Bilateral intermediate uveitis in a healthy teenager with the multisystem inflammatory syndrome in children secondary to COVID‐19 infection

Abstract

To the Editor, Coronavirus disease 2019 (COVID-19) is a novel worldwide pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Children and adolescents generally present with mild symptoms. Nevertheless, 0.14% of them can develop a lifethreatening complication, the multisystem inflammatory syndrome in children (MIS-C). 1 This rare but serious condition can lead to multiorgan failure. To date, ocular reports associated with MIS-C are scarce. We report a case of bilateral intermediate uveitis in a healthy teenager with MIS-C secondary to COVID-19 infection.A 14-year-old male, the healthy adolescent was admitted for high-grade fever, vomiting, and rash for 3 days. Initial nasopharyngeal swab for COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) was positive and dengue serology was negative.On Day 3 of admission, his condition deteriorated with presumed septic shock, myocarditis with pericardial effusion, pleural effusion, and transaminitis. His lowest blood pressure was 87/48 mmHg with a heart rate of 147 bpm and the highest temperature was 40.4°C. He was transferred to the intensive care unit and a comprehensive workup was performed. Notable markedly elevated laboratory investigations were inflammatory markers like C-reactive protein of 10.83 mg/dl and procalcitonin of 16.14 ng/ml. Other elevated levels include D-dimer level (10.13 µg/ml), ferritin (916.23 µg/L), troponin (176 µg/L), and lactate dehydrogenase (336 µ/L). Infective screenings like blood, urine, and stool cultures were negative. Computed tomography angiogram of the thorax showed minimal pericardial effusion and bilateral pleural effusion with no evidence of coronary artery aneurysm or pulmonary thrombosis. The diagnosis was revised to MIS-C secondary to COVID-19 infection. He required inotrope support for 3 days and received two doses of intravenous immunoglobulin 1 g/kg; subcutaneous enoxaparin 40 mg od for 7 days and intravenous dexamethasone 0.2 mg/kg for 5 days followed by oral dexamethasone tapered within a month. Intravenous ceftriaxone 1 g bd for 7 days and intravenous azithromycin 250 mg od for 5 days were given as prophylaxis.

Case Report: Anterior Scleritis Presenting as a Primary Ocular Manifestation in Multisystem Inflammatory Syndrome in Children With COVID-19

“…Posterior involvement in KD is rare and is usually limited to case reports (13). Similarly, fundus findings in MIS-C are scarce in the literature, but some reports have demonstrated normal findings, as described in this case (6,7,9). Considering that both MIS-C and KD mainly involve the anterior segment of the eyes, we speculate that MIS-C and KD have a similar pathogenesis.…”

“…Therefore, MIS-C can present with various clinical features. While the literature is limited regarding ocular reports associated with MIS-C, anterior uveitis has recently been reported in addition to conjunctivitis (5)(6)(7)(8)(9). The present case was unique for the following two reasons: 1) the patient showed severe ocular manifestations as the primary symptom of MIS-C prior to other findings, such as fever or gastrointestinal manifestations, which could lead to delay in diagnosis, and 2) he suffered anterior scleritis, an unusual and severe form of inflammatory eye disease, rather than conjunctivitis.…”

New onset or recurrence of uveitis following COVID-19 infection

“…A recent case report showed that a 14-year-old male pneumonia patient was diagnosed with COVID-19-associated bilateral anterior uveitis. The patient’s ocular symptoms improved after treatment with local and systemic corticosteroids [ 23 ]. Iriqat et al reported a case of anterior uveitis that occurred after recovery from COVID-19, which was severe but was relieved after local and systemic steroid treatment [ 5 ].…”

Evaluation of Ocular Findings Following Multisystem Inflammatory Syndrome in Children

“…22 Subsequently, several case reports have been reported. [23][24][25][26] Apart from case reports, in a study including the clinical features of 45 MISC patients from a single center, acute anterior uveitis was detected in 9 (20%) of 29 patients with ocular findings . 27 It has been stated in the publications that ocular findings improve with topical or systemic antiinflammatory therapy.…”

“…27 It has been stated in the publications that ocular findings improve with topical or systemic antiinflammatory therapy. [21][22][23][24][25][26][27] Apart from uveitis, cases of optic disc edema associated with MIS-C have been reported. 11,28 In our study, we did not find any signs of acute anterior uveitis or optic disc edema.…”