Rare disease mimicking Multisystem İnflammatory Syndrome In Children

Rare disease mimicking Multisystem İnflammatory Syndrome In Children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Rare disease mimicking Multisystem İnflammatory Syndrome In Children asuman akar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7469493/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Multisystem inflammatory syndrome (MIS) is a rare but serious condition associated with SARS-CoV-2, the virus that causes COVID-19, in which different internal and external body parts become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, gastrointestinal tract. In this report, a female patient who presented with complaints of fever, abdominal pain, headache and fatigue lasting for seven days and whose systemic examination revealed positive findings of meningeal irritation is presented. The patient was initially evaluated as MIS-C due to the presence of hematological, gastrointestinal and central nervous system involvement along with fever and Covid antibody positivity, and was diagnosed with Visceral leishmenia in further examinations. Pediatrics Multisystem İnflammatory Syndrome In Children Visceral leishmenia Figures Figure 1 İntroduction In December 2019, a new coronavirus Severe Acute was detected in the city of Wuhan. respiratory Syndrome Identified as Coronavirus − 2 (SARS- CoV − 2) ( 1 ). A pandemic was declared by the World Health Organization on March 11, 2020. On April 27, 2020, The Pediatric Intensive Resort The Society of the United Kingdom is a multisystem disease with overlapping disease characteristics with Kawasaki Disease (KD) and Toxic Shock Syndrome, most of which test positive for COVID-19. issues a warning about the increasing number of children presenting with an inflammatory disease ( 2 ). The first report of this syndrome came from the United Kingdom, a cohort of 8 children with evidence of severe inflammation and Kawasaki disease-like features. ( 3 ). From May 22 to May 29, 2020, working groups, the US Centers for Disease Control and Prevention (CDC), the world health organization and the Royal College of Paediatrics and child Health (RCPCH) reported this disease in children associated with COVID − 19 in a multisystem inflammatory syndrome (MIS-C). The case definition was made as evidence of fever, hypotension/cardiac shock, high troponin, d - dimer, increase in acute phase reactants and SARS-COV-2 in individuals under 19 years of age (4; 5; 6). It occurs approximately 4–6 weeks after acute SARS-CoV-2 infection and develops from an excessive immune response triggered by the infection rather than the acute manifestation of the viral disease.Although the exact etiology has not been clearly clarified, it is thought that the current picture is immune dysregulation after infection. ( 7 ). Case report A 16-year-old 4-month-old female patient no relevant past medical history was brought to the Emergency Room with the complaints of general condition disorder, fever, abdominal pain, and headache that started 7 days before her admission. Systemic examination: fever: 40°C, respiratory rate: 20/ min blood pressure: 100 /60 mmHg oxygen-free saturation : 99% GCS: 15 poor general condition, frail appearance, positive neck stiffness, herpes around the lips labialis was present. No feature was detected in other systemic examination. White blood cell count: 1530 /mm3 neutrophil count: 610/mm lymphocyte count: 230/mm3 hemoglobin: 10.2 g/ dl platelet : 27000 d- dimer : 12790 ng / ml⁹ C-reactive protein: 59.5 mg/L procalcitonin : 0.68 ng / ml sedimentation : 53 mm/ st ferritin : 3176 µg/L triglyceride : 268 mg/ dl fibrinogen: 100mg/ dl Aspartate Aminotransferase : 321 U/L Alanine aminotransferase : 344 U/L lactate dehydrogenesis : 4264 U/L. She has never been vaccinated with a covid vaccine before. Covid PCR negative, no agent detected in respiratory virus panel. Covid IgM negative and IgG positive in rapid antibody test. COVID IgG was against both the nucleocapsid or spike protein. High fever, central nervous system involvement, gastrointestinal system involvement, high acute phase reactants, and antibody positivity were considered as MIS-C. Meninges lumbar puncture was performed in the patient with positive evidence of irritation, glucose : 54 mg/ dl, protein: 21 mg/ dl, no