, the virus that causes COVID-19, by polymerase chain reaction (PCR) or antibody assays indicating recent infection. Reports of these patients highlight the recognition of an illness referred to here as multisystem inflammatory syndrome in adults (MIS-A), the heterogeneity of clinical signs and symptoms, and the role for antibody testing in identifying similar cases among adults. Clinicians and health departments should consider MIS-A in adults with compatible signs and symptoms. These patients might not have positive SARS-CoV-2 PCR or antigen test results, and antibody testing might be needed to confirm previous SARS-CoV-2 infection. Because of the temporal association between MIS-A and SARS-CoV-2 infections, interventions that prevent COVID-19 might prevent MIS-A. Further research is needed to understand the pathogenesis and long-term effects of this newly described condition.

Potential MIS-A patients were identified from several sources: reports from clinicians and health departments, published case reports, and published case series. Clinicians and health departments in the United States voluntarily reported adult patients with suspected MIS-A to CDC using the case report form* developed for MIS-C after a Health Advisory was published on May 14, 2020, calling for reporting of MIS-C cases. The case report form included information on patient demographics, underlying medical conditions, clinical findings, complications, laboratory test results including those from SARS-CoV-2 testing, imaging findings, treatments, and outcomes. Two clinician reviewers selected patients who fulfilled the working MIS-A case definition used in this report, which included the following five criteria: 1) a severe illness requiring hospitalization in a person aged ≥21 years; 2) a positive test result for current or previous SARS-CoV-2 infection (nucleic acid, antigen, or antibody) during admission or in the previous 12 weeks; 3) severe dysfunction of one or more extrapulmonary organ systems (e.g., hypotension or shock, cardiac dysfunction, arterial or venous thrombosis or thromboembolism, or acute liver injury); 4) laboratory evidence of severe inflammation (e.g., elevated CRP, ferritin, D-dimer, or interleukin-6); and 5) absence of severe respiratory illness (to exclude patients in which inflammation and organ dysfunction might be attributable simply to tissue hypoxia). Patients with mild respiratory symptoms who met these criteria were included. Patients were excluded if alternative diagnoses such as bacterial sepsis were identified.

To identify potential published cases, a literature search was performed on August 20, 2020, and 355 publications were identified. Abstracts were screened by one reviewer to determine whether cases met the working MIS-A case definition; when no abstract was available, the full paper was examined. The references were reviewed to identify additional relevant articles. Data were obtained from published reports; authors were contacted to confirm published data and, when necessary, to provide data not included in the original articles.

*Multisystem Inflammatory Syndrome Associated with COVID-19 Case Report Form. https://www.cdc.gov/mis-c/pdfs/hcp/mis-c-form-fillable.pdf.
Medline (OVID), Embase (OVID), CINAHL (EBSCOHost) and Cochrane Library were searched as primary sources, which were supplemented with searches in the following databases: Global Health, CAB abstracts, PsycInfo, Scopus, PubMed Central, Global Index Medicus, and several preprint databases. Each database was searched using the following terms: novel coronavirus/COVID-19 (multiple iterations) and severe inflammation/multisystem, cardiogenic shock/Kawasaki disease, and adult.

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