Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) Aged 12–20 Years in the United States Who Received COVID-19 Vaccine, December 2020 through August 2021

BackgroundMultisystem inflammatory syndrome in children (MIS-C) is a hyperinflammatory condition associated with antecedent SARS-CoV-2 infection. In the United States, reporting of MIS-C after vaccination is required under COVID-19 vaccine emergency use authorizations. This case series describes persons aged 12–20 years with MIS-C following COVID-19 vaccination reported to passive surveillance systems or through clinician outreach to CDC.MethodsWe investigated potential cases of MIS-C after COVID-19 vaccination reported to CDC’s health department-based national MIS-C surveillance, the Vaccine Adverse Event Reporting System (VAERS, co-administered by CDC and the U.S. FDA), and CDC’s Clinical Immunization Safety Assessment Project (CISA) from December 14, 2020, to August 31, 2021. We describe cases meeting the CDC MIS-C case definition. Any positive SARS-CoV-2 serology test satisfied the case criteria although anti-nucleocapsid antibody indicates SARS-CoV-2 infection, while anti-spike protein antibody indicates either infection or COVID-19 vaccination.FindingsWe identified 21 persons with MIS-C after COVID-19 vaccination. Of these 21 persons, median age was 16 years (range, 12–20 years); 13 (62%) were male. All were hospitalized; 12 (57%) had intensive care unit admission, and all were discharged home. Fifteen (71%) of the 21 had laboratory evidence of past or recent SARS-CoV-2 infection, and six (29%) did not. Through August 2021, 21,335,331 persons aged 12–20 years had received ≥1 dose of COVID-19 vaccine, making the overall reporting rate for MIS-C following vaccination 1·0 case per million persons receiving ≥1 vaccine dose in this age group. The reporting rate for those without evidence of SARS-CoV-2 infection was 0·3 cases per million vaccinated persons.InterpretationIn our case series, we describe a small number of persons with MIS-C who had received ≥1 COVID-19 vaccine dose before illness onset. Continued reporting of potential cases and surveillance for MIS-C illnesses after COVID-19 vaccination is warranted.FundingThis work was supported by the Centers for Disease Control and Prevention Clinical Immunization Safety Assessment (CISA] Project contracts 200-2012-50430-0005 to Vanderbilt University Medical Center and 200-2012-53661 to Cincinnati Children’s Hospital Medical Center.Research in context panelEvidence before this studyMultisystem inflammatory syndrome in children (MIS-C), also known as paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS), is an uncommon, but serious, complication described after SARS-CoV-2 infection that is characterized by a generalized hyperinflammatory response. A review of the literature using PubMed identified reports of six persons aged 12–20 years who developed MIS-C following COVID-19 vaccination. Search terms used to identify these reports were: “multisystem inflammatory syndrome in children”, “MIS-C”, “MISC”, “multisystem inflammatory syndrome in adults”, “MIS-A”, “MISA”, “paediatric inflammatory multisystem syndrome”, and “PIMS-TS” each with any COVID-19 vaccine type. There were no exclusion criteria (i.e., all ages and languages).Added value of this studyWe conducted integrated surveillance for MIS-C after COVID-19 vaccination using two passive surveillance systems, CDC’s MIS-C national surveillance and the Vaccine Adverse Event Reporting System (VAERS), and clinician or health department outreach to CDC, including through Clinical Immunization Safety Assessment (CISA) Project consultations. We investigated reports of potential MIS-C occurring from December 14, 2020, to August 31, 2021, in persons aged 12–20 years any time after receipt of COVID-19 vaccine to identify those that met the CDC MIS-C case definition. Any positive serology test was accepted as meeting the CDC MIS-C case definition, although anti- nucleocapsid antibody is indicative of SARS-CoV-2 infection, while anti-spike protein antibody may be induced either by SARS-CoV-2 infection or by COVID-19 vaccination. We investigated 47 reports and identified 21 persons with MIS-C after receipt of COVID-19 vaccine. Of the 21 persons with MIS-C, median age was 16 years (range 12–20 years), and 13 (62%) were male. Fifteen (71%) had laboratory evidence of past or recent SARS-CoV-2 infection (positive SARS-CoV-2 nucleic acid amplification test [NAAT], viral antigen, or serology test before or during MIS-C illness evaluation), and 5 (33%) of those 15 had illness onset after their second vaccine dose. Six (29%) of 21 persons had no laboratory evidence of past or recent SARS-CoV-2 infection, and five of those six (83%) had onset of MIS-C after the second vaccine dose.Implications of all the available evidenceDuring the first nine months of the COVID-19 vaccination program in the United States, >21 million persons aged 12 to 20 years received ≥1 dose of COVID-19 vaccine as of August 31, 2021. This case series describes MIS-C in 21 persons following vaccine receipt during this time period; the majority of persons reported also had evidence of SARS-CoV-2 infection. The surveillance has limitations, but our findings suggest that MIS-C as identified in this report following COVID-19 vaccination is rare. In evaluating persons with a clinical presentation consistent with MIS-C after COVID-19 vaccination it is important to consider alternative diagnoses, and anti-nucleocapsid antibody testing may be helpful. Continued surveillance for MIS-C illness after COVID-19 vaccination is warranted, especially as pediatric COVID-19 vaccination expands. Providers are encouraged to report potential MIS-C cases after COVID-19 vaccination to VAERS.