cells were seen in direct examination. There was no growth in the culture. Since the patient can not differentiate between cefotaxime and secondary HLH-MIS-C, less than 2 gr/ kg ivig replacement was given. Blood, urine, bone marrow aspirate culture, ebstein barr, cytomegalovirus, toxoplasma, herpes simplex, adenovirus, parvovirus -B19, Human Immunodeficiency Virus (HIV), hepatitis, brucella serology was sent and it was found negative. Abdominal ultrasonography hepatosplenomegaly was not detected. No pathology was observed in echocardiography. On day 3 of hospitalization bone marrow aspiration was performed to exclude leukemia in the patient who had pancytopenia and did not respond to IVIG replacement therapy. Bone marrow aspiration amastigote was seen (FİGURE-1) . Patient classified as visceral leishmania. Liposomal Amphotericin B treatment was started at 3 mg/kg/ day. On the 3rd day of his treatment, his pancytopenia improved, fever height decreased. The treatment was completed for 7 days. Discussion There is a wide clinical spectrum in patients with MIS-C ( 8 ). If there is no alternative diagnosis and fever, high inflammatory symptoms and two or more system involvement are detected in a patient with contact with a known COVID case or COVID PCR positivity or COVID antibody positivity, MIS-C is diagnosed ( 9 ). Systemic examination of the patient revealed high fever, abdominal pain, headache; pancytopenia, elevated ferritin, elevated liver function tests, elevated lactate dehydrogenase, and covid antibody positivity. MIS-C could not be ruled out because of fever, elevated acute phase reactants, haematological, gastrointestinal and central nervous system involvement. Lumbar puncture was performed in the patient whose cerebral tomography showed no pathology and cerebrospinal fluid examination did not reveal any findings in favour of infection. brucella serology, which is the most common zoonosis in our region, was first sent and found negative. ebstein barr, cytomegalovirus, toxoplasma, herpes simplex, adenovirus, parvovirus -B19, Human Immunodeficiency Virus (HIV), hepatitis serologies sent simultaneously were negative. IVIG replacement was firstly tried because of the patient's poor clinical condition and secondary haemophagocytic syndrome was detected. No infectious disease was detected in serological tests and visceral leishmania was diagnosed with amostigote in bone marrow biopsy performed to rule out possible leukaemia. Visceral leishmenia is one of the most widespread human diseases, with more than 20 Leishmania species identified worldwide. It is a zoonosis that is transmitted to humans through Phlebotomus flies and can be life-threatening if not treated( 10 ). It is among the most neglected infectious diseases ( 11 ). Approximately 0.2 to 0.4 million cases of visceral leishmaniasis occur each year ( 12 ). Typical clinical findings are fever, pancytopenia, organomegaly, and elevation of inflammation markers. The laboratory findings are leukopenia, neutropenia,lymphocytosis, and monocytosis and increased transaminases. It has been reported that hemophagocytic lymphohistiocytosis accompanies in 2% of cases ( 13 ). Mild nonspecific neurologic signs findings may be observed in cases accompanied by hemophagocytic lymphohistiocytosis ( 14 ). In studies reported from Sudan, it was emphasized that 4% of patients with visceral leishmaniasis do not have splenomegaly, and that it should be included in the differential diagnosis, especially in patients with fever lasting longer than a week, even if splenomegaly is not present( 15 ) In the differential diagnosis, it can be confused with many diseases such as miliary tuberculosis, brucellosis, typhoid, salmonellosis, infective endocarditis, infectious mononucleosis, collagen tissue diseases and lymphoma, and therefore the diagnosis of patients is delayed ( 16 ). Definitive diagnosis of visceral leishmaniasis is made by demonstrating amastigote forms of the parasite in smears from bone marrow, spleen, liver or lymph node aspirate samples ( 17 ). Direct agglutination test (DAT); immunofluorescence assay (IFA); immunofluorescence antibody test (IFAT) and recombinant K39 antigen tests have suboptimal diagnostic accuracy ( 18 ). Laboratory evaluation of miniature direct-on-blood PCR nucleic acid lateral flow immunoassay