Age: 8.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Electrocardiogram ST segment elevation, Epstein-Barr virus test negative, Gallbladder enlargement, Headache, Hypotension
Clinical narrative: Pediatric Infectious Disease is following this patient for elevated troponin, hypotension, red eyes, chest pain, and abdominal pain with concern for possible MIS-C vs atypical KD.  He has remained afebrile throughout his hospital admission.  Overnight he was starting on IVIG and steroids due to rising BNP and inflammatory markers for suspicion of MIS-C. He was able to be weaned off norepinephrine.  His labs show stable inflammation, but improving troponin, WBC, ALC, and Cr.  ASO titer negative; antiDNAse b pending. CMV and EBV studies negative. COVID Ab sent.    He reports sore throat resolved, abdominal pain improving, still with some chest pain. Red eyes resolved per mom.     Mom at bedside and provided additional history: Tues 3/1: Started with headache/neck pain after being hit by a football at school Wednesday 3/2: Episode of vomiting, not wanting to get up/not feeling well Thursday 3/3: Sore throat started Friday 3/4: Admitted   Patient received his COVID vaccines on 12/10 and 12/30 per mom.  His father had COVID 1/2/22, but was not living at home and did not have contact until he came over 1/16 when he had a negative test.  He is currently staying with them to help care for the other children.  No one else at the home has been sick; none of them have had COVID.  He did have one episode about a month ago where he complained of sore throat that quickly resolved; no other illnesses recently.    Lives at home with mom, dad, 25 year old brother (who is moving out), and 5 other siblings (ages 4, 6, 7, 13 and 17).  His 7 year old sibling has ADHD; otherwise everyone is healthy.  No history of immunodeficiencies, MRSA.  He is UTD on vaccines except yearly influenza.   REVIEW OF SYSTEMS: General: No fever and feeling better overall, HEENT: sore throat resolved.  Eye redness resolved. , Respiratory: reports breathing better with O2 on, Cardiovascular: Hemodynamically stable and off pressors, Gastrointestinal: No abdominal pain/diarrhea, Musculoskeletal: No history of joint swelling, joint pain, or loss of range of motion., Neuro: No headaches and vision improved and Skin: Negative for lesions, rash, and itching  PHYSICAL EXAMINATION:  BP 88/52 | Pulse 107 | Temp (Src) 97.9 (Axillary) | Resp 42 | Ht 4' 3.575" (1.31m) | Wt 77 lb 2.6 oz (35.0kg) | SpO2 97% | BMI 20.40 kg/(m^2).  O2 Therapy: Nasal Cannula, Liters: 2   General: Well appearing, no acute distress and sitting in bed, cooperative, mom at bedside Head: Normocephalic Eyes: Conjunctiva clear, no drainage Mouth: Moist mucous membranes and no red/cracked lips Oropharynx: Normal and normal tongue, no oral lesions noted, no difficulty opening mouth Lymph Nodes: No significant lymphadenopathy Cardiovascular: regular rate; murmur heard yesterday at apex not appreciable on exam today Lungs: tachypnic, but clear bilaterally with NC in place Abdomen: Abdomen is soft, nontender  Extremities: Normal exam without deformities.  Joints are without edema or erythema Neurological: Awake, alert and Answering questions appropriately Skin: Without lesions or rash  Ultrasound abdomen 3/5/22: 1.  Nonspecific gallbladder wall thickening without other findings of  cholecystitis.  This may relate to adjacent hepatic inflammatory process  such as hepatitis, hepatic congestion or low protein state.  Correlation  with LFTs and albumin is recommended.  2.  0.9 cm hyperechoic focus adjacent to the falciform ligament most  consistent with focal fatty infiltration.  3.  Moderate free fluid in all 4 abdominal quadrants.  Small bilateral  pleural effusions.   Patient is a 9 year old male who presented with 3 days of sore throat, bilateral conjunctivitis, abdominal pain, nausea/vomiting, and chest pain with one episode of fever (38.3C in ED) who presented with hypotension and evidence of inflammation and troponin leak with MIS-C vs viral myocarditis.  ARF unlikely with negative ASO titer, GAS testing, and no further fevers.  He was started on IVIG and steroids last night due to worsening labs for presumed MIS-C with improvement in blood pressure as well as some lab parameters (WBC, Cr, troponin).    Plan/Recommendation:  o Recommend discontinuing ceftriaxone and vancomycin if cultures negative at 48 hours o Monitor fevers and clinical course o Continued therapy for MIS-C with guidance of Rheumatology o Will follow pending COVID Ab, antiDNAse B, and throat culture