Fatal Multisystem Inflammatory Syndrome in Adult after SARS-CoV-2 Natural Infection and COVID-19 Vaccination

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A multisystem infl ammatory syndrome in chil- dren (MIS-C) and adults (MIS-A) occurring after coronavirus disease (COVID-19) has been identifi ed; onset is ≈4-6 weeks after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (1-3).A case defi nition for MIS-A has been developed by the Centers for Disease Control and Prevention (CDC) (4); MIS-A after vaccination is rare and remains of great clinical and public health interest (5).We report a case study and histopathologic fi ndings from a fatal MIS-A case after SARS-CoV-2 infection and subsequent complete COVID-19 vaccination. The PatientThe patient was a healthcare worker in his 30s with no notable medical history.In December 2020, he experienced mild COVID-19-like illness symptoms, including fatigue and loss of taste and smell.He did not undergo testing for SARS-CoV-2 at that time and was unaware of the need for isolation.Six days after onset of COVID-19-like symptoms, and when fully recovered, the patient received the fi rst dose of Pfi zer/BioNTech (https://www.pfizer.com) mRNA COVID-19 vaccine.He received the second dose 20 days later.After the second dose, he reported fatigue and malaise, which resolved within 2 days.Twenty-two days after receiving the second dose of the COVID-19 vaccine, he had onset of new fever, malaise, headache, and odynophagia.He was examined by an outpatient medical provider.Diagnostic testing was notable for a negative COVID-19 test by reverse transcription PCR (RT-PCR), negative rapid infl uenza antigen, and negative rapid antigen detection for group A Streptococcus. Four days later, the patient visited an emergency department because of worsening symptoms.Assessment of vital signs revealed a temperature of 37.2°C, heart rate 113 beats/min, and blood pressure of 117/66 mmHg.Physical examination identifi ed right-sided cervical lymphadenopathy, marked bilateral conjunctival erythema, and a faint papular rash on the pelvis and left fl ank.Laboratory testing revealed a peripheral-blood leukocyte count of 11,000 cells/ µL, 93.5% segmented neutrophils, and thrombocytopenia with a platelet count of 110,000/µL (Table).Portable chest radiograph results were without notable fi ndings.On hospital day 2, the patient remained febrile and tachycardic (heart rate 90-135 beats/min) and Fatal Multisystem Infl ammatory Syndrome in Adult after SARS-CoV-2 Natural Infection and COVID-19 Vaccination

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