studies for visceral leishmaniasis appear promising for diagnosis ( 19 ). Treatment option for leishmaniasis are antimonials compounds, miltefosine. Due to the development of resistance, side effects and the need for patients to be hospitalized for 3 weeks, less toxic and better tolerated amphotericin B is used as an alternative drug. In patients without immune deficiency, parenteral administration of liposomal amphotericin B at a dose of 3 mg/kg/day every day for the first 5 days, with repeat doses on days 14 and 21 is recommended ( 20 ). Conclusion Case of cytopenia, high ferritin and triglyceride, low fibrinogen, fever, hemophagocytic syndrome secondary to infection should not be forgotten in regions such as Turkey where zoonotic infections such as brucella and Leishmania and plasmodium are common. Although the absence of orgonamegaly in our patient initially excluded the diagnosis of leishmenia, all causes should be reviewed with the suspicion of the clinician . Abbreviations SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus-2 COVID-19: SARS-CoV-2-induced coronavirus disease MIS-C: Multisystem İnflammatory Syndrome İn Children KD: Kawasaki Disease CDC: United Stataes Centers for Disease Control and Prevention WHO: World Health organization RCPCH: Royal College of Paediatrics and Child Health CRP: C-reactive protein IVIG: Intravenous İmmunglobuline PCR: Polymerase Chain Reaction HLH: hemophagocytic lymphohistiocytosis DAT: Direct agglutination test IFA: immunofluorescence assay IFAT : immunofluorescence antibody test HIV : Human Immunodeficiency Virus Declarations Informed Consent The parents’ of this patient consent was obtained for this study. References Dong E, Du H, Gardner L (2020). An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis [Internet]. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1473309920301195 WHO Director-General’s opening remarks at the media briefing on COVID-19–11 March 2020 [Internet]. [cited (2021) Jun 16]. Available from : https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on- Pediatric Intensive Care Society. Pediatric Intensive Care Society (PICS) Statement: Increased Number of Reported Cases of Novel Presentation of Multi-System Inflammatory Disease [Internet]. [cited (2021) Jun 20]. Available from : https://pccsociety.uk/wp-co. Centers for Disease Control and Prevention. Emergency Preparedness and Response [Internet]. 2020 [cited 2021 Jun 17]. Available from : https://emergency.cdc.gov/han/2020/han00432.asp World Health Organization. Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19: Scientific Brief 15 May 2020. Who [Internet]. (2020) Available from: https://www.who.int/news-room/commentaries/detail/mult. Royal College of Pediatrics and Child Health. Paediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS) - guidance for clinicians | RCPCH [Internet]. 2020 [cited 2021 Jun 17]. Available from : https://www.rcpch.ac.uk/resources Dufort EM, Koumans EH, Chow EJ, Rosenthal EM, Muse A, Rowlands J et al Multisystem Inflammatory Syndrome in Children in New York State. N Engl J Med (2020) ; 383 ( 4 ):347–358 Patel JM (2022) Multisystem Inflammatory Syndrome in Children (MIS-C). Curr Allergy Asthma Rep. doi: 10.1007/s11882-022-01031-4. Epub 2022 Mar 22. PMID: 35314921; PMCID: PMC8938222 Center for Disease Control and Prevention. Multisystem infammatory syndrome in children (MIS-C) 2021. https://www.cdc.gov/mis-c/cases . Accessed 18 Mar 2022 Bi K, Chen Y, Zhao S, Kuang Y, John Wu CH (2018) Current Visceral Leishmaniasis Research: A Research Review to Inspire Future Study. Biomed Res Int. doi: 10.1155/2018/9872095. PMID: 30105272; PMCID: PMC6076917 van Griensven J, Diro E (2012) Visceral leishmaniasis. Infect Dis Clin North Am. doi: 10.1016/j.idc.2012.03 . 005. Epub 2012 Apr 24. PMID: 22632641. Alvar J, Vélez ID, Bern C, Herrero M, Desjeux P, Cano J (2012), Jannin J, den Boer M; WHO Leishmaniasis Control Team. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. doi: 10.1371/journal.pone.0035671. Epub 2012 May 31. PMID: 22693548; PMCID: PMC3365071 Bode SF, Bogdan C, Beutel K, Behnisch W, Greiner J, Henning S et al (2014) Hemophagocytic lymphohistiocytosis in imported pediatric visceral. leishmaniasis in a nonendemic area. J Pediatr 165(1):147–153e141 Mottaghipisheh H, Kalantar K, Amanati A, Shokripour M, Shahriari M, Zekavat OR, Zareifar S, Karimi M, Haghpanah S, Bordbar M (2021) Comparison of the clinical features and outcome of children with hemophagocytic lymphohistiocytosis (HLH) secondary to visceral. leishmaniasis and primary HLH: a single-center study. BMC Infect Dis 21(1):732. 