Severe Dengue With Multisystem Inflammatory Syndrome in Children Due to COVID-19: A Co-infection Case Series

Severe dengue with the multisystem inflammatory syndrome in children (MIS-C) can be difficult to diagnose as both diseases have similar symptoms and laboratory findings. Bangladesh is currently facing a double burden of severe dengue and SARS-CoV-2 infection. Co-infection with these viruses can result in severe morbidity. Worldwide this co-infection is rare. However, we present five cases of severe dengue with possible MIS-C due to SARS-CoV-2 infection in children. All the children presented with shock with variable degrees of plasma leakage. Mucocutaneous and gastrointestinal involvement were common. All tested positive for dengue nonstructural protein 1 antigen on the second to the third day of fever and tested positive for anti-SARS-CoV-2 IgG by enzyme-linked immunosorbent assay. Echocardiographic evaluation in all patients showed coronary arterial abnormalities. Cardiac enzymes were abnormal, and there were raised inflammatory markers and abnormal coagulation profiles. One patient had neurological involvement and needed mechanical ventilatory support. All cases were successfully managed according to dengue shock syndrome guidelines and required intravenous immunoglobulin with prednisolone, aspirin, and in some cases, enoxaparin for the management of coronary arterial involvements, which is not a documented feature for severe dengue infection, but typically found in MIS-C due to SARS-CoV-2 infection or Kawasaki disease. This case series aims to describe the possibility of co-infection of severe dengue with MIS-C due to SARS-CoV-2 infection in a dengue-endemic region during the coronavirus disease 2019 (COVID-19) pandemic, and alternatively, dengue virus as an unusual etiology for Kawasaki disease was also entertained. Severe dengue in endemic regions can coexist with COVID-19 during an outbreak, making it hard to diagnose. It can be fatal without early, appropriate management.