Infectious diseases

A 21-year-old white man presented with a 3-day history of central blurry vision in his right eye in the context of 3 weeks of right frontotemporal headaches and earaches, fevers, and drenching night sweats

Peter ZX Cui · Elaine Chong · Thomas G Campbell

A 70-year-old man was admitted for investigation of confusion, agitation and falls

Andrew P Gador‐Whyte · Jared Harris · Karen Gunanayagam · Aaron Walton · Andrew Hughes · Eugene Athan

A 51-year-old man presented with a 24- hour history of headache, neck stiffness, photophobia and lower abdominal rash

Rhiannon L Holdsworth · Elizabeth Downie · Matthew J Georgiades · Ross Bradbury · Julian Druce · James Collett

TO THE EDITOR: Multisystem inflammatory syndrome in children (MIS‐C) or adults (MIS‐A) is a rare but severe systemic inflammatory syndrome,1 with an epidemiological peak occurring 4–6 weeks after severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) outbreaks.2 Also known as paediatric inflammatory multisystem syndrome temporally associated with SARS‐CoV‐2, MIS‐C is the subject of active surveillance across paediatric centres.3 The peak age for the syndrome is 9 years,1 although cases have been reported in adults.4 We report, to our knowledge, the first Australian case of MIS‐A, diagnosed 2 months into the SARS‐CoV‐2 Delta outbreak in New South Wales, with 60 075 coronavirus disease 2019 (COVID‐19) notifications in the period 29 June to 4 October 2021.5 A 42‐year‐old woman presented with 7 days of subjective fevers, myalgia, light‐headedness, abdominal pain, nausea, palpitations and non‐pleuritic chest pain. Presentation occurred 27 days after acute COVID‐19 pneumonitis, confirmed by polymerase chain reaction and serology testing. The acute illness was mild, requiring neither oxygen nor hospitalisation, and the patient recovered fully 72 hours before onset of this new symptom complex. She was unimmunised against SARS‐CoV‐2. The patient was febrile (38.2°C), with tachycardia (114 beats per minute) and hypotension (79/56 mmHg) but no respiratory distress. She had bilateral conjunctival injection, a widespread blanching macular rash (Box), and oedema of the hands bilaterally. There was no lymphadenopathy or oral mucosal change. Investigations revealed significant inflammation, with a raised C‐reactive protein level (119 mg/L; reference interval [RI], ≤ 4 mg/L), lymphopenia (0.5 × 109/L; RI, 1.0–4.0 × 109/L), thrombocytopenia (74 × 109/L; RI, 150‐400 × 109/L), neutrophilia (12.2 × 109/L; RI, 2.0–8.0 × 109/L), deranged liver function tests (alanine transaminase, 160 U/L; RI, 10–35 U/L), and hypoalbuminemia (20 g/L; RI, 35–50 g/L). Her D‐dimer level was raised (2.34 mg/L; RI, < 0.5 mg/L), as was her brain natriuretic peptide level (1660 ng/L; RI, ≤ 125 ng/L); troponin and creatine kinase levels were normal. Blood and urine cultures were negative, and anti‐streptolysin O and anti‐DNase B titres were not raised. No echocardiographic evidence of myocarditis was seen, and there was no coronary artery dilatation. The patient responded to two doses of intravenous immunoglobulin (2 g/kg each) following 48 hours of inotropic support (metaraminol infusion then low dose noradrenaline). Aspirin (3 mg/kg daily) was administered, as well as intravenous antibiotics for 72 hours while cultures were pending. MIS‐A was diagnosed on the basis of current case definitions,6,7 although the patient also fulfilled criteria for probable toxic shock syndrome, as described in other case series.8 Adults and adolescents with MIS‐A typically present with multisystem involvement, often incorporating myocarditis, shock and gastrointestinal features,4,9 whereas younger children present more commonly with a Kawasaki disease‐like illness.9 Given the absence of specific diagnostic markers, the overlapping phenotype with toxic shock syndrome and the poor sensitivity of cultures and serological markers for these alternative diagnoses, such differentials must be carefully considered in the early phase of illness. Nonetheless, clinicians should be aware of MIS‐C or MIS‐A in patients presenting with shock, mucocutaneous changes and/or gastrointestinal symptoms, even without preceding symptomatic SARS‐CoV‐2 infection. Prompt treatment with intravenous immunoglobulin and/or steroids is essential to minimise long term morbidity from coronary artery dilatation.1 Although rare, further cases of MIS‐C and MIS‐A are anticipated following increasing COVID‐19 case notifications in NSW and Victoria. This letter was published as a peer‐reviewed Accepted Article (prior to structural editing and typesetting) on 14 October 2021. Box – Bilateral conjunctival injection (A) and diffuse blanching macular rash (B) in an adult with multisystem inflammatory syndrome

Annaleise R Howard‐Jones · Sam R Orde · Zoe Jennings

A 66-year-old man presented to a tertiary emergency department following a fall

Sophie C Burn · Akash Kalro

To the Editor: Burrell and colleagues captured data from 77 hospitals containing 91% (n = 204) of coronavirus disease 2019 (COVID‐19) intensive care unit (ICU) cases during the first four months of the pandemic.1 Overall mortality (n = 30, 15%) for mechanically ventilated and non‐ventilated patients in this study was lower than other published data. In contrast, overseas reports have indicated mortality rates for patients with COVID‐19 admitted to ICUs of 40%, 44%, 60% and 70% in the United Kingdom, China, Italy and the United States, respectively.2 Evidence indicates that within developed countries, mortality rates associated with COVID‐19 vary according to physiological parameters but also markedly according to location.3 Low ICU bed occupancy and the distribution of cases across a large number of institutions1 has positively influenced Australian COVID‐19 mortality rates. Less obvious is the role and effect of critical care nurses. ICU nurse to patient ratios in Australian units were 1:1 and 2:1 for 77.8% and 7.5% of ICU days, respectively.1 Mortality is affected by local practice3 and in countries where ratios of 1:6 or more are common,2 mortality rates in ventilated patients can exceed 80%.4 Globally, point‐of‐care pandemic practice in ICUs has involved fewer critical care nurses, variously supported by redeployed nurses without critical care qualifications or experience. Critical care nurse expertise augments pre‐emptive rather than reactive strategies for ICU patient management. In the study by Burrell and colleagues, invasive ventilation was instituted for 119 (58%) patients: 79 (66%) of these on day 1, increasing to 94/113 (83%) by the end of week 1.1 Eighty‐five (42%) patients were able to be supported with either non‐invasive ventilation, high flow oxygen therapy or supplemental oxygen, monitored and managed by critical care nurses. Within an ICU model of care, critical care nurse staffing levels, skills mix, advanced practice functions and level of education ensure the high quality and safety of care delivery. Australian critical care nurses are expert clinicians with advanced education, training and experience who directly influence patient outcomes at the micro (patient and family), meso (unit or organisation) and macro (policy) level.5 Clearly elucidating workforce issues and composition is critically important for documenting models of care and associated outcomes in critical care.

Rochelle Wynne · Caleb Ferguson · Patricia M Davidson

In reply

Aidan JC Burrell · Tessa Broadley · Andrew A Udy