Telogen Effluvium in Patients recovering from COVID-19

Objective: To characterize and summarize clinical and demographic features in patients with post-COVID 19 Telogen Effluvium and compare with those reported in the literature. Design: A observational study of 10 patients who reported symptoms of Telogen Effluvium following COVID-19 symptoms. Medical history, physical exam and any relevant lab findings were conducted during an initial visit and patients were re-evaluated after 14 weeks. Setting: Patients presented to an outpatient dermatology clinic affiliated with a large, urban academic center New York City from May to August 2020, approximately 3 months after a surge in COVID-19 cases. Participants: Adult patients who were diagnosed with Telogen Effluvium and had laboratory evidence of previous COVID-19 infection who were seen in person or through telehealth virtual visits were consented for this study. Exposures: All participants had laboratory evidence and clinical symptoms consistent with previous COVID-19 symptoms. Main Outcomes and Measures: We collected data from 10 participants and measured average onset of TE from initial COVID-19 symptoms, medical intervention for COVID-19 infection, physical exam findings, and whether or not patient experienced resolution of TE symptoms after 14 weeks. We performed a literature review using the terms “telogen effluvium”, “covid” and “hair” and investigation was limited to adult case reports and cohort studies appearing in the English-Language literature as of March 2021. Clinical and demographic findings were analyzed and compared with those of our patient cohort. Results: Nine out of ten patients in our cohort had mild COVID-19 symptoms only with mean onset of hair shedding was 73 days following infection. None had previous history of hair loss. By contrast, of the 28 patients identified in the literature review 50% of these patients were hospitalized for severe COVID-19 infection with average onset of TE 87 day after infection. 12% of these patients had pre-existing androgenic alopecia. Conclusions and Relevance: Telogen Effluvium is a distressing, yet self-limited condition that can occur following both mild and severe COVID-19 infection. Dermatologists should expect an increase in TE in areas heavily affected by COVID-19 and reassure patients of the likely cause and that symptoms will resolve over time.

Geochronological implications of 210Pb and 137Cs mobility in cave guano deposits

Some recent publications on the paleo- and historical environmental interpretation of bat guano sequences have relied on 210Pb and 137Cs distribution to establish age-depth models, even when these are at odds with radiocarbon models in the lower parts of the sequence. Here, we present both field and laboratory evidence for the unpredictable mobility of lead and cesium in decomposing bat guano deposits. We suggest that 210Pb- and 137Cs-based chronologies of bat guano deposits should only be used when independently supported, for example, by a robust radiocarbon age-depth model.

Adult multisystem inflammatory syndrome in a patient who recovered from COVID-19 postvaccination

Multisystem inflammatory syndrome in children has become a recognised syndrome, whereas a parallel syndrome in adults, multisystem inflammatory syndrome in adults (MIS-A), has not been well defined. Most cases occur several weeks following confirmed or suspected SARS-CoV-2 infection, but none have been reported in association with SARS-CoV-2 vaccines. Here we describe the case of a 22-year-old man, who received the inactivated SARS-CoV-2 vaccine 6 weeks following a mild COVID-19 infection. He presented after his second dose of the vaccine with a clinical picture of a multisystem inflammatory syndrome-like illness. Additionally, there was laboratory evidence of acute inflammation. The patient’s condition markedly improved after initiation of steroids. Whether the vaccine augmented an already-primed immunity from the infection and contributed to the occurrence of MIS-A is difficult to prove. Understanding the pathogenesis of this condition will shed light on this question and entail major implications on treatment and prevention.