10.1186/s12879-021-06408-w . PMID: 34340686; PMCID: PMC8330039 Elshikh ESS, El Sanousi H, El Amin E, Mohammed N, Verdonck A, Jacobs K, Boelaert J, Chappuis M (2018) Case Report: Visceral Leishmaniasis with Salmonella Paratyphi and Brucella melitensis Coinfection as a Cause of Persistent Fever in a Patient from. Sudan. Am J Trop Med Hyg 99(5):1150–1152. 10.4269/ajtmh.18-0466 . PMID: 30255832; PMCID: PMC6221239 F. Zümrütdal A, Erken E, Turunç T et al Delayed and overlooked diagnosis of an unusual opportunistic infection in a renal transplant recipient: visceral leishmaniasis. Turkiye Parazitol Derg (2010) ; 34 ( 4 ): 183–185 Sundar S, Rai M (2002). Laboratory diagnosis of visceral leishmaniasis. Clin Diagn Lab Immunol 9 : 951–958 Chappuis F, Rijal S, Jha UK, Desjeux P, Karki BM, Koirala S, Loutan L, Boelaert M. Field validity, reproducibility and feasibility of diagnostic tests for visceral leishmaniasis in rural Nepal. Trop Med Int Health. 2006. Jan;11(1):31–40. 10.1111/j.1365-3156.2005.01533.x . PMID: 16398753 van Dijk NJ, Hagos DG, Huggins DM, Carrillo E, Ajala S, Chicharro C, Kiptanui D, Solana JC, Abner E, Wolday D (2024) Schallig HDFH. Simplified molecular diagnosis of visceral leishmaniasis: Laboratory evaluation of miniature direct-on-blood PCR nucleic acid. lateral flow immunoassay. PLoS Negl Trop Dis 18(5):e0011637. 10.1371/journal.pntd.0011637 . PMID: 38713648; PMCID: PMC11075898 van Griensven J, Diro E (2019) Visceral Leishmaniasis: Recent Advances in Diagnostics and Treatment Regimens. Infect Dis Clin North Am. doi: 10.1016/j.idc.2018.10 . 005. PMID: 30712769. Ural S, Kaptan F, Sezak N, El S, Örmen B, Türker N et al (2015) Evaluation of clinical and laboratory findings of adult visceral leishmaniasis cases Mikrobiyol Bul. doi: 10.5578/mb.9780 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7469493","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":506256777,"identity":"c7cf7358-69b0-4947-bd6a-26e238607bfa","order_by":0,"name":"asuman akar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYDADCQYGxgc8BgwyUA5xWpgNgFp4oBwDorSwSQDVE9bC33/GdMPPHQzyku1nn1W8KbDj4WdgPnibh+FPPk7Db+SY3ew9w2A4myfd7OYcg2QeyQa2ZGseBgPLBlx6bvCY3eBtY2Ccx5DGdpvH4AAImUkDteB0mfz5M2Y3/7Yx2M/jf8ZWDFJvf4D/G14tBgdyzG4DbUmcLZHGxgy2hYGHDa8WwxtpZbdl2ySSZ854xiwJ8ovEYTZjyzkGxji1yJ0/vO3m2zYb2xnn0xg/vPljJ8ff3vzwxpsKOUIRgxzdzGAHE9AwCkbBKBgFowAvAAD8o0h9Ozh/+QAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-5265-3271","institution":"dicle university","correspondingAuthor":true,"prefix":"","firstName":"asuman","middleName":"","lastName":"akar","suffix":""}],"badges":[],"createdAt":"2025-08-27 08:33:55","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7469493/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7469493/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90318086,"identity":"0f4cc483-6db5-40b3-8faa-821074ec2d5a","added_by":"auto","created_at":"2025-09-01 10:30:21","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":71440,"visible":true,"origin":"","legend":"\u003cp\u003eappearance of amostigote in bone marrow aspiration (H\u0026amp;amp;E, 100X)\u003c/p\u003e","description":"","filename":"IMG20211110WA0034.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7469493/v1/a47409424cc960bdc72cc982.jpg"},{"id":90319133,"identity":"9c1874d9-f359-4d2a-9dc0-067df4082639","added_by":"auto","created_at":"2025-09-01 10:38:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":321642,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7469493/v1/50efd3f5-5024-40ad-9d46-8bf7599c0ecc.