Case presentation:
A nine-year-old girl presented to the emergency department of Dr.
Mohammad Kermanshahi Pediatric Hospital in Kermanshah City, Iran on
September 25, 2021. She complained of fever, myalgia, loss of appetite,
headache, cough, diarrhea, abdominal pain, and skin rashes. Her symptoms
initiated five or six days prior to this hospitalization and her fever
was not controlled by Acetaminophen syrup. She also complained of
blurred vision, photophobia, pain, and redness of the eyes on the day of
hospitalization. Her parents claimed that she had had mild
gastrointestinal symptoms such as diarrhea about four weeks ago which
lasted for two days and resolved completely without specific treatment.
Her past medical history and familial history were unremarkable.
On general examination, her vital signs were as follows: pulse rate of
98 beats/minute, respiratory rate of 20, blood pressure of 100/65 and
she was not febrile on the day of admission. Jaundice, paleness, and
cyanosis of the skin were absent. Lymphadenopathy was not detected.
Diffuse erythematous patches and plaques were observed on her face,
trunk, and limbs. A ciliary injection was detected in her eyes. Eye
movements were normal in all directions and were not painful. Pupil’s
size and their reaction to light were normal. Examination of the
respiratory and cardiovascular systems was within normal limits.
Abdominal examination was unremarkable.
Laboratory investigation showed hemoglobin of 13.4 mg/dl, white blood
cell count (WBC) 8.9 x103/mm3(differential count: neutrophils 88%, lymphocytes 7%), platelet counts
191 x103/mm3, creatinine 0.9 mg/dl,
aspartate transaminase (AST) 16 IU/L (normal:0-31 IU/L), alanine
transaminase (ALT) 20 IU/L (normal:0-34 IU/L), alkaline phosphatase
(ALP) 196 U/L (normal:64-306 U/L), erythrocyte sedimentation rate (ESR)
26 mm/hr and C-reactive protein (CRP) was positive. Urine analysis and
stool examination were normal. Blood and urine cultures were sterile.
PCR (polymerase chain reaction) testing for COVID-19 was positive.
Ultrasonography of the abdomen was done and revealed no pathological
finding. Chest CT (computerized tomography) scan showed mild bilateral
pleural effusion, mediastinal lymphadenopathy, and sub-segmental
atelectasis (Figure 1). Echocardiography was remarkable for the
pericardial effusion of 6-millimeter thickness, mild MR (mitral
regurgitation), and mild TR (tricuspid regurgitation). MIS-C (a
multisystem inflammatory syndrome in children) was suspected and she was
started on Methylprednisolone 30 mg/ daily with gradual tapering to oral
prednisolone 5 mg/ daily and IVIG 2 gr/kg in four divided doses.
An ophthalmologist visited the patient. Slit lamp examination and
indirect ophthalmoscopy were performed. Bilateral acute anterior uveitis
was documented. Findings of the slit lamp examination included mild
ciliary injection, anterior chamber reaction with 2+ cells, and flares.
The posterior chamber was clear. Examination of the fundus showed
bilateral optic disc edema. Orbital sonography showed increased
thickness of both optic nerves. Corticosteroids and cycloplegic eye
drops were added to the ongoing treatment. The ocular symptoms improved
gradually. In the follow-up echocardiography, pericardial effusion
decreased to 3mm. She was discharged in stable condition. Repeated
ophthalmologic examinations after discharge showed gradual improvement.