Femia, director of inpatient dermatology at NYU Langone Health in New York City, was looking at a patient’s chart, which included several photos of a 45-year-old man who cared for his wife when he was ill in recent weeks. COVID-19. The man had dusky-red circular patches on the palms of his hands and the soles of the feet. His eyes were pink, and his lips were very tight.
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At that time, his body was bursting with excessive swelling occurring almost exclusively in children.
“Before I even saw the patient,” Famia recalled, “I said: ‘It’s not reported yet. It must be NIS-A.”
MIS-A means “multi-system inflammatory syndrome in adults”. When the status of children was identified this spring, it was named MIS-C, with C standing for “children”.
Children were developing dangerous inflammation around the heart and other organs, often after their initial infection with SARS-COV-2, the virus that causes Kovid-19.
The Centers for Disease Control and Prevention alerted physicians to MIS-C in May. As of 1 October, the CDC had reported 1,027 confirmed cases of MIS-C, with more cases under investigation. Twenty children have died.
In some cases, children developed rashes similar to the one noted in their adult patient.
Femia and colleagues published a description of the case in The Lancet in July to alert other physicians to the search for similar patients.
“You have skin right in front of your eyes,” Famia said. “You can’t see it.”
But many doctors may not really recognize the condition in adults. Only a few dozen cases of MIS-A have been reported. And not all patients have obvious rashes.
Dr. Sapna Bamrah Morris, clinical leadership for the Health Care Systems and Worker Safety Task Force, part of the CDC’s response to Kovid-19, detailed 27 cases in a report the agency published last week.
Morris said that MIS-A’s “true prevalence is unknown.” “We have to convince physicians that it can be rare, but we don’t know. It may be more common than we think.”
Part of the problem is that the virus has been circulating among humans for less than a year. Doctors around the world are still learning about how SARS-CoV-2 functions in patients.
Usually critically ill Kovid-19 patients reach the hospital because they have difficulty breathing. Not so in MIS-A.
Many MIS-A patients report fever, chest pain or other heart problems, diarrhea or other gastrointestinal issues – but not shortness of breath. And diagnostic tests for Kovid-19 are negative.
Instead, patients will test positive for Kovid-19 antibodies, meaning they were infected two to six weeks ago, even if they never had symptoms.
“Just because a person is not present with respiratory symptoms because their primary manifestation does not mean that what they are experiencing is not a result of Kovid-19,” Morris said.
The disease can be fatal. Patients usually have severe dysfunction of at least one organ, such as the heart or liver.
The CDC report required ten patients to be hospitalized in intensive care units. Some need to be placed on the ventilator. Two have died.
What’s more, the CDC report showed that members of racial and ethnic minority groups appear to be disproportionately affected. Almost all of the MIS-A patients were African American or Hispanic. But far fewer cases have been reported to fully understand the underlying mechanisms at play.
Although some types of genetic links may be possible, Kovid-19 has been shown to be “due to social minority factors possibly affecting underdeveloped minorities”. Understanding health conditions that pose risks for Kovid-19 complications, such as obesity and type 2 diabetes, are also more prevalent among members of racial and ethnic minority groups.
Over the summer, Florida doctors saw an increase in Kovid-19 cases. Dr. Jackson’s head of infection prevention for the Jackson Health System in Miami. Lillian Ebo said, “Our emergency departments or hospitals miss a very high amount of people coming in because they are very ill.”
The most sensitive and reliable test for the Kovid-19, called PCR test, was not always available, and it may take several days to return results. The influx of patients to turn to the Abbo antibody test for a Covid-19 unit or elsewhere in the health system.
People usually develop antibodies to an infection within a week or so. At least this would indicate to Abbu and his colleagues that Kovid-19 was somehow involved in his patients’ symptoms, she argued.
This was when Abbu discovered a subset of critically ill patients after having Kovid-19, but without the telltale pulmonary issues of an acute infection.
“We were a little disappointed,” said Abbu. “We will do molecular PCR tests, and they will be negative. Then the antibody tests were positive.”
In addition, blood tests revealed extremely high levels of inflammation in the body.
Abbu said that when the more seriously ill Kovid-19 patients are over 65 years of age or have many underlying health problems, these patients were “young people who would expect you not to be ill”, Abbu said .
“That’s what caught our attention.”
There is no proven treatment for MIS-A. “We need to identify this syndrome and develop data” to identify which therapy may be most effective, “said Abbu.
Assistant Professor of Infectious Diseases and Tropical Medicine at Baylor College of Medicine in Houston, Drs. Jill Weatherhead explains that the CDC case report suggests that doctors have tried a variety of drugs for patients with MIS-A, including steroids and drugs that may affect the immune system, called interleukin – 6 are called inhibitors.
Weatherhead said, “The problem with these diseases is that we don’t know the mechanisms that are causing MIS-A and MIS-C.” “It is difficult to know what standard treatment should be until we have more information.”
In children, MIS-C is usually treated with intravenous immunoglobulin, a blood product that contains a variety of antibodies. It can also be used for adults, but the effects are largely unproven.
Intravenous immunoglobulin, or IVIG, is different from convulsive plasma, another blood-derived antibody treatment. The latter is taken from patients who have recovered from Kovid-19 and have specifically targeted antibodies to the virus in their blood. IVIG, on the other hand, contains a large proportion of antibodies that are not specific for coronaviruses.
The idea is that Covid-19 antibodies are already present in patients with MIS-A, so adding more with convulsive plasma is unlikely to help.
The current theory for MIS-A patients is that “the infection is gone, as far as we know,” Dr. Said Hugh Cassiere, director of critical care services for Sandra Atlas Bass Heart Hospital, part of North Shore University Hospital, North Shore. On Health, Long Island, New York.
“It is the antibodies that have been produced that are causing a problem,” he said.
Cassier was part of a larger team of physicians who treated an increase of Kovid-19 patients this spring. Even though MIS-A was not identified at the time, Cassier is sure that such patients were present all along.
“We were seeing patients who were admitted to the ICU with organ failure,” Kaiser said. They tested negative for Kovid-19, he said, but tested positive for Kovid-19 antibodies, suggesting they were previously infected.
“You look back, and maybe they had this multi-system inflammatory syndrome,” Kaiser said. “We didn’t have all the pieces to put together.”
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Months later, the puzzle begins to reveal itself. But it would take an all-hands-on-deck approach to identify patients with MIS-A.
“It needs to be at the forefront of every intensive care unit physician looking at patients, especially when they have Kovid-19 antibodies,” Kaiser said.
Given the experience of Fimia, which also includes dermatology specialists.
“It’s really the beauty of medicine, where, for this syndrome, many different specialists need to come together to help make the diagnosis,” Famia said.
Physicians worry that many MIS-A patients will become unspecified – and perhaps untreated.
“There is not enough data for me to explain what its long-term effects may be,” Kaiser said. “It could be the tip of the iceberg. That’s what I’m worried about.”
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