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eRare disease mimicking Multisystem İnflammatory Syndrome In Children\u003c/p\u003e","fulltext":[{"header":"İntroduction","content":"\u003cp\u003eIn December 2019, a new coronavirus Severe Acute was detected in the city of Wuhan. respiratory Syndrome Identified as Coronavirus − 2 (SARS- CoV − 2) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A pandemic was declared by the World Health Organization on March 11, 2020. On April 27, 2020, The Pediatric Intensive Resort The Society of the United Kingdom is a multisystem disease with overlapping disease characteristics with Kawasaki Disease (KD) and Toxic Shock Syndrome, most of which test positive for COVID-19. issues a warning about the increasing number of children presenting with an inflammatory disease (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The first report of this syndrome came from the United Kingdom, a cohort of 8 children with evidence of severe inflammation and Kawasaki disease-like features. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). From May 22 to May 29, 2020, working groups, the US Centers for Disease Control and Prevention (CDC), the world health organization and the Royal College of Paediatrics and child Health (RCPCH) reported this disease in children associated with COVID − 19 in a multisystem inflammatory syndrome (MIS-C). The case definition was made as evidence of fever, hypotension/cardiac shock, high troponin, d - dimer, increase in acute phase reactants and SARS-COV-2 in individuals under 19 years of age (4; 5; 6). It occurs approximately 4–6 weeks after acute SARS-CoV-2 infection and develops from an excessive immune response triggered by the infection rather than the acute manifestation of the viral disease.Although the exact etiology has not been clearly clarified, it is thought that the current picture is immune dysregulation after infection. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 16-year-old 4-month-old female patient no relevant past medical history was brought to the Emergency Room with the complaints of general condition disorder, fever, abdominal pain, and headache that started 7 days before her admission. Systemic examination: fever: 40°C, respiratory rate: 20/ min blood pressure: 100 /60 mmHg oxygen-free saturation : 99% GCS: 15 poor general condition, frail appearance, positive neck stiffness, herpes around the lips labialis was present. No feature was detected in other systemic examination. White blood cell count: 1530 /mm3 neutrophil count: 610/mm lymphocyte count: 230/mm3 hemoglobin: 10.2 g/ dl platelet : 27000 d- dimer : 12790 ng / ml⁹ C-reactive protein: 59.5 mg/L procalcitonin : 0.68 ng / ml sedimentation : 53 mm/ st ferritin : 3176 µg/L triglyceride : 268 mg/ dl fibrinogen: 100mg/ dl Aspartate Aminotransferase : 321 U/L Alanine aminotransferase : 344 U/L lactate dehydrogenesis : 4264 U/L. She has never been vaccinated with a covid vaccine before. Covid PCR negative, no agent detected in respiratory virus panel. Covid IgM negative and IgG positive in rapid antibody test. COVID IgG was against both the nucleocapsid or spike protein. High fever, central nervous system involvement, gastrointestinal system involvement, high acute phase reactants, and antibody positivity were considered as MIS-C. Meninges lumbar puncture was performed in the patient with positive evidence of irritation, glucose : 54 mg/ dl, protein: 21 mg/ dl, no cells were seen in direct examination. There was no growth in the culture. Since the patient can not differentiate between cefotaxime and secondary HLH-MIS-C, less than 2 gr/ kg ivig replacement was given. Blood, urine, bone marrow aspirate culture, ebstein barr, cytomegalovirus, toxoplasma, herpes simplex, adenovirus, parvovirus -B19, Human Immunodeficiency Virus (HIV), hepatitis, brucella serology was sent and it was found negative. Abdominal ultrasonography hepatosplenomegaly was not detected. No pathology was observed in echocardiography. On day 3 of hospitalization bone marrow aspiration was performed to exclude leukemia in the patient who had pancytopenia and did not respond to IVIG replacement therapy.\u003c/p\u003e\u003cp\u003eBone marrow aspiration amastigote was seen (FİGURE-1) .\u003c/p\u003e\u003cp\u003ePatient classified as visceral leishmania. Liposomal Amphotericin B treatment was started at 3 mg/kg/ day. On the 3rd day of his treatment, his pancytopenia improved, fever height decreased. The treatment was completed for 7 days.