Alexandra Lauren Solomon1, Sali Merjanah2, Salah Abdelgadir3, Meena Bolourchi4. 1. Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, 72 E. Concord St. Boston, MA 02118, USA. 2. Department of Medicine, Section of Rheumatology, Boston University School of Medicine, 72 E. Concord St. Boston, MA 02118, USA. 3. Department of Medicine, Section of Infectious Disease, Boston Medical Center, Boston University School of Medicine, 72 E. Concord St. Boston, MA 02118, USA. 4. Department of Pediatrics, Section of Pediatric Cardiology, Boston Medical Center, Boston University School of Medicine, 850 Harrison Ave, Boston, MA 02118, USA.
A previously healthy, 25-year-old gentleman presented for 3 days of fever, headache, nausea/vomiting, and rash following travel.Vitals notable for: temperature 39.2°C, heart rate 128 b.p.m., blood pressure 130/80 mmHg. Examination revealed cervical lymphadenopathy and a pruritic, macular truncal rash (Panel A: truncal rash). Platelet count 139 (150–450k/µL), absolute lymphocyte count 0.9 (1.1–3.5 k/µL), creatinine 1.1 (0.7–1.3 mg/dL), alanine transaminase 39 (9–67 U/L), albumin 3.9 (3.5–5.0 g/dL), erythrocyte sedimentation rate >130 (0–5 mm/h), C-reactive protein 220 (0–15 mg/L), ferritin 3815 (26–209 ng/mL), D-dimer 732 (<243 ng/mL DDU), procalcitonin 2.87 (<0.50 ng/mL), and interleukin-6 171.5 (2.5–7 pg/mL). Comprehensive autoimmune, oncologic, and infectious work-up were unrevealing (see Supplementary material online, ), aside from a positive SARS-CoV-2 anti-N IgG/IgM (indicating recent exposure). The patient denied known SARS-CoV-2 infection and received the Janssen Ad26.CoV2.S vaccine.Hospitalization was complicated by persistent fever (Tmax40.7°C), tachycardia, hypotension, and supplemental oxygen requirement. Left-sided facial droop occurred with hypotension; computed tomography angiogram showed a 1.5 mm left internal carotid artery aneurysm (Panel B, red arrow tip).On hospital day 2, strawberry tongue, injected conjunctiva, and faint rash of palms and soles appeared, meeting full Kawasaki Disease (KD) criteria.[1] Cardiac evaluation was pursued: electrocardiogram was unremarkable; BNP 1788 (0–33.3 pg/mL); troponin peak 2.6 (<0.033 ng/mL); and transthoracic echocardiogram (TTE) showed left ventricular ejection fraction (LVEF) 35% with global hypokinesis (see Supplementary material online, video) and small aneurysms of left main and proximal left anterior descending (LAD) coronary arteries (Panel C: left main aneurysm, Panel E: LAD aneurysm).Criteria were also met for MIS-A,[2] which exists with KD on the spectrum of inflammatory diseases associated with SARS-CoV-2 infection[3] (see Supplementary material online, ). Given this differential, the patient was treated with intravenous immunoglobulin (1 g/kg/dose for two doses), medium-dose aspirin (800 mg four times per day), methylprednisolone (1–2 mg/kg/day), and lisinopril with dramatic improvement and sustained normothermia. He was discharged on hospital day 10 on lisinopril, low-dose aspirin, and a prednisone taper.One week post-treatment, outpatient TTE demonstrated resolution of coronary artery aneurysms and LVEF recovery (Panel D: resolved left main aneurysm, Panel F: resolved LAD aneurysm). At 6-week follow-up, lisinopril and aspirin were discontinued given normal TTE. At 6-month follow-up, TTE remained stable.
Supplementary material
Supplementary material is available at European Heart Journal – Case Reports online.Click here for additional data file.