A second case of multisystem inflammatory syndrome associated with SARS-CoV-2 in a liver-transplanted child

To the editor, We read Petters et al.’s case report of a 3yearold liver transplant recipient with multisystem inflammatory syndrome in children (MISC) with great interest.1 Since MISC is a very rare complication of COVID19, the probability of a child with liver transplant developing MISC should be extremely low. We present another case of MISC in a liver transplant recipient, that of a 5yearold boy of Comorian origin, with NBAS deficiency who received a reduced deceased donor transplant at the age of 2 years (previously reported in Chavany et al.2). He developed hepatic artery thrombosis postoperatively and EBVrelated lymphoproliferative disease, which resolved after immunosuppression was decreased. He was on tacrolimus monotherapy at presentation and was admitted to the emergency department for fever (39°C) with abdominal pain and nonbloody diarrhea. Initial laboratory tests showed inflammatory syndrome (C reactive protein (CRP), 58 mg/L; fibrinogen, 5.64 g/L; white blood cells, 6.8 G/L; neutrophils, 4.5 G/L; lymphocytes, 1.4 G/L) and normal hepatic function and enzymes. Fever persisted for 6 days with headaches, asthenia, anorexia, abdominal pain, vomiting, and diarrhea. Ultrasound imaging on hospital days 1 and 5 showed a thickening of the terminal ileum with multiple mesenteric nodes. On day 3, CRP levels had increased up to 247 mg/L, ferritin was at 500 μg/L, triglyceride levels were normal (1.4 mmol/L). He had transient lymphopenia (0.7 G/L). He developed renal failure, with a nadir creatinine level on day 4 of 47 μmol/L (Schwartz creatinine clearance, 63 mL/min) and urea at 10.4 mmol/L with a normal therapeutic tacrolimus level. He also had mildly increased liver enzymes on day 5 which normalized spontaneously. He was treated empirically by triple antibiotic therapy: ceftriaxone for 7 days, metronidazole for 5 days, and amikacin for 2 days. His status improved on day 6 with resumption of feeding and gastrointestinal function. Chest Xray, electrocardiogram and cardiac ultrasonography results were all