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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 2

Demographic, laboratory, and clinical characteristics of patients who had multisystem inflammatory syndrome without SARS-CoV-2 immunization, California, USA

Characteristic Patient 4 Patient 5 Patient 6
62 y/M
29 y/F
23 y/M
Underlying conditions
Hyperlipidemia, gout, atrial fibrillation
Asthma, obesity
Signs and symptoms
6 d of fever, vomiting, abdominal pain, 4 d of hearing loss; shock, acute renal failure
4 d of fever, headaches, vomiting, abdominal pain; conjunctivitis, shock, 
acute kidney injury
4 d of fever, abdominal pain, diarrhea, cough, SOB; shock
Initial vital signs
Pulse 121 beats/min, BP 112/63 mm Hg, RR 20 breaths/min, temp 101.6°F, O2 sats 98%; within 1 h in ER: BP 70/56 mm Hg, pulse 112 beats/min, RR 28 breaths/ min, O2 sat 97%; BMI: 28.1
Pulse 140 beats/min, BP 102/71 mm Hg (61/48 mm Hg after 5 h of being in ER), RR 20, temp 105.2°F, O2 
sats 99%; BMI: 31.63
Pulse 125 beats/min, BP 87/27 mm Hg, temp 98.2°F, O2 sats 98% on RA; 
BMI: 40.3
Vasopressors, methylprednisolone 125 mg every 6 h, broad spectrum antibiotics, enoxaparin
Vasopressors, methylprednisolone 30 mg every 12 h, IVIG 100 g, heparin, ceftriaxone, ciprofloxacin
Vasopressors, IVIG 2 g/kg, methylprednisolone 1 g daily for 3 d, broad spectrum antibiotics
EKG: diffuse ST elevation; TTE: mild concentric LVH, mild LV systolic dysfunction, EF 50%; CT angiogram: no evidence of embolus; increased interstitial markings and hazy ground glass changes, small bilateral pleural effusions; 6 mm pericardiac effusion; ultrasound: 
right popliteal DVT
TTE: LVEF 50%–55%, mild TR regurgitation, abdominal CT with colitis and enlarged lymph nodes
EKG: sinus tachycardia, no ST changes; TTE: LVEF 20%, global hypokinesis, abdominal CT with mesenteric adenitis
Length of hospital stay
7 d
10 d
12 d; deceased
First vaccine
Second vaccine
Previously known COVID-19
23 days before symptom onset
28 d before symptom onset
38 d before symptom onset
Initial lab results (reference ranges)
Serum leukocytes, × 1,000/mcL
(4.5–14.5) 18.4 10.2 6.8
Lymphocytes absolute, 
× 1,000/mcL (1.5–6.8) 0.00 0.35 0.52
Neutrophils absolute, 
× 1,000/mcL (1.5–8.00) 17.66 9.66 14.35
Platelets, × 1,000/mcL 
(130–400) 102 170 185
Creatinine, mg/dL (<1.00) 2.24 0.78 2.49
C-reactive protein, mg/L (<7.4) 351.7 364.9 246.3
D-dimer, µg FEU/mL (<0.49) 7.21 5.79 >4
Ferritin, ng/mL (17–168) 5,032 606 1,273 at admission, >18,000 at its peak 2 days later
Fibrinogen, mg/dL (218–441) N/A N/A 454
Troponin, ng/mL (<0.03) 0.85 0.06 <0.02
BNP, pg/mL (<99) 931 331 228
LDH, U/L (<279) 267 N/A 224
AST, U/L (<34) 38 N/A 42
ALT, U/L (<63) 40 55 8 88
Procalcitonin, ng/mL (0.0–0.1) Not done 8.15 29.37
SARS-COV-2 nucleocapsid 
IgG qualitative Not done Positive Not done
SARS-COV-2 PCR Positive Negative Positive
Blood culture Negative x 2 Negative x 4 Negative x 9
Urine culture Negative (after antibiotics) Negative (after antibiotics) Negative (after antibiotics)
Bacterial GI PCR panel Not done Negative Not done

*ALT, alanine aminotransferase; AST, aspartate aminotransferase; BMI, body mass index; BNP, brain natriuretic peptide; BP, blood pressure; CT, computed tomography; COVID-19, coronavirus disease; DVT, deep venous thrombosis; 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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