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Volume 27, Number 11—November 2021

Fatal Multisystem Inflammatory Syndrome in Adult after SARS-CoV-2 Natural Infection and COVID-19 Vaccination

Heather N. GromeComments to Author , Michael Threlkeld, Steve Threlkeld, Charles Newman, Roosecelis Brasil Martines, Sarah Reagan-Steiner, Michael A. Whitt, Maria Gomes-Solecki, Nisha Nair, Mary-Margaret Fill, Timothy F. Jones, William Schaffner, and John Dunn
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (H.N. Grome, R.B. Martines, S. Reagan-Steiner); Tennessee Department of Health, Nashville, Tennessee, USA (H.N. Grome, M.-M. Fill, T.F. Jones, J. Dunn); Baptist Memorial Health Care, Memphis, Tennessee, USA (M. Threlkeld, S. Threlkeld); Methodist LeBonheur Healthcare, Memphis (M. Threlkeld, S. Threlkeld); Pathology Group of the MidSouth, Germantown, Tennessee, USA (C. Newman); Trumbull Laboratories, Germantown (C. Newman); University of Tennessee Health Science Center, Memphis (M.A. Whitt, M. Gomes-Solecki, N. Nair); Vanderbilt University School of Medicine, Nashville (W. Schaffner)

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Results of pertinent laboratory testing completed during the 4-day hospitalization of a patient with fatal multisystem inflammatory syndrome in adult, Tennessee, USA, 2021*

Variable Hospital day
Reference range
Day 1 Day 2 Day 3† Day 4†
Hematologic testing
Peripheral leukocyte count, 1,000/μL 11.0 14.4 28.1 8.8 4.2–10.2
Hemoglobin, g/dL 13.7 11.7 10.8 9.5 12.8–16.4
Hematocrit, % 39.6 33.8 34.3 27.7 38.8–48.1
Platelets, 1,000/μL 110.0 86.0 45.0 17.0 150–400
Absolute neutrophils, 1,000/μL 10.5 13.7 23.9 1.8–7.1
Absolute lymphocytes, 1,000/μL 0.4 0.4 5.0 1.3–5.9
Segmented neutrophil, % 95.3 95.3 76.6 40.0–76.0
Lymphocytes, % 3.8 2.8 15.9 14.0–46.0
Monocytes, %

Chemical testing
Creatinine, mg/dL 1.2 1.3 3.4 1.9 0.70–1.30
AST, U/L 78.0 5,938.0 8,861.0 15–37
ALT, U/L 61.0 3,386.0 3,421.0 16–61
Total bilirubin, mg/dL 1.9 1.4 1.6 0.2–1.0
Alkaline phosphatase, U/L 76.0 74.0 295.0 202.0 45–117
Ferritin, serum, mg/dL


aPTT, s 29.3 54.2 80.9 23.2–34.1
PT, s 13.9 39.6 11.7–14.5
INR 1.1 4.2 3.6 0.9–1.0
Fibrinogen, mg/dL 642.0 750.0 208–475
D-Dimer, µg FEU/mL

Troponin-I, ng/mL


Immunochemical testing
ESR, mm/h 40.0 0–15
C-reactive protein, mg/L 284.0 174.0 <3.0
Procalcitonin level, ng/mL


Microbiologic testing
SARS-CoV-2 RT-PCR, index value Negative Negative
SARS-CoV-2 IgG antibody,‡ index value 4.96 <1.39
Adenovirus DNA PCR, qualitative Not detected Not detected
CMV PCR, quantitative Negative Negative
Mononucleosis screen Negative Negative
Ehrlichia chaffeensis DNA PCR Not detected Not detected
HIV-1 p24 Ag Nonreactive Nonreactive
Peripheral blood culture, 2 sets No growth No growth No growth No growth No growth

*Laboratory values represent pertinent laboratory results during the patient’s hospitalization. Not all laboratory studies completed during hospitalization are represented in this table. Blank cells indicate test not done. ALT, alanine aminotransferase; AST, aspartate aminotransferase; aPTT, activated partial thromboplastin time; CMV, cytomegalovirus; ESR, erythrocyte sedimentation rate; FEU, fibrinogen equivalent units; INR, international normalized ratio; PT: prothrombin time; RT-PCR, reverse transcription PCR; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. †Laboratory values indicate studies after cardiac arrest, which occurred at ≈3 a.m. on hospital day 3. Note patient was initiated on extracorporeal membrane oxygenation shortly after return of spontaneous circulation; anticoagulation treatments affect laboratory values. ‡SARS-CoV-2 IgG test specific for nucleocapsid protein antibody.

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Page created: September 02, 2021
Page updated: October 19, 2021
Page reviewed: October 19, 2021
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.