Author(s)
Lauren C. Williams, MD
Kiley Trott, MD
Sarah Maurrasse, MD
Affiliation(s)
Otolaryngology- Head and Neck Surgery, Yale University School of Medicine, New Haven, CT.;
Abstract:
Delays in Diagnosis of COVID-19-Associated Multisystem Inflammatory Syndrome in Children due to Suspected Head and Neck Infections
Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) is a hyperinflammatory syndrome caused by immune system dysregulation following either symptomatic or asymptomatic COVID-19 infection. It often presents with fever, and in severe cases, hemodynamic instability, which can be misdiagnosed as sepsis if there is suspicion for infectious etiology. Here we describe two patients who presented with suspected head and neck infections but who were ultimately diagnosed with MIS-C. We argue that the presence of these suspected infections led to an anchoring bias which delayed accurate diagnosis.
Case Descriptions: Case #1: A 15-year-old female presented with profound hypotension, fevers, and sore throat, with imaging suggestive of retropharyngeal fluid collection. Urgent operative exploration revealed retropharyngeal phlegmon without abscess. Postoperatively, her hypotension and fevers persisted, and on further workup she was found to have MIS-C.
Case #2: A 14-year-old male re-presented with fevers after having undergone mastoidectomy for acute mastoiditis two weeks prior. Despite lack of otologic symptoms, he was taken back to the operating room for re-exploration of the mastoid cavity, which revealed post-surgical changes without infection. Postoperatively he underwent additional workup which led to a diagnosis of MIS-C.
Discussion: In both cases, despite atypical presentations for suspected otolaryngologic infections, it was only after surgical intervention that other diagnoses such as MIS-C were considered. These cases highlight the nonspecific constellation of symptoms associated with MIS-C as well as a tendency to associate these symptoms with infectious processes before considering inflammatory processes. In cases of unusually severe systemic symptoms or unexplained postoperative fevers, surgeons should consider MIS-C as an alternative diagnosis.