Introduction

The COVID-19 virus which causes the SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) belongs to a family of viruses that mostly affects animals but can sometimes be transmitted to persons [1]. The recent appearance of COVID-19 and consequently SARS-CoV-2 has led to the current pandemic which is a global sanitary crisis [2]. In children, respiratory affection suggests a more benign illness, but in these patients the appearance of MIS-C (Multi-systemic Inflammatory Syndrome in Children) can be seen, it is associated to shock and myocardial dysfunction. Several coagulopathies have been described, which might be caused by the inflammatory state itself [3-5]. Since April 2020 we have evidenced that MIS-C shares several characteristics with KD (Kawasaki Disease). Both diseases are predominantly seen in male patients, but KD has a predilection for Asian children and MIS-C for afro-descendants and LatinAmericans [6-9]. On the other hand, in the Ecuadorian provinces that have a warm-humid and tropical weather Dengue fever is endemic during the months of November until May. COVID-19 has been associated with Dengue and the development of MIS-C with symptoms and characteristics like KD that can cause death [10]. The goal of this publication is to describe the first known case in Ecuador, in particular the surgical management performed due to the vascular complications seen in this patient who led to the amputation of bilateral forefoot and left hand. Also, it is important to acknowledge the Kawasaki like presentation that can be seen due to the association between COVID-19 and Dengue fever.

Case Presentation

A 5-year-old female patient who is an afro-descendent with history of being hospitalized for 16 days in another Hospital. The patients’ chief complaints were fever 40°C, abdominal pain and dyspnea. Dengue serology was IgM positive. On the second day fever persists, generalized edema and hemodynamic decompensation appear which warrant orotracheal intubation. Supraventricular tachycardia was also seen which was controlled with electric cardio version. On the 9th day COVID-19 PCR test was negative. At the 10th day a COVID-19 rapid test was performed which was positive for both IgM and IgG. At the 16th day of hospitalization there was a cardiac arrest which successfully reverted after 5 minutes of Advanced CPR. After the cardiac arrest, hypertension developed and skin colour changes were seen in the distal region of the inferior limbs and the left hand which progressed to ischemia and necrosis, reason why the patient is referred to a third level Institution (Our hospital) (Figures 1a-1c).

Important laboratory values

Ferritin: 996 ng/mL. D-dimer: 6,4 ug/mL, CKMB 53, CPK 243, CRP 8,6 and a PRO-BNP of 933. CT where ground-glass opacifications are seen (Figure 2) and Echocardiogram shows pericardial effusion. Also, an echo-doppler was performed on the left upper extremity where diminished blood flow can be seen (Figure 3). The patient’s diagnosis was Arterial thrombotic disease of the upper and lower extremities, MIS-C, Heart failure and lung disease secondary to SARS-CoV-2. The patient had a multidisciplinary management by: Pediatric and Plastic surgery, P-ICU and Pediatric Orthopaedic. At the 28th day it was decided to manage it surgically and the patient underwent amputation of the affected areas (Figure 4). After the surgery, the patient was hospitalized during an additional 2 weeks where she received broad spectrum antibiotic coverage and had a favourable evolution which led to her discharge. The patient was then followed with regular controls in the outpatient clinic.