MIS in Children After SARS-CoV-2 Vaccination

Abstract and Introduction

Abstract

Multisystem inflammatory syndrome in children (MIS-C) is a hyperinflammatory state that occurs after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We present 2 cases of MIS-C after SARS-CoV-2 vaccination; 1 patient had evidence of recent SARS-CoV-2 infection. Our findings suggest that vaccination modulates the pathogenesis of MIS-C.

Introduction

Multisystem inflammatory syndrome in children (MIS-C) was first described in 2020 during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.^[1] MIS-C is a systemic hyperinflammatory state necessitating hospitalization in patients <21 years of age who experienced ≥24 hours of fever, recent SARS-CoV-2 exposure or positive testing, involvement of ≥2 organ systems, and ≥1 of the following laboratory results: elevated C-reactive protein (CRP), erythrocyte sedimentation rate, fibrinogen, procalcitonin, D-dimer, ferritin, lactate dehydrogenase, interleukin-6, neutrophils, reduced lymphocytes, or reduced albumin.^[2] It is unknown whether vaccination can precipitate or abrogate MIS-C and whether natural infection preceding or at the time of vaccination plays a role.^[1] We describe MIS-C in 2 adolescents recently vaccinated with BNT162b2 (Pfizer-BioNTech, https://www.pfizer.com) and raise the possibility of vaccination modulating MIS-C pathogenesis.

Table. Data for 2 adolescent patients experiencing multisystem inflammatory syndrome after initial dose of BNT162b2 vaccination against severe acute respiratory syndrome coronavirus 2, United States*
Data	Patient 1	Patient 2
Age, y/sex	15/F	17/F
Underlying conditions	Asthma, seasonal allergies	None
Time since BNT162b2 dose, d	6	7
Initial symptoms	102°F fever, headache, nonbilious emesis, myalgias, chest pain, diffuse blanching rash	103.1°F fever, headache, abdominal tenderness, fatigue, myalgias, and costovertebral angle tenderness
Initial vital signs	Blood pressure 115/56 mm Hg, pulse 105 beats/min, temperature 100.4°F, respiratory rate 20 breaths/min, oxygen saturation 100%, weight 60.8 kg	Blood pressure 104/59 mm Hg, pulse 124 beats/min, temperature 103.1°F, respiratory rate 18 breaths/min, oxygen saturation 99%, weight 58 kg
Laboratory test results (reference range)
Leukocytes, K/μL (4.2–9.4)	17	21.1
% PMNs (39–74)	91	90
% Lymphocytes (18–50)	3	5
CRP, mg/dL (0–0.60)	15.1	36.7
ESR, mm/H (0–15)	13	83
LDH, U/, sL (130–230)	176	326
Fibrinogen, mg/dL (200–475)	516	>800
Prothrombin time, s (9–11.1)	11.4	11.3
BNP, pg/mL (<125)	169	560
Troponin, ng/mL (<0.05)	<0.05	0.18
D-dimer, mg/L (0–0.65)	2.84	2.58
Creatinine, mg/dL (0.3–1.10)	0.92	1.39
AST U/L (15–37)	16	71
ALT, U/L (12–78)	22	73
Alkaline phosphate, U/L (40–120)	73	258
Additional work-up
Urinalysis	Trace protein, large blood, moderate leukocyte esterase, 10–20 leukocytes, 1+ bacteria	100 mg/dL of protein, moderate blood, moderate leukocyte esterase, 10–20 leukocytes, 5–10 red blood cells, no bacteria
Urine culture	Not performed	10,000 CFUs Escherichia coli
Blood culture	Not performed	Negative
Chest radiograph	No abnormal findings	No abnormal findings
Chest CT	No abnormal findings	Not performed
Electrocardiogram	No abnormal findings	Sinus tachycardia, nonspecific T-wave abnormalities
Echocardiogram	No abnormal findings	No abnormal findings
Abdomen/pelvis CT	Not performed	Diffuse left renal enlargement, possible polycystic ovaries
COVID-19 labs
Nasopharyngeal RT-PCR	Negative	Negative
Spike antibody	Negative	Positive
Nucleocapsid antibody	Positive	Not performed
PICU admission	Yes	No
Treatment	2 g/kg IVIG	2 g/kg IVIG for 1 d, 30 mg IV methylprednisolone 2×/d for 3 d to continue at home orally for 2 d then 2–3 wk steroid taper, 325 mg aspirin reduced to 81 mg on day 3, cefdinir 7 d course
Length of hospital stay	1 d	3 d

Table. Data for 2 adolescent patients experiencing multisystem inflammatory syndrome after initial dose of BNT162b2 vaccination against severe acute respiratory syndrome coronavirus 2, United States*

Data

Patient 1

Patient 2

Age, y/sex

15/F

17/F

Underlying conditions

Asthma, seasonal allergies

None

Time since BNT162b2 dose, d

Initial symptoms

102°F fever, headache, nonbilious emesis, myalgias, chest pain, diffuse blanching rash

103.1°F fever, headache, abdominal tenderness, fatigue, myalgias, and costovertebral angle tenderness

Initial vital signs

Blood pressure 115/56 mm Hg, pulse 105 beats/min, temperature 100.4°F, respiratory rate 20 breaths/min, oxygen saturation 100%, weight 60.8 kg

Blood pressure 104/59 mm Hg, pulse 124 beats/min, temperature 103.1°F, respiratory rate 18 breaths/min, oxygen saturation 99%, weight 58 kg

Laboratory test results (reference range)

Leukocytes, K/μL (4.2–9.4)

21.1

% PMNs (39–74)

% Lymphocytes (18–50)

CRP, mg/dL (0–0.60)

15.1

36.7

ESR, mm/H (0–15)

LDH, U/, sL (130–230)

176

326

Fibrinogen, mg/dL (200–475)

516

>800

Prothrombin time, s (9–11.1)

11.4

11.3

BNP, pg/mL (<125)

169

560

Troponin, ng/mL (<0.05)

<0.05

0.18

D-dimer, mg/L (0–0.65)

2.84

2.58

Creatinine, mg/dL (0.3–1.10)

0.92

1.39

AST U/L (15–37)

ALT, U/L (12–78)

Alkaline phosphate, U/L (40–120)

258

Additional work-up

Urinalysis

Trace protein, large blood, moderate leukocyte esterase, 10–20 leukocytes, 1+ bacteria

100 mg/dL of protein, moderate blood, moderate leukocyte esterase, 10–20 leukocytes, 5–10 red blood cells, no bacteria

Urine culture

Not performed

10,000 CFUs Escherichia coli

Blood culture

Not performed

Negative

Chest radiograph

No abnormal findings

Chest CT

No abnormal findings

Not performed

Electrocardiogram

No abnormal findings

Sinus tachycardia, nonspecific T-wave abnormalities

Echocardiogram

No abnormal findings

Abdomen/pelvis CT

Not performed

Diffuse left renal enlargement, possible polycystic ovaries

COVID-19 labs

Nasopharyngeal RT-PCR

Negative

Spike antibody

Negative

Positive

Nucleocapsid antibody

Positive

Not performed

PICU admission

Yes

Treatment

2 g/kg IVIG

2 g/kg IVIG for 1 d, 30 mg IV methylprednisolone 2×/d for 3 d to continue at home orally for 2 d then 2–3 wk steroid taper, 325 mg aspirin reduced to 81 mg on day 3, cefdinir 7 d course

Length of hospital stay

1 d

3 d