1 - Pediatric Infectious Diseases Unit, Dona Estefânia Hospital, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
- Publicação sob a forma de Carta ao Editor no Archives de Pédiatrie Volume 31, Issue 1, January 2024, Pages 92-93
Background: Multisystem inflammatory syndrome in children (MIS-C) is a rare hyperinflammatory condition, which can lead to life-threatening illness in healthy children. The Centers for Disease Control and Prevention (CDC) case definition is based on fever, laboratory evidence of inflammation, multisystem organ involvement with no alternative diagnosis, and current or recent SARS-CoV-2 infection or exposure to a suspected or confirmed COVID-19 case. Little is known about atypical presentations of MIS-C.
Case Report: We report the case of a 12-year-old healthy African boy with a retropharyngeal phlegmon who presented with a history of 1 week of fever, sore throat, vomiting, neck pain, and drooling. On physical examination, we observed tonsillar hypertrophy, multiple cervical adenopathies, neck stiffness, torticollis, and sialorrhea. The initial work-up revealed leukocytosis (10,200/μL) and a C-reactive protein (CRP) level of 256 mg/L. A throat swab was negative for group A Streptococcus antigen and neck CT showed a retropharyngeal phlegmon. Prior to admission, a SARS-CoV-2 rRT-PCR test was positive, which was interpreted as asymptomatic COVID-19. He developed bilateral conjunctival hyperemia and tachycardia. The subsequent work-ups showed anemia, lymphopenia, hypoalbuminemia and elevation of inflammation markers. Serology for SARS-CoV-2 yielded positive results. The echocardiogram showed ectasia of left coronary artery and anterior descending artery (z-score +4.78 and +4.95, respectively). A pulmonary CT scan suggested viral pneumonitis. Given this characteristic clinical condition and after excluding other infectious diseases, MIS-C was considered and he was started on IV immunoglobulin, methylprednisolone and acetylsalicylic acid. There A complete resolution of fever was observed with an improvement of inflammatory markers. Cardiac magnetic resonance imaging (MRI) after 2 months showed no active myocardial inflammation or fibrosis but ectasia of the left main coronary artery.
Conclusions: This case describes a retropharyngeal phlegmon as the initial manifestation of MIS-C. Other similar cases have been reported in the literature; however, our case is of great relevance as it meets all the MIS-C criteria. It is a rare presentation, also described in Kawasaki disease, and therefore alerts us to an early diagnosis and target therapy, especially in the absence of suppurative complications and if there is no improvement with antibiotics.
Palavras Chave: retropharyngeal phlegmon, MIS-C, atypical presentation