Kawasaki-like illness following COVID-19 infection in a minor β-thalassemic girl Giusto Trevisan 1 , Serena Bergamo 2 , Serena Bonin 2 ✉ 1 Department of Medical Sciences, University of Trieste, Trieste, Italy. 2 Dermatology Unit, ULSS 2 Marca Trevigiana, Ca’ Foncello Hospital, Treviso, Italy. 35 2025;34:35-39 doi: 10.15570/actaapa.2025.10 Introduction During the COVID-19 pandemic, some children infected with COV- ID-19 developed symptoms a few weeks after infection, including prolonged fever, conjunctivitis, oral mucosal alterations, cervical lymphadenopathy, and skin rashes. These symptoms can be clas- sified under post-COVID-19 multisystem inflammatory syndrome (MIS) or Kawasaki-like illness (KLI), which is considered in the differential diagnosis of Kawasaki disease (KD) (1). Although these conditions share several symptoms, they differ notably in terms of the age of onset. MIS has been diagnosed in neonates (MIS-N) (2), children up to 8 years old (MIS-C), and older children up to 19 and 21 years old (MIS-A) (3), whereas the age of onset of KD is between 0 and 5 years. The most widely accepted definition of MIS is the one proposed by the Centers for Disease Control and Prevention (CDC) (4), which includes clinical symptoms and signs developing within 60 days of COVID-19 detection. The diagnosis of MIS-C requires the fulfillment of the following criteria: i) Fever (≥ 38 °C) ii) Clinical severity necessitating hospitalization iii) Evidence of systemic inflammation, indicated by a C-reactive protein (CRP) level ≥ 3.0 mg/dl iv) New-onset manifestations in at least two of the following cat- egories: a) Cardiac involvement b) Mucocutaneous involvement, characterized by oral mu- cosal inflammation, lip fissuring, strawberry tongue, and conjunctivitis c) Shock d) Gastrointestinal involvement e) Hematologic abnormalities, including a white blood cell count > 10,000/mm³, lymphopenia, and a platelet count < 150,000/µl v) Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA via molecular amplification testing (PCR) in a clinical specimen within 60 days prior to or during medi- cal evaluation vi) Exclusion of alternative diagnoses (4, 5). In addition to the clinical forms meeting all the abovementioned criteria, less serious cases have been reported as self-limiting MIS in children (6). KD is a form of vasculitis, affecting medium-sized vessels. It is characterized by a fever lasting more than 5 days and at least four clinical criteria: bilateral non-exudative bulbar conjuncti- vitis, changes in the lips or oral cavity, non-suppurative cervical lymphadenopathy, polymorphic rash, erythema, and edema of the hands and feet (7–9). In rare cases, clinicians may establish the diagnosis with fewer than 5 days of fever. The etiology of KD re- mains unknown, but it is hypothesized that some viral infections, including adenoviruses and coronaviruses, may act as triggers (10) in genetically predisposed children (7). Cases of KD or KLI have been reported after COVID-19, even in asymptomatic forms (11). Al- though KD is similar to MIS, there are some differences, as outlined in Table 1 (12). Case report An 8-year-old girl presented in late November 2023 with flu- like symptoms, diffuse myalgia, mild fever, and a positive PCR- based swab test for COVID-19. She is affected by a mild form of β-thalassemia, inherited from her mother, previously diagnosed in the pediatrics department and documented by a consistently low Mentzer index (< 13). When she was 6 years old, she developed her- petic keratitis in her left eye, which was successfully treated with acyclovir. In mid-November, she experienced mild flu-like symptoms, in- cluding a brief cold lasting a few days. Approximately 5 days later, a molecular swab test for COVID-19 was performed, yielding a positive result. However, 3 weeks later, she developed a high fever (39–40 °C) persisting for 4 days, accompanied by bilateral non-ex- udative conjunctivitis, inflammation of the lips and oral mucosa, strawberry tongue, and pruritic erythematous patches on her legs, as shown in Figure 1a. In the subsequent days, the erythematous patches on her legs expanded, and new lesions appeared on her face and trunk (Fig. 1b). The patient was taken to the emergency department, where hos- pitalization was initially recommended but ultimately replaced by Abstract Multisystem inflammatory syndrome (MIS), also known as a Kawasaki-like illness, is a rare condition linked to severe acute respir- atory syndrome coronavirus 2 (SARS-CoV-2). It presents with systemic inflammation and organ dysfunction, and it shares several clinical features