Infliximab Post COVID-19 Multisystem Inflammatory Syndrome in A Child on ECMO

Study: Introduction: Immunomodulators are gaining attention for multisystem inflammatory syndrome (MIS-C). A timely knowledge gap exists, especially for refractory cases. We describe the use of Infliximab (INF), a monoclonal antibody that binds TNF-alpha, for a child on ECMO with MIS-C. Methods: Case report Results: Case: 13-year-old 86 Kg female presented with 4 days of fever, rash, abdominal pain, diarrhea and vomiting. She tested positive for COVID-19 34 days prior. She was treated with corticosteroids, Anakinra, intravenous immunoglobulin (IVIG) and aspirin. On day 4 of admission, she developed vasodilatory-cardiogenic shock and ventricular arrhythmia despite escalation of vasopressin, epinephrine, intubation and lidocaine infusion. She was percutaneously cannulated for VV-A ECMO (cannulation: 25 Fr femoral and 20 Fr internal jugular veins, 21 Fr femoral arterial, 6 Fr distal perfusion cannula) to support 4.5L/min flow. She received INF 7.5mg/kg, IV, 5 hours post-cannulation. She was anticoagulated with bivalirudin without complications. Anakinra was resumed 2 days later. Laboratory and echocardiographic parameters are shown on Table. Arrhythmia resolved 48 hours post-INF and she was weaned off inotropes. She was decannulated 131 hours post-INF (136 hours of ECMO), and extubated the day after. She remains admitted at the time of this abstract writing. Conclusion: MIS-C post COVID-19 is a newly recognized disease process. INF is a promising therapy to attenuate cytokine storm and a potential rescue strategy for patients with disease refractory to corticosteroids, IVIG, and IL-1 blockade.