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThere is a wide clinical spectrum in patients with MIS-C (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). If there is no alternative diagnosis and fever, high inflammatory symptoms and two or more system involvement are detected in a patient with contact with a known COVID case or COVID PCR positivity or COVID antibody positivity, MIS-C is diagnosed (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Systemic examination of the patient revealed high fever, abdominal pain, headache; pancytopenia, elevated ferritin, elevated liver function tests, elevated lactate dehydrogenase, and covid antibody positivity. MIS-C could not be ruled out because of fever, elevated acute phase reactants, haematological, gastrointestinal and central nervous system involvement. Lumbar puncture was performed in the patient whose cerebral tomography showed no pathology and cerebrospinal fluid examination did not reveal any findings in favour of infection. brucella serology, which is the most common zoonosis in our region, was first sent and found negative. ebstein barr, cytomegalovirus, toxoplasma, herpes simplex, adenovirus, parvovirus -B19, Human Immunodeficiency Virus (HIV), hepatitis serologies sent simultaneously were negative. IVIG replacement was firstly tried because of the patient's poor clinical condition and secondary haemophagocytic syndrome was detected. No infectious disease was detected in serological tests and visceral leishmania was diagnosed with amostigote in bone marrow biopsy performed to rule out possible leukaemia.\u003c/p\u003e\u003cp\u003eVisceral leishmenia is one of the most widespread human diseases, with more than 20 \u003cem\u003eLeishmania\u003c/em\u003e species identified worldwide. It is a zoonosis that is transmitted to humans through Phlebotomus flies and can be life-threatening if not treated(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). It is among the most neglected infectious diseases (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Approximately 0.2 to 0.4\u0026nbsp;million cases of visceral leishmaniasis occur each year (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Typical clinical findings are fever, pancytopenia, organomegaly, and elevation of inflammation markers. The laboratory findings are leukopenia, neutropenia,lymphocytosis, and monocytosis and increased transaminases. It has been reported that hemophagocytic lymphohistiocytosis accompanies in 2% of cases (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Mild nonspecific neurologic signs findings may be observed in cases accompanied by hemophagocytic lymphohistiocytosis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In studies reported from Sudan, it was emphasized that 4% of patients with visceral leishmaniasis do not have splenomegaly, and that it should be included in the differential diagnosis, especially in patients with fever lasting longer than a week, even if splenomegaly is not present(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) In the differential diagnosis, it can be confused with many diseases such as miliary tuberculosis, brucellosis, typhoid, salmonellosis, infective endocarditis, infectious mononucleosis, collagen tissue diseases and lymphoma, and therefore the diagnosis of patients is delayed (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Definitive diagnosis of visceral leishmaniasis is made by demonstrating amastigote forms of the parasite in smears from bone marrow, spleen, liver or lymph node aspirate samples (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Direct agglutination test (DAT); immunofluorescence assay (IFA); immunofluorescence antibody test (IFAT) and recombinant K39 antigen tests have suboptimal diagnostic accuracy (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Laboratory evaluation of miniature direct-on-blood PCR nucleic acid lateral flow immunoassay studies for visceral leishmaniasis appear promising for diagnosis (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Treatment option for leishmaniasis are antimonials compounds, miltefosine. Due to the development of resistance, side effects and the need for patients to be hospitalized for 3 weeks, less toxic and better tolerated amphotericin B is used as an alternative drug. In patients without immune deficiency, parenteral administration of liposomal amphotericin B at a dose of 3 mg/kg/day every day for the first 5 days, with repeat doses on days 14 and 21 is recommended (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCase of cytopenia, high ferritin and triglyceride, low fibrinogen, fever, hemophagocytic syndrome secondary to infection should not be forgotten in regions such as Turkey where zoonotic infections such as brucella and Leishmania and plasmodium are common. Although the absence of orgonamegaly in our patient initially excluded the diagnosis of leishmenia, all causes should be reviewed with the suspicion of the clinician .