key: cord-0845990-wu9ozxjz authors: Pandrowala, Ambreen; Panchal, Honey; Mudaliar, Sangeeta; Bodhanwala, Minnie; Prabhu, Shakuntala; Jain, Shreepal; Mishra, Jayashree; Hiwarkar, Prashant title: SARS‐CoV‐2‐related multisystem inflammatory syndrome in an immunocompromised child with leukemia date: 2021-03-04 journal: Pediatr Blood Cancer DOI: 10.1002/pbc.28995 sha: 8158ef561c1a0ccb1191e5479472ca683eda1812 doc_id: 845990 cord_uid: wu9ozxjz nan Her complete blood count showed haemoglobin 8 mg/dl, total white cell count 30,500/mm 3 with absolute neutrophil count 610/mm, 3 68% blasts and platelets 12,000/mm 3 ; procalcitonin was 2.12 mg/ml; and lactate 2.3 mmol/L. Blood cultures were taken and she was started on meropenem and amikacin. On hospital day 3 (day 2 of illness), she was tachycardic with a heart rate up to 150 beats/min during an afebrile period, and a new onset S3 gallop was heard on auscultation. A chest radiograph showed clear lung fields but was suggestive of cardiomegaly ( Figure S1A ). 2D echocardiography reported a structurally normal heart with mild concentric left ventricular hypertrophy and a dilated left ventricle. Ejection fraction was 61%. On hospital day 4 (day 3 of illness), she had two episodes of loose stools with no vomiting. Premature ventricular contractions were present on the ECG monitor ( Figure S1B ). She was febrile and tachycardic with no respiratory distress. Her chest had no added sounds and abdomen was soft with no tenderness. Procalcitonin had escalated over 48 h from 2.12 ng/ml at illness onset to 28.21 ng/ml, and C-reactive protein increased from 48 to 192 mg/L but blood cultures had no growth. Suspecting myocarditis, we measured creatine phosphokinase myocardial band, which was elevated at 349 U/L (normal range ≤ 25 U/L). During a fever spike, she had an episode of oxygen desaturation to 93% in room air and was started on supplemental oxygen delivered by a face mask at 4 L/min. Given the rapid worsening of clinical condition with high inflammatory markers and cardiac involvement, we con- On hospital day 7, after three doses of methylprednisolone, her ectopic heart beats had resolved and inflammatory markers were resolving (ferritin decreased to 6200 ng/ml; interleukin-6 5.56 pg/ml, C-reactive protein 51 mg/l, and procalcitonin 1.3 ng/ml) (Supplementary Figure 2A and B). Antibiotics were discontinued and steroids were tapered and stopped over 2 weeks. Unfortunately, her disease was refractory to venetoclax and azacytidinetherapy with total white blood cell counts escalating to 172 × 10 9 /L, so she was discharged home for palliation. There is one case of MIS-C published in a child with acute lymphoblastic leukemia prior to chemotherapy. 1 No case of MIS-C has been reported following immunosuppressive or myelosuppressive therapy for cancer (Table S1 ). The syndrome has not been described Hyperinflammatory shock in children during COVID-19 pandemic An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study Severe SARS-CoV-2 infection in children with suspected acute abdomen: a case series from a tertiary hospital in Spain SARS-CoV-2-related paediatric inflammatory multisystem syndrome, an epidemiological study Overcoming COVID-19 investigators; CDC COVID-19 response team. Multisystem inflammatory syndrome in U.S. children and adolescents Multisystem inflammatory syndrome in children: clinical features and management-intensive care experience from a pediatric public hospital in western India An insertion unique to SARS-CoV-2 exhibits superantigenic character strengthened by recent mutations Anti-spikeIgG causes severe acute lung injury by skewing macrophage responses during acute SARS-CoV infection post-infectious syndrome or persistent infection? Lancet Infect Dis. 2020 Multi-system inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection: review of clinical presentation, hypothetical pathogenesis, and proposed management Mapping systemic inflammation and antibody responses in multisystem inflammatory syndrome in children (MIS-C) Membrane Fc-IgG and C3b receptors on myeloid leukaemia cells: a comparison with cytoplasmic acid naphthyl acetate esterase cytochemistry Evidence-based diagnosis and treatment of macrophage activation syndrome in systemic juvenile idiopathic arthritis