Jeremiah Claudine CalacalInstitute of pediatrics and child health, St. Luke’s medical center , Philippines
Title: MIS-c with group B streptococcal sepsis and meningitis co-infection in an infant
Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a novel clinical entity with hyperinflammatory process in the setting of recent COVID-19 infection. Early reports described a mild course of COVID-19 in pediatric patients, but serious complications may occur in conjunction with both COVID-19 and MIS-C.
Objective: This case is presented to highlight the unusual presentation of MIS-C, with Group B streptococcal (GBS) sepsis and meningitis co-infection, and its successful management.
Clinical case: A previously well 6-week-old male presented with three days history high grade fever, bloody stools, poor cry and activity. Patient had exposure to household contacts positive for SARS COV-2 two weeks prior. On admission, he was drowsy, highly febrile, tachycardic, tachypneic, and pale looking. He had non-tensed fontanelles, sunken eyeballs, alar flaring, dry lips, subcostal retractions, bilateral crackles, cold extremities, full and equal pulses and CRT of 3 seconds, needing fluid boluses and non-invasive positive pressure ventilation. He was admitted to the pediatric intensive care unit. Laboratory results showed leukopenia, lymphopenia, elevated procalcitonin, C reactive protein, D-dimer and interleukin-6. There was bilateral pneumonia on chest x-ray. RT-PCR for SARS COV-2 was positive on admission. Patient was initially treated for severe COVID pneumonia with remdesivir, dexamethasone and cefotaxime. Blood culture showed growth of Streptococcus agalactiae. He developed seizure on day 6 of illness when he was afebrile. Lumbar tap findings were suggestive of bacterial meningitis, with positive Phadebact test for Streptococcus agalactiae. Serology for COVID IgG was positive. Pro BNP was also elevated. Due to highly elevated inflammatory markers, myocarditis, anemia and neurologic involvement, he was treated for MIS-C with intravenous immunoglobulin and methylprednisolone. He completed antibiotics for meningitis for 21 days and steroid was slowly tapered. Cranial ultrasound was normal and inflammatory markers gradually normalized. He was discharged improved.
Conclusion: This was a highly challenging case of overlapping signs and symptoms, laboratory abnormalities. The presentation of MIS-C can overlap with symptoms and findings of SARS-CoV-2 and non SARS-CoV 2 infection. Although this patient seems to have completely recovered, close follow-up is still warranted since the natural history of MIS-C is still unclear. The long term sequelae remain unknown and represent a very important area for future studies.
Jeremiah Claudine Calacal completed her undergraduate studies in BS Human Biology in De La Salle University – Manila last 2013. She pursued further studies in medicine in De La Salle Health Sciences Institute and graduated last 2016. From 2016 to 2017, she had internship in Department of Health’s Rizal Medical Center and subsequently earned her medical license last September 2017, granted by the Philippine Regulation Commission. She proceeded with residency last January 2018 in Pediatrics in St. Luke’s Medical Center – Global City, Philippines and served as the chief resident January 2021 to January 2022.