Multisystem Inflammatory Syndrome in a Child with Scrub Typhus and Macrophage Activation Syndrome

Kawasaki disease (KD), multisystem inflammatory syndrome in children (MIS-C) and macrophage activation syndrome (MAS) have been speculated as three distinct phenotypes of hyperinflammation seen in children during coronavirus disease (COVID-19) pandemic. KD has been reported in association with dengue, scrub typhus and leptospirosis. COVID-19 and dengue coinfection has also been described. However, MIS-C with concomitant infection has rarely been reported. We report an adolescent girl with clinical and laboratory parameters of MIS-C resembling KD with positive serology for scrub typhus at presentation. Clinical manifestations resolved and laboratory parameters improved with IVIG, azithromycin and corticosteroids. However, she developed fever recurrence with thrombocytopenia, elevated inflammatory markers, hypofibrinogenemia and hypertriglyceridemia which were consistent with MAS. With the emergence of MIS-C and increase in the number of such cases being reported throughout world, physicians should be aware of different phenotypes of hyperinflammation associated with COVID-19 and the possibility of coexistence of MIS-C with other infections.