Volume 27, Number 11—November 2021
Dispatch
Fatal Multisystem Inflammatory Syndrome in Adult after SARS-CoV-2 Natural Infection and COVID-19 Vaccination
, Michael Threlkeld, Steve Threlkeld, Charles Newman, Roosecelis Brasil Martines, Sarah Reagan-Steiner, Michael A. Whitt, Maria Gomes-Solecki, Nisha Nair, Mary-Margaret Fill, Timothy F. Jones, William Schaffner, and John Dunn
Table
Results of pertinent laboratory testing completed during the 4-day hospitalization of a patient with fatal multisystem inflammatory syndrome in adult, Tennessee, USA, 2021*
| Variable | Hospital day |
Reference range | |||
|---|---|---|---|---|---|
| Day 1 | Day 2 | Day 3† | Day 4† | ||
| Hematologic testing | |||||
| Peripheral leukocyte count, 1,000/μL | 11.0 | 14.4 | 28.1 | 8.8 | 4.2–10.2 |
| Hemoglobin, g/dL | 13.7 | 11.7 | 10.8 | 9.5 | 12.8–16.4 |
| Hematocrit, % | 39.6 | 33.8 | 34.3 | 27.7 | 38.8–48.1 |
| Platelets, 1,000/μL | 110.0 | 86.0 | 45.0 | 17.0 | 150–400 |
| Absolute neutrophils, 1,000/μL | 10.5 | 13.7 | 23.9 | 1.8–7.1 | |
| Absolute lymphocytes, 1,000/μL | 0.4 | 0.4 | 5.0 | 1.3–5.9 | |
| Segmented neutrophil, % | 95.3 | 95.3 | 76.6 | 40.0–76.0 | |
| Lymphocytes, % | 3.8 | 2.8 | 15.9 | 14.0–46.0 | |
| Monocytes, % |
1.9 |
0.9 |
0.9 |
4.0–12.0 |
|
| Chemical testing | |||||
| Creatinine, mg/dL | 1.2 | 1.3 | 3.4 | 1.9 | 0.70–1.30 |
| AST, U/L | 78.0 | 5,938.0 | 8,861.0 | 15–37 | |
| ALT, U/L | 61.0 | 3,386.0 | 3,421.0 | 16–61 | |
| Total bilirubin, mg/dL | 1.9 | 1.4 | 1.6 | 0.2–1.0 | |
| Alkaline phosphatase, U/L | 76.0 | 74.0 | 295.0 | 202.0 | 45–117 |
| Ferritin, serum, mg/dL |
1434.9 |
>40,000.0 |
26.0–388.0 |
||
| Coagulation | |||||
| aPTT, s | 29.3 | 54.2 | 80.9 | 23.2–34.1 | |
| PT, s | 13.9 | 39.6 | 11.7–14.5 | ||
| INR | 1.1 | 4.2 | 3.6 | 0.9–1.0 | |
| Fibrinogen, mg/dL | 642.0 | 750.0 | 208–475 | ||
| D-Dimer, µg FEU/mL |
5.2 |
4.3 |
12.2 |
0.0–0.44 |
|
| Cardiac | |||||
| Troponin-I, ng/mL |
18.0 |
15.5 |
0.0–0.045 |
||
| Immunochemical testing | |||||
| ESR, mm/h | 40.0 | 0–15 | |||
| C-reactive protein, mg/L | 284.0 | 174.0 | <3.0 | ||
| Procalcitonin level, ng/mL |
4.9 |
0.50–2.0 |
|||
| Microbiologic testing | |||||
| SARS-CoV-2 RT-PCR, index value | Negative | Negative | |||
| SARS-CoV-2 IgG antibody,‡ index value | 4.96 | <1.39 | |||
| Adenovirus DNA PCR, qualitative | Not detected | Not detected | |||
| CMV PCR, quantitative | Negative | Negative | |||
| Mononucleosis screen | Negative | Negative | |||
| Ehrlichia chaffeensis DNA PCR | Not detected | Not detected | |||
| HIV-1 p24 Ag | Nonreactive | Nonreactive | |||
| Peripheral blood culture, 2 sets | No growth | No growth | No growth | No growth | No growth |
*Laboratory values represent pertinent laboratory results during the patient’s hospitalization. Not all laboratory studies completed during hospitalization are represented in this table. Blank cells indicate test not done. ALT, alanine aminotransferase; AST, aspartate aminotransferase; aPTT, activated partial thromboplastin time; CMV, cytomegalovirus; ESR, erythrocyte sedimentation rate; FEU, fibrinogen equivalent units; INR, international normalized ratio; PT: prothrombin time; RT-PCR, reverse transcription PCR; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. †Laboratory values indicate studies after cardiac arrest, which occurred at ≈3 a.m. on hospital day 3. Note patient was initiated on extracorporeal membrane oxygenation shortly after return of spontaneous circulation; anticoagulation treatments affect laboratory values. ‡SARS-CoV-2 IgG test specific for nucleocapsid protein antibody.