HPI: 

• Initial sx 6 days prior: erythematous, cracked lips
• Presented to urgent care next day with fever and sore throat
• Noted to have a “strawberry tongue” on evaluation and started on Amoxicillin for possible strep pharyngitis
• Covid and strep tests sent: negative
• Day 3: developed whole body erythematous rash which resolved after  1-2 days
• Patient now with diffuse, intermittent, abdominal pain X 2 days ago w/vomiting and diarrhea
• Mother notes fatigue and decreased activity
• Of note, dad had COVID 3 weeks ago
• No urinary complaint

PE:

BP 112/55 | Pulse 118 | Temp 97.8 °F (36.6 °C) (Oral) | Resp 24 | SpO2 100%

General:  In fetal position. Moaning. Fatigued

HEENT: +Strawberry tongue. No oropharyngeal exudates, erythema, lesions or swelling. Uvula midline without swelling. No cervical LAD

Eyes:　Conjunctivae are normal.

Neck:　Supple.

Cardiovascular: Tachycardia. No murmurs.

Pulmonary: Lungs clear. No respiratory distress

Abdomen: Soft, bowel sounds are normal. Diffuse tenderness, worse in the RLQ. Negative Rovsing’s. Non-peritoneal.

Differential:

• COVID with multi-systemic inflammatory syndrome
• Mononucleosis
• Gastroenteritis
• Kawasaki syndrome

Results:

• CBC: WBC 24, 24% bands, plt 118
• BMP: BUN 58, Cr 1.41
• ESR: 27
• CRP: 32
• LFTs WNL
• Monospot: negative
• POC Covid: negative
• ECG: Sinus tachycardia. Rate 124. TWI V2. No STE or STD
• COVID PCR POSITIVE
• hsTrop: 145
• NT-proBNP: 10,815 
• Lactate: 2.3
• D-dimer: 0.6
• Ferritin: 706
• UA unremarkable
• CXR unremarkable

Clinical Course:

• Repeat vitals: BP 85/49 | Pulse 122 | Temp 102 °F (38.9 °C) (Oral) | Resp 40 | SpO2 100%
• Reassessed, more ill-appearing w/ worsening vitals as above.
• Discussed with peds ID - agreed with suspected multi-system inflammatory syndrome from COVID.
• Transferred to peds tertiary care center for escalation of care: started on IVIG and high dose ASA there.

CDC Information for Multisystem Inflammatory Syndrome in Children (MIS-C) 

https://www.cdc.gov/mis-c/hcp/index.html

Pearls:

• Suspect MIS-C in patients <21 with evidence of multisystem involvement, elevated inflammatory markers, and severe clinical illness in the setting of possible or confirmed Covid-19 infection or exposure within the last 4 weeks
• This is reportable to local and state health departments
• Consider early transfer to pediatric referral center