Bilateral intermediate uveitis in a healthy teenager with the multisystem inflammatory syndrome in children secondary to COVID‐19 infection

To the Editor, Coronavirus disease 2019 (COVID‐19) is a novel worldwide pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Children and adolescents generally present with mild symptoms. Nevertheless, 0.14% of them can develop a life‐ threatening complication, the multisystem inflammatory syndrome in children (MIS‐C). This rare but serious condition can lead to multiorgan failure. To date, ocular reports associated with MIS‐C are scarce. We report a case of bilateral intermediate uveitis in a healthy teenager with MIS‐C secondary to COVID‐19 infection. A 14‐year‐old male, the healthy adolescent was admitted for high‐grade fever, vomiting, and rash for 3 days. Initial nasopharyngeal swab for COVID‐19 reverse transcriptase‐polymerase chain reaction (RT‐PCR) was positive and dengue serology was negative. On Day 3 of admission, his condition deteriorated with presumed septic shock, myocarditis with pericardial effusion, pleural effusion, and transaminitis. His lowest blood pressure was 87/48mmHg with a heart rate of 147 bpm and the highest temperature was 40.4°C. He was transferred to the intensive care unit and a comprehensive workup was performed. Notable markedly elevated laboratory investigations were inflammatory markers like C‐reactive protein of 10.83mg/dl and procalcitonin of 16.14 ng/ml. Other elevated levels include D‐dimer level (10.13 μg/ml), ferritin (916.23 μg/L), troponin (176μg/L), and lactate dehydrogenase (336μ/L). Infective screenings like blood, urine, and stool cultures were negative. Computed tomography angiogram of the thorax showed minimal pericardial effusion and bilateral pleural effusion with no evidence of coronary artery aneurysm or pulmonary thrombosis. The diagnosis was revised to MIS‐C secondary to COVID‐19 infection. He required inotrope support for 3 days and received two doses of intravenous immunoglobulin 1 g/kg; subcutaneous enoxaparin 40mg od for 7 days and intravenous dexamethasone 0.2mg/kg for 5 days followed by oral dexamethasone tapered within a month. Intravenous ceftriaxone 1 g bd for 7 days and intravenous azithromycin 250mg od for 5 days were given as prophylaxis. He showed drastic improvement after 10 days of treatment. However, he reported bilateral blurring of vision with floaters and was referred to the ophthalmology team on Day 12 of admission. There were no red eyes, flashes of light, photophobia, or pain. His past ocular history was insignificant. Initial ocular examinations revealed best‐corrected visual acuity of 20/30 in both eyes with normal intraocular pressure of 12mmHg bilaterally. There were bilateral occasional anterior chamber cells with anterior vitreous cells of 1+ (Figure 1). However, there was no conjunctival hyperemia or other signs of anterior uveitis including keratic precipitate, posterior synechiae, peripheral anterior synechiae, iris nodule, or iris atrophy. The cornea and lens were clear. Both pupils were equally reactive and there was no relative afferent pupillary defect. Gonioscopy was normal and funduscopy showed normal retina and optic discs through clear media. Optical coherence tomography of the macula showed bilateral normal macula layers although there were multiple hyperreflective spots in the posterior vitreous (Figure 2B,D) indicating preretinal vitreous cells. There was no intraretinal or subretinal fluid. He was diagnosed with bilateral intermediate uveitis and treated with topical dexamethasone 0.1% qid. His vision improved to 20/20 bilaterally after 2 weeks with no ocular complaints and completely resolved ocular inflammation. Both COVID‐19 and MIS‐C can have ocular manifestations. It varied between 4.3% and 32% with COVID‐19 infection. These include conjunctivitis, corneal subepithelial infiltration, pseudodendrite, and anterior uveitis with ocular hypertension. While the ocular conditions in MIS‐C are less reported, conjunctivitis and bilateral anterior uveitis have been recently reported. In this patient, bilateral intermediate uveitis following MIS‐C secondary to COVID‐19 infection was diagnosed based on the assumption that his symptoms occurred following a severe multisystem inflammation after a positive COVID‐19 PCR test. We did not confirm it with an aqueous or tears PCR test as the positive detection rate of the SARS‐CoV‐2 virus by RT‐PCR of conjunctival tears or secretion is low. The optimal window period for a positive yield in detecting SARS‐Cov‐2 from the conjunctiva has not been determined, and the sampling condition was also not ascertained. We ruled out other common aetiologies of uveitis including tuberculosis with a negative Mantoux test; negative serology for syphilis, HIV, hepatitis B and C; and negative antinuclear antibody for autoimmune diseases such as systemic lupus erythematosus. In any case, the complete resolution of the uveitis with topical corticosteroid suggests a mild form of uveitis that responds well to treatment. Although other possible causes of uveitis cannot be completely excluded due to the absence of additional tests, the time course of the presenting symptoms in this patient strongly suggests an association between the SARS‐CoV‐2 virus and intermediate uveitis.