LAUSR

A 4-year-old previously healthy child was admitted for persisting fever, conjunctivitis, and skin rush. Nasopharyngeal swab for SARSCoV-2 was negative but anti-SARSCoV-2 IgG was positive (108 U/mL). Laboratory findings showed elevated inflammatory markers (CRP 190 mg/ L, neutrophilia 16.75 10/L) and absence of any other potential causative organisms. At admission, ECG was normal and echocardiogram showed dilatation of the left descending coronary artery (Z score þ3) with normal ventricular function (ejection fraction 57%). Thus, IVIG 2 g/kg, ASA 40 mg/kg, and prednisone 25 mg/die were started with resolution of fever and cutaneous rash. On Day 6, the child was irritable, had several vomit episodes. The ECG showed ST-elevation changes (Panel A), troponin I was 2801 ng/L. Echo showed reduced left ventricular ejection fraction 35%, akinetic septum, and apex, a thrombus occluding a gigantic aneurysmally dilated left descending coronary artery (Panel B). Alteplase was started at standard dose 0.5 mg/kg/h for 6 h with low-dose intravenous heparin (10 U kg 1 h ) and low-dose ASA, followed by an additional Alteplase low-dose cycle (0.05 mg/kg/h for 12 h). ECG and echo after successful thrombolysis are showed in Panels C and D. To the best of our knowledge, this is the first published case of myocardial infarction in children with multisystem inflammatory syndrome following exposure to SARS-CoV-2. COVID-19 in children is generally perceived as benign. Our case could contribute to increase awareness about multisystem inflammatory syndrome SAR-CoV-2 infection related in previously healthy children. (Panel A) Pre-thrombolisys ECG showed new onset right bundle branch block in V1–V3, Q wave, and ST elevation in DIII, aVF, and V4– V5, respectively. (Panel B) Pre-thrombolysis echocardiography showing a thrombus in the left descending coronary artery (star). (Panel C) Post-thrombolysis ECG: disappearance of the RBBB, normalization of the ST segments in DIII–aVF, near normalization in V5, marked reduction in V4, and Q waves in DIII–aVF and V3–V4. (Panel D) Post-thrombolysis echo demonstrating the dissolution of the clot (star) in the left descending coronary artery.