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.