It was a rash that settled on Dr. Alisa Femia.
Femia, director of inpatient dermatology at NYU Langone Health in New York City, looks at the patient chart, which includes several photos of the 45-year-old man who, in recent weeks, has taken care of his wife while he was ill. Covid-19. The man had dark-red circular patches on the palms of his hands and the soles of his feet. Her eyes were pink, and her lips were severely cut off.
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Her body exploded with the type of severe swelling mentioned almost exclusively in children at the time.
“Before I saw the patient,”; Femia recalled, “I said: ‘It has not been reported. It must be MIS-A.'”
MIS-A stands for “multi-system inflammatory syndrome in adults.” When the condition was recognized in children this spring, it was named MIS-C, with C standing for “children.”
Children develop dangerous inflammation around the heart and other organs, often weeks after their initial infection with SARS-CoV-2, the virus caused by Covid-19.
The Centers for Disease Control and Prevention alerted physicians to MIS-C in May. As of October 1, the CDC has reported 1,027 confirmed cases of MIS-C, with more cases under investigation. Twenty children died.
In some cases, children develop rashes as mentioned by Femia in her adult patient.
Femia and colleagues published case details in The Lancet in July to alert other physicians to watch out for similar patients.
“The skin is right there right in front of your eyes,” Femia said. “You won’t see it.”
But many doctors may not, in fact, recognize the condition in adults. Only a few dozen MIS-A cases have been reported. And not all patients have obvious rashes.
Dr. Sapna Bamrah Morris, clinical leader for the Health Care Systems and Worker Safety Task Force, part of the CDC’s Covid-19 response, was detailed in 27 cases in a report published by the agency last week.
“The true spread of MIS-A is unknown,” Morris said. “We need to realize physicians. It may be rare, but we do not know. It may be more common than we think.”
Part of the problem is that the virus has been spreading to humans for less than a year. Doctors around the world are still learning about how SARS-CoV-2 works in patients.
Typically, seriously ill Covid-19 patients tend to get to the hospital because they have trouble breathing. That is not the case with 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 Covid-19 tend to be negative.
Instead, patients will test positive for Covid-19 antibodies, meaning they were infected two to six weeks earlier, even though they had no symptoms.
“Just because a person does not show respiratory symptoms as their primary manifestation does not mean that what they are experiencing is not a result of Covid-19,” Morris said.
The disease can be life threatening. Patients usually have some type of severe defect in at least one organ, such as the heart or liver.
Ten patients in the CDC report need to be hospitalized in intensive care units. Some need to be placed in the fans. Two died.
What’s more, the CDC report shows that members of racial and ethnic minority groups appear to be disproportionately affected. Almost all patients with MIS-A are American or Hispanic. But too many cases have been reported to fully understand the underlying mechanisms at play.
While some type of genetic link may be possible, Covid-19 has been shown to be “disproportionately affecting less representative minorities, possibly due to socioeconomic factors,” Femia said. Underlying health conditions that increase the risk for Covid-19 complications, such as being overweight and Type 2 diabetes, also tend to be more prevalent among members of racial and ethnic minority groups.
In the summer, doctors in Florida began to see case increases in the Covid-19 case. Dr. Lilian Abbo, head of infection prevention for Jackson Health System in Miami, recalls a “very high number of people passing through our emergency departments or hospitals.”
The most sensitive and reliable test for Covid-19, called a PCR test, is not always available, and may take several days to return results. Abbo returned to the antibody test to capture the influx of patients who have been exposed to a Covid-19 unit or anywhere in the health system.
People generally develop antibodies to an infection for about a week or more. At least it will give Abbo and his colleagues an indication that Covid-19 is somehow involved in the symptoms of their patients, he reasoned.
Abbo then discovered a subset of patients critically ill after having Covid-19, but without mentioning the pulmonary issues of a severe infection.
“We were a bit unconcerned,” Abbo said. “We will do molecular PCR tests, and they will be negative. Then antibody tests will be positive.”
Further blood tests revealed a very high level of inflammation in the body.
What’s more, while the most serious illness Covid-19 patients tend to be over the age of 65 or have a lot of underlying health problems, these patients are “younger than you expect to not get sick, “said Abbo.
“That’s what got our attention.”
There is no proven treatment for MIS-A. “We need to identify this syndrome and generate data” to find out which therapies may be most effective, “Abbo said. We are all just blindfolded. “
Dr. Jill Weatherhead, an assistant professor of infectious diseases and tropical medicine at Baylor College of Medicine in Houston, mentioned that CDC case reports show that doctors have tried different drugs for MIS-A patients, including steroids and drugs that may affect the immune system, are called interleukin-6 inhibitors.
“The problem with these diseases is that we do not know the mechanisms that cause MIS-A and MIS-C,” Weatherhead said. “It’s hard to know what the treatment standard should be until we have more information.”
In children, MIS-C is usually treated with intravenous immunoglobulin, a blood product that contains various antibodies. That can also be used for adults, but the effects are much less proven.
Intravenous immunoglobulin, or IVIG, differs from another treatment of antibodies derived from the blood, the convalescent plasma. The latter was taken from patients who recovered from Covid-19 and had antibodies specifically targeted at the virus in their blood. IVIG, on the other hand, is more of a hodgepodge of antibodies that are not specific to coronavirus.
The thought is that MIS-A patients already have Covid-19 antibodies, so adding more to convalescent plasma is unlikely to help.
The current theory for MIS-A patients is that “infection, as far as we know, is gone,” said Drs. Hugh Cassiere, director of critical care services for Sandra Atlas Bass Heart Hospital at North Shore University Hospital, part of Northwell Health, in Long Island, New York.
“These are antibodies that have been produced that seem to be causing a problem,” he said.
Cassiere is part of a large team of physicians who treated the surge of Covid-19 patients in New York this spring. Although MIS-A was not yet known at the time, Cassiere was convinced that such patients existed all the time.
“We see patients admitted to the ICU with organ failure,” Cassiere said. They will test negative for Covid-19, he said, but test positive for Covid-19 antibodies, indicating that they have been infected before.
“You look back, and they probably had this multi-system inflammatory syndrome,” Cassiere said. “We don’t have all those pieces to put together.”
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After a month, the puzzle begins to expose itself. But it will take an all-hands-on-deck approach to identify patients with MIS-A.
“It should be at the forefront of every doctor’s intensive care unit who sees patients, especially when they have Covid-19 antibodies,” Cassiere said.
Femia’s experience includes dermatology specialists.
“This is really the beauty of medicine, where, for this syndrome, many different experts need to come together to help the diagnosis,” Femia said.
Physicians are concerned that many MIS-A patients will not be seen – and may not be cured.
“There is not enough data for me to tell you what its long-term effects might be,” Cassiere said. “It might be the end of the iceberg. That’s what I’m worried about.”
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