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Volume 27, Number 7—July 2021

Multisystem Inflammatory Syndrome after SARS-CoV-2 Infection and COVID-19 Vaccination

Mark B. SalzmanComments to Author , Cheng-Wei Huang, Christopher M. O’Brien, and Rhina D. Castillo
Author affiliations: Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California, USA (M.B. Salzman); Kaiser Permanente Los Angeles Medical Center, Los Angeles (C.-W. Huang); Kaiser Permanente Zion Medical Center, San Diego, California, USA (C.M. O’Brien); Kaiser Permanente Tustin Ranch Medical Offices, Tustin, California, USA (R.D. Castillo)

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Table 1

Demographic, laboratory, and clinical characteristics of 3 patients who had multisystem inflammatory syndrome after SARS-CoV-2 immunization, Southern California, USA

Characteristic Patient 1 Patient 2 Patient 3
Age, y/sex
20 y/F
40 y/M
18 y/M
Underlying conditions
Depression, hyperlipidemia
Fever and rash for 3 d, diarrhea, vomiting, cardiogenic shock, acute renal failure
6 d of fevers, malaise, diarrhea, neck pain, headache, lethargy
3 d of fever, 2 d of abdominal pain, diarrhea, vomiting and headache
Initial vital signs
Pulse: 130 beats/min, BP 73/56 mm Hg, RR 20 breaths/min, temp 99.4°F, repeat temp 101.4, O2 sats 99% on RA; BMI: 27.85
Pulse 102 beats/min, BP 136/88 mm Hg, RR 20 breaths/min, temp 99.2°F, O2 sats 97% on RA; BMI: 28.89
Pulse 96 beats/min, BP 98/58 mm Hg, RR 20 breaths/min, temp 97.9°F, sats 97% on RA;
BMI: 23.99
Vasopressors × 3 d, IVIG 100 g, methylprednisolone 1 g/d for 3 d, heparin, broad spectrum antibiotics, remdesivir
Dexamethasone 6 mg/d for 10 d, ceftriaxone, azithromycin, enoxaparin
IVIG 100 g, methylprednisolone 1 g/d for 3 d, anakinra 100 mg/d for 3 d, broad-spectrum antibiotics, aspirin
TTE: normal LV, mildly reduced EF 45% which decreased to 30%–35% the next day; chest radiograph: subtle bibasilar ground glass opacities
EKG: ST depression and T wave inversion in inferior leads; TTE: normal LV; EF: 50%–55%; CT angiogram: no pulmonary embolism, minimal ground glass opacities
TTE: normal LV size with mild to moderately reduced EF 40%–45%, right ventricle mildly dilated with normal systolic function; chest radiograph: right pleural effusion; CT abdomen and pelvis: hepatomegaly, splenomegaly, small ascites; pericholecystic fluid; retroperitoneal adenopathy.
Length of hospital stay
8 d
3 d
9 d
First vaccine
12 d before symptom onset
42 d before symptom onset
19 d before symptom onset
Second vaccine
4 d before symptom onset
Previously known COVID-19 disease
34 d before symptom onset
43 d before symptom onset
Initial lab results (reference range)
Serum leukocytes, × 1,000/mcL
(4.5–14.5) 32.3 11.3 7
Lymphocytes absolute, 
× 1,000/mcL (1.5–6.8) 0.55 0.94 0.26
Neutrophils absolute, 
× 1,000/mcL (1.5–8.00) 31.75 12.68 6.28
Platelets, × 1,000/mcL 
(130–400) 155 312 63
Creatinine, mg/dL (<1.00) 2.64 1.12 1.12
C-reactive protein, mg/L (<7.4) 378 199.4 185.5
D-dimer, µg FEU/mL (<0.49) 3.01 1.15 3.44
Ferritin, ng/mL (17–168) 533 1,079.7 3,002
Fibrinogen, mg/dL (218–441) 801 875 693
Troponin, ng/mL (<0.03) 1.54 0.37 0.06
BNP, pg/mL (<99) 1,498 672 106
LDH, U/L (<279) 251 156 291
AST, U/L (<34) 43 55 59
ALT, U/L (<63) 28 83 58
Procalcitonin, ng/mL (0.0–0.1) 160.92 0.01 4.41
SARS-COV-2 nucleocapsid 
IgG qualitative Positive Positive Positive
SARS-COV-2 PCR Positive Positive Negative
Blood culture Negative × 2 Negative × 2 Negative × 2
Urine culture Negative Not done Negative (after antibiotics)
Bacterial GI PCR panel Negative Not done Negative

*All patients received the Pfizer-BioNTech vaccine ( ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; BNP, brain natriuretic peptide; BP, blood pressure; CT, computed tomography; EF, ejection fraction; EKG, electrocardiogram; GI, gastrointestinal; IVIG, intravenous immunoglobulin; LDH, lactate dehydrogenase; LV, left ventricle; MR, mitral regurgitation; NA, not applicable; RA, room air; RR, respiratory rate; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; sats, saturations; temp, temperature; TR, tricuspid regurgitation; TTE, transthoracic echocardiogram.

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Page created: May 25, 2021
Page updated: June 17, 2021
Page reviewed: June 17, 2021
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