with Kawasaki disease (KD). This case report describes an 8-year-old girl that developed symptoms suggestive of MIS or KD several weeks after a COVID-19 infection. She experienced a high fever lasting 4 days, followed by the appearance of itchy, erythematous patches on her legs, which later spread to her trunk and face. The inflammatory symptoms resolved spontane- ously in less than 2 months without any lasting effects. Keywords: multisystem inflammatory syndrome, Kawasaki-like illness, COVID-19, children, β-thalassemia Acta Dermatovenerologica Alpina, Pannonica et Adriatica Acta Dermatovenerol APA Received: 3 September 2024 | Returned for modification: 27 November 2024 | Accepted: 4 March 2025 ✉ Corresponding author: sbonin@units.it 36 Acta Dermatovenerol APA | 2025;34:35-39 G. Trevisan et al. a 5-day observation stay. She experienced intense pruritus associ- ated with her skin lesions, prompting the initiation of prednisone at 1 mg/kg per day for 3 weeks. However, this treatment did not provide relief because the lesions continued to expand over 3 weeks before gradually regressing and resolving within approxi- mately 1 week. The cutaneous manifestations included erythematous patches on the face, forehead, trunk, and lower limbs, as well as erythema Table 1 | Symptoms of multisystem inflammatory syndrome (MIS) and Kawasaki disease (KD) and case report data. Clinical case MIS-C KD Age (years) 8 6–11 < 5 Geographic area Italy Europe, North America, Africa, Asia; highest incidence in children of African and Hispanic heritage Asia, Europe, North America; highest incidence in Japan, China, South Korea, Taiwan (35) Fever 4 days 3–5 days ≥ 4 days Clinical severity / hospitalization Two emergency room visits, proposed hospitalization, emergency room observation Hospitalization Hospitalization, especially cases with cardiac involvement Skin manifestations Large patches of rash, telogen effluvium Maculopapular rash, skin eruptions Maculopapular diffuse erythroderma or erythema multiforme-like; less commonly urticarial or fine micro- pustular eruptions Mucous involvement Lip and oral inflammation, strawberry tongue Lip and oral inflammation Erythema and cracking of lips, strawberry tongue Lymphadenopathy Absent Some cases Acute, non-suppurative cervical lymphadenopathy Ocular involvement Bilateral non-purulent conjunctivitis especially on right Non-purulent conjunctivitis Bilateral non-exudative conjunctival infection, often limbic sparing Changes in extremities Erythema and edema of hands, especially thumbs Erythema of hands and feet Acute phase: erythema and edema of hands and feet; sub-acute phase: periungual desquamation Cardiovascular manifestations Echocardiography and troponin normal Myocardial disfunction, coronary abnormalities, pericarditis Myocardial disfunction, coronary abnormalities, pericarditis Abdominal pain Absent Relatively high incidence of gastrointestinal symptoms and abdominal pain Abdominal pain (not always) C-reactive protein 3.94 mg/dl ≥ 3.0 mg/dl ≥ 3.0 mg/dl White blood count 12,340/mm³, neutrophils = 77% > 10,000/mm³, according to (36) > 20,000/mm³ > 15,000/mm³, neutrophilia Platelets Thrombocytosis: platelets = 580,000/mm³ Thrombocytopenia: platelets < 150,000/mm³ Thrombocytosis: platelets > 450,000/mm³ ALT Normal Normal Elevation above normal range Autoimmunity ANA = 1:160 Autoantibodies could be involved in pathogenesis (13) Autoantibodies in 22% (14) Trigger Onset around 3–4 weeks after SARS-CoV-2 exposure Onset around 3–6 weeks after SARS-CoV-2 exposure Unknown but some data suggest possible preceding viral or bacterial infection Detection of SARS-CoV-2 RNA Yes Yes Some cases MIS-C = Multisystem Inflammatory Syndrome-Children, KD = Kawasaki disease, SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2, ANA = antinu- clear antibody, ALT = alanine aminotransferase. Figure 1 | Dermatological manifestations developed by the patient: erythematous patches on the legs (a) and trunk (b). 