Published: 2021-06-24

Multi-system inflammatory syndrome presenting with refractory shock in an infant, temporally associated with SARS-CoV2 infection

Sahana Devadas, Shruthi Ganesh, Varun Govindarajan


Children with COVID-19 largely remain asymptomatic or mildly symptomatic with gastroenteritis or influenza like presentation. However, few of them go on to develop features of multi-system inflammatory syndrome secondary to dysregulated cytokine release, resulting even in death.  We report a 45 days old infant who presented to us with fluid unresponsive shock following protracted vomiting few hours prior to arrival. Eight days prior, child was admitted in COVID Isolation centre with mild illness, after testing positive on rapid Antigen Test and discharged 3 days later. Child when brought was severely acidotic and hence electively intubated. Shock did not improve even following multiple boluses and inotropic support on mechanical ventilation. Encephalopathy, myocardial dysfunction and acute kidney injury, with elevated inflammatory markers post COVID-19 suggested multi-system inflammation syndrome in him. The infant deteriorated rapidly and succumbed even before targeted therapy could be initiated. MIS-C presenting with refractory shock is increasingly being reported in pediatric age group and these children rapidly deteriorate without early recognition and treatment. Clinicians need a heightened suspicion for cytokine storm related complications and institute early immune-modulative therapy, especially during the present COVID-19 pandemic.


SARS CoV-2, Infantile COVID-19, PIMS-TS, Cytokine storm, Hyperinflammatory shock, Multisystem inflammatory Syndrome in children

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Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J. SARS-CoV-2 infection in children. N Engl J Med. 2020;382:1663-5.

Feldstein LR, Rose EB, Horwitz SM. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383:334-46.

Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020;6736:2019-20.

Pouletty M, Borocco C, Ouldali N. Paediatric Multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): a multi-centre cohort. Ann Rheum Dis 2020;79:999-1006.

Whittaker E, Bamford A, Kenny J, Kaforou M, Jones CE, Shah P. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA. 2020;324:259-69.

Cheung EW, Zachariah P, Gorelik M, Boneparth A, Kernie SG, Orange JS et al. Multisystem inflammatory syndrome related to COVID-19 in previously healthy children and adolescents in New York City. J Am Med Assoc. 2020.

Harwood R, Allin B, Jones CE, Whittaker E, Ramnarayan P, Ramanan A et al. A national consensus management pathway for paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS): results of a national Delphi process. Lancet Child Adolescent Health. 2020.

Ragab D, Salah Eldin H, Taeimah M, Khattar R, Salem R. The COVID-19 Cytokine Storm; What We Know So Far. Front Immunol. 2020;11:1446.

Honore PM, Barreto Gutierrez L, Kugener L. Liver injury without liver failure in COVID-19 patients: how to explain, in some cases, elevated ammonia without hepatic decompensation. Crit Care. 2020;24:352.

Balasubramanian S, Nagendran TM, Ramachandran B. Hyper-inflammatory syndrome in a child with COVID-19 treated successfully with intravenous immunoglobulin and tocilizumab. Indian Pediatr. 2020;57:681-3.