Multisystem inflammatory syndrome in an adult with SARS-CoV-2 infection.

A 26-year-old male pharmacist presented with a 5-day history of dry cough, myalgia, diarrhoea, vomiting, fever, and abdominal pain following exposure to COVID-19. SARS-CoV-2 polymerase chain reaction (PCR) tests were negative but SARS-CoV-2 IgG/IgM was positive. Computed tomography (CT) showed bilateral pulmonary basal ground-glass changes and bowel oedema (Panels A and B). No coronary aneurysms were seen. The patient was hypotensive and hypoxic. He required vasopressor therapy, high-dose aspirin, and broad-spectrum antibiotics in intensive care and recovered over 10 days. Immunomodulatory therapy was not given due to the good response to aspirin.

Blood tests showed lymphopenia (0.64 × 109/L), C-reactive protein (CRP) 419 mg/L, ferritin 3275 μg/L (<322 μg/L), procalcitonin 164 μg/L (<50 μg/L), troponin I 2030 ng/L (<57 ng/L), and D-dimer 2722 ng/mL (<220 ng/mL). Initial transthoracic echocardiography demonstrated severe left ventricular (LV) systolic dysfunction with pericardial effusion (Supplementary material online, ). Repeat echocardiography showed improving LV function. Cardiac magnetic resonance (CMR) imaging on day 9 showed normal biventricular systolic function, reduced LV and right ventricular (RV) peak global circumferential strain (–13.3% and –10.3%, respectively), and reduced global longitudinal strain (–14.5% and –14.2%, respectively), elevated native T1 (1305 ms, normal range 1015–1125 ms, Panel C), and focal mid-inferior and apical–lateral mid-wall late gadolinium enhancement (Panels D and E).

A diagnosis of multisystem inflammatory syndrome temporally associated with SARS-CoV-2 was made. This condition has been described in children, but not yet in adults. The patient described here showed no mucocutaneous signs and did not require immunomodulating therapy. CMR showed evidence of myocardial oedema as anticipated, but unexpectedly showed findings commonly associated with viral myocarditis.

Panels A and B: CT of the abdomen demonstrating mesenteric lymphadenopathy and small bowel oedema, respectively. Panel C: diffusely elevated T1 value on mid-ventricular CMR T1 map. Panel D: apical short axis slice on CMR showing lateral mid-wall fibrosis. Panel E: vertical long axis slice on CMR demonstrating mid-inferior mid-wall fibrosis.

Supplementary material

Supplementary material is available at European Heart Journal – Cardiovascular Imaging online.

Conflict of interest: none declared.

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