Discussion
This case highlights the relationship between likely SARS-CoV-2
associated MIS-C and thrombotic complications, particularly pulmonary
embolism. Although this patient’s SARS-CoV-2 PCR was negative multiple
times, the SARS-CoV-2 IgM antibody was positive during hospitalization.
Her positive antibody test coupled with fever, age less than 21 years,
hospitalization, laboratory evidence of inflammation and evidence of
multisystem involvement fit reported criteria for
MIS-C2. The negative PCR is not unusual in MIS-C
cases; recent evidence has demonstrated only 70% of patients have PCR
or antibody evidence of SARS-CoV-2 infection and up to 44% of reported
pediatric patients with MIS-C have a negative or unknown SARS-CoV-2 PCR
test during hospitalization2.
Thrombotic complications have been described in adults in both previous
case reports and more recently in large case series and prospective
studies1,3,4. A case series in a French hospital
reported rates of pulmonary embolism of 20.6% of COVID-19 patients,
rates twice as high compared to a similar time period in 2019 in their
institution. A multicenter study also in France reported significantly
higher rates of pulmonary embolism of 16.7% in COVID-19 ARDS patients
vs. 1.3% in non-COVID-19 ARDS patients, and this association persisted
after matching
between groups4. The high incidence of thrombotic
complications amongst COVID-19 has led to much discussion regarding
appropriate prevention of deep vein thrombosis, with pharmacologic VTE
prophylaxis recommended in hospitalized patients without other risk
factors5,6.
Thrombotic complications in children with COVID-19 are not as well
described as in adults, perhaps due to the less severe nature of the
disease in younger patients. To our knowledge, the youngest patient
described in a case report prior to this case is a 17 year old pregnant
female7. Thrombotic complications with MIS-C are
relatively uncommon, but increase with age, with the incidence highest
in the 13-20 year age group at a rate of 7%2. The
patient in this case had a particular set of known risk factors that
likely contributed to her thrombotic complications, particularly obesity
and recent surgery.
Given the increased incidence of pulmonary embolism in COVID-19 in older
teenagers, pediatric providers taking care of these patients may be
confronted with treatment decisions regarding pulmonary embolism. In
this patient, catheter directed thrombolysis for twenty-four hours
provided resolution of bilateral pulmonary emboli on CT angiography
within three days. Catheter directed thrombolysis has previously been
described as safe and effective in pediatric patients, and has recently
been described in a case report for an adult patient with COVID-19 and
pulmonary embolus8,9. In pediatric patients with
massive pulmonary embolus and COVID-19, it should also be considered as
definitive therapy. Despite the successful treatment of the pulmonary
emboli in this patient, unfortunately, due to her associated cardiac
arrest, her overall neurologic outcome remains poor.