37 Acta Dermatovenerol APA | 2025;34:35-39 Kawasaki-like illness in a β-thalassemic girl and edema of the hands, particularly affecting the thumbs. The lesions were persistent, with some on the thighs reaching up to 10 cm in diameter or larger. Physical examination revealed conjunc- tivitis, more pronounced in the right eye, along with a moderately swollen tongue, cheilitis, and hair loss. The patient experienced hair loss of approximately 15% to 20%, which developed 2 months after COVID-19 infection and 1 month following the onset of skin manifestations. This presentation was consistent with telogen effluvium, likely attributable to COVID-19 rather than the subse- quent inflammatory syndrome. Laboratory findings showed leukocytosis (white blood cell count = 12,340 cells/µl) with moderate neutrophilia (neutrophils = 76.9%, lymphocytes = 14.6%, monocytes = 8.2%, eosinophils = 0.1%, basophils = 0.2%). Additional hematologic values in- cluded red blood cell count = 5,690,000 cells/µl, hemoglobin = 11 g/dl, mean corpuscular volume = 64 fl, and a Mentzer index of 11.25. Platelet count was elevated at 580,000 cells/µl. Inflam- matory markers included CRP = 3.94 mg/l and erythrocyte sedi- mentation rate = 30 mm/h. Liver function tests showed aspartate aminotransferase = 17 U/l and alanine aminotransferase = 14 U/l. Cardiac assessment revealed a troponin T level < 0.1 μg/l. Immu- nologic analysis demonstrated an elevated total immunoglobu- lin M level of 187.0 mg/dl, an antinuclear antibody (ANA) titer of 1:160, and anti-tissue transglutaminase IgA < 0.1 U/ml. Serum iron levels were normal (64 µmol/l) in previous tests, including during the COVID-19 infection. However, these levels rose to 315 µmol/l in January 2024 before returning to normal in February 2024. The symptoms of the inflammatory syndrome re- solved spontaneously by late January 2024, although the patient experienced sleeplessness for 3 consecutive nights following re- covery. Platelet counts decreased to 437,000 cells/µl in December 2023 but returned to normal (323,000 cells/µl) in January 2024. An echocardiogram was performed, with normal results. The COVID-19 infection and associated MIS/KD/KLI lasted less than 2 months, from the end of November 2023 to the end of Janu- ary 2024. At the follow-up in February 2024, her skin appeared normal. The mother reported that, during the previous week, on two or three non-consecutive mornings, the patient woke up very early, around 5:00 am, and was unable to sleep thereafter. However, the patient did not experience fatigue or other symptoms during the day. Echocardiography, troponin T (< 0.1 μg/l), and brachial artery blood pressure (100/50 mmHg) were all within normal limits. Blood tests were normalized, showing an erythrocyte sedi- mentation rate = 2 mm/h, CRP = 0.69 mg/l, red blood cell count = 5,320,000 cells/µl, hemoglobin = 10.7 g/dl, mean corpuscular volume = 63 fl, Mentzer index of 11.84 (< 13), white blood cell count = 5,200 cells/µl (neutrophils = 48%, lymphocytes = 38.5%, monocytes = 8.5%, eosinophils = 4.4%, basophils = 0.6%), plate- let count = 323,000 cells/µl, transferrin = 251 mg/dl, fibrinogen = 214 mg/dl, and D-dimer = 0.259 µg/ml fibrinogen equivalent units. Liver function tests showed aspartate aminotransferase = 21 U/l, alanine aminotransferase = 12 U/l, and lactate dehydrogenase = 216 U/l. The ANA test was negative, and molecular testing for COVID-19 was negative. Discussion In COVID-19, particularly in children, skin manifestations can emerge, making it difficult to determine whether they are directly attributable to the infection. During the post-infectious phase, a papulo-macular eruption may occur, often accompanied by urti- caria and sometimes with vesicular components, which presents a clinical picture distinct from that observed in the girl described in this case. Other post-COVID skin manifestations include live- doid changes and lesions, such as purple discoloration on the toes, which are especially common among younger individuals (10). The precise diagnosis of these systemic vasculitic forms can be challenging. There are overt forms of MIS-C as well as “self- limiting” forms that meet the criteria for KD (6, 15). Although MIS-C shares many similarities with KD, the classic symptoms of KD, such as bilateral conjunctival infection, strawberry tongue, and rash, are not always present. Laboratory findings indicate that MIS-C typically presents with significantly higher CRP levels, ferritin, and D-dimer, elevated cardiac enzymes, and a reduced lymphocyte count in the complete blood count, in contrast to KD (11). Pediatric patients with COVID-19 (especially those under 18, particularly those 5 years old or younger) are at an increased risk of developing MIS-C and KD (16). COVID-19 has also been linked to KLI (1, 17), even in patients with mild or paucisymptomatic in- fections, as seen in our case (11). The diagnosis in this child is complex because she meets the criteria for both MIS-C and KD. She experienced fever for 4 days following a positive molecular test for COVID-19 3 weeks prior. The clinical presentation was significant enough to warrant hospitali- zation; however, at the parents’ request, the child was instead observed in the emergency room. The girl exhibited CRP levels exceeding 3.0 mg/dl with mucocutaneous involvement, charac- terized by inflammation of the oral mucosa, fissuring of the lips, strawberry tongue, and conjunctivitis and abnormal blood test results (white blood cell count > 10,000 mm³ and platelet count > 500,000 mm³). These findings should be considered when evalu- ating other differential diagnoses. Nevertheless, there are some aspects that can instead point toward a KD or KLI diagnosis: there was fever, bilaterality of conjunctivitis, fissures of the lips, changes of the oral cavity, strawberry tongue, polymorphic rash, and edema of the hands. The CRP value was weakly positive (in MIS-C it is usually higher than in KD), and the abdominal pain characteristic of MIS-C was absent in our patient. Another aspect supporting KD was the in- crease in platelets (580,000 cells/μl), which in MIS are normal or decreased. In contrast, the absence of lymphadenopathy points to a self-limiting MIS-C. The presence of ANA can be observed both in KD (22%) (14) and in MIS-C (13). The dermatological lesions developed by the patient were not discriminatory to support the diagnosis of MIS-C or KD. Taking this evidence into account, we believe that a post-COVID-19 inflammatory vasculitic form with a heterogeneous spectrum of clinical characteristics resembling both MIS-C and KD or KLI may have developed (18). The telogen effluvium observed in our patient is more likely a consequence of COVID-19 infection than a manifestation of inflammatory syn- drome, as already reported (Table 2) (19, 20). The transient iron overload observed in our patient after MIS Table 2 | Hair loss characteristics and case report data. Hair loss: clinical presentation Telogen Anagen Clinical case Onset of shedding after infection 2–4 months 1–4 weeks 2 months Hair loss 20%–50% 80%–90% 20% Hair shaft Normal Narrowed or fractured Normal 38 Acta Dermatovenerol APA | 2025;34:35-39 G. Trevisan et al. References 1. 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Distinguishing multisystem inflammatory syndrome in children from COVID-19, Kawasaki disease and toxic shock syndrome. Pediatr Infect Dis J. 2022;41:315– 23. 27. Belay ED, Erdman DD, Anderson LJ, Peret TC, Schrag SJ, Fields BS, et al. Kawa- saki disease and human coronavirus. J Infect Dis. 2005;192:352–3. could be related to β-thalassemic or autoimmune hemolysis (21), as supported by the detection of ANA (1:160) (22), which was neg- ative in February 2024. KD is a vasculitis of early childhood, and it is the most common cause of cardiac ischemia in this age group. The etiology of KD remains unknown (23). However, it seems to be due to an abnor- mal immunologic response due to exposure to infectious agents (24). This hypothesis is supported by the observed increase in KD cases during the winter months, when influenza viruses are more frequent (25). To date, the specific microorganism responsible has not been identified, although some authors have suggested virus- es, such as adenoviruses (26) and coronaviruses (27), as potential etiological or triggering agents (17). The clinical case described above can be interpreted as a post- COVID inflammatory syndrome with clinical and laboratory as- pects resembling both MIS and KD (17). Some studies before the COVID-19 pandemic showed that 7% of patients with symptoms of KD had tested positive for corona- viridae, particularly the Haven coronavirus (HCoV-NH), similar to HCoV NL-63, which has attracted more attention (28). Specifically, eight out of 11 KD patients (72.7%) tested positive for HCoV-NH by PCR (29). It is noteworthy that serological tests to detect the virus showed a higher infection rate than PCR-based detection (30). The potential causative role of COVID-19 in MIS/KLI is further supported by evidence that, during the pandemic, the number of patients affected by clinical manifestations similar to KD in an Italian province—an epicenter of the SARS-CoV-2 outbreak—was 30 times higher than usual (31). The significant inflammatory response to the novel coronavi- rus, along with epidemiological studies, supports the theory of COVID-19 as a trigger for the immune system and as an etiological agent for MIS (32). The girl described above, as reported in other cases, was positive for COVID-19 some weeks before the develop- ment of MIS. Conclusions The incidence of children presenting with characteristics resem- bling MIS similar to KD increased during the COVID-19 pandemic. However, cases have also been observed in the post-pandemic phase (33), as for our patient. 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