\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus-2\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOVID-19: SARS-CoV-2-induced coronavirus disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMIS-C: Multisystem İnflammatory Syndrome İn Children\u003c/p\u003e\n\u003cp\u003eKD: Kawasaki Disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCDC: United Stataes Centers for Disease Control and Prevention\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO: World Health organization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRCPCH: Royal College of Paediatrics and Child Health\u003c/p\u003e\n\u003cp\u003eCRP: C-reactive protein\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIVIG: Intravenous İmmunglobuline\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePCR: Polymerase Chain Reaction\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHLH:\u0026nbsp;hemophagocytic lymphohistiocytosis\u003c/p\u003e\n\u003cp\u003eDAT: Direct agglutination test\u003c/p\u003e\n\u003cp\u003eIFA: \u0026nbsp;immunofluorescence assay\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIFAT : immunofluorescence antibody test\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIV : Human Immunodeficiency Virus\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eInformed Consent The parents’ of this patient consent was obtained for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDong E, Du H, Gardner L (2020). \u003cem\u003eAn interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis [Internet].\u003c/em\u003e Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://linkinghub.elsevier.com/retrieve/pii/S1473309920301195\u003c/span\u003e\u003cspan address=\"https://linkinghub.elsevier.com/retrieve/pii/S1473309920301195\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO Director-General\u0026rsquo;s opening remarks at the media briefing on COVID-19\u0026ndash;11 March 2020 [Internet]. [cited (2021) \u003cem\u003eJun 16]. Available from\u003c/em\u003e: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-\u003c/span\u003e\u003cspan address=\"https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003ePediatric Intensive Care Society. Pediatric Intensive Care Society (PICS) Statement: Increased Number of Reported Cases of Novel Presentation of Multi-System Inflammatory Disease [Internet]. [cited\u003c/em\u003e (2021) \u003cem\u003eJun 20]. Available from\u003c/em\u003e: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pccsociety.uk/wp-co.\u003c/span\u003e\u003cspan address=\"https://pccsociety.uk/wp-co.\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eCenters for Disease Control and Prevention. Emergency Preparedness and Response [Internet]. 2020 [cited 2021 Jun 17]. Available from\u003c/em\u003e: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://emergency.cdc.gov/han/2020/han00432.asp\u003c/span\u003e\u003cspan address=\"https://emergency.cdc.gov/han/2020/han00432.asp\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eWorld Health Organization. Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19: Scientific Brief 15 May 2020. Who [Internet].\u003c/em\u003e (2020) Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/commentaries/detail/mult.\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/commentaries/detail/mult.\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoyal \u003cem\u003eCollege of Pediatrics and Child Health. Paediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS) - guidance for clinicians | RCPCH [Internet]. 2020 [cited 2021 Jun 17]. Available from\u003c/em\u003e: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rcpch.ac.uk/resources\u003c/span\u003e\u003cspan address=\"https://www.rcpch.ac.uk/resources\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDufort EM, Koumans EH, Chow EJ, Rosenthal EM, Muse A, Rowlands J et al Multisystem Inflammatory Syndrome in Children in New York State. N Engl J Med (2020) ;\u003cem\u003e383\u003c/em\u003e(\u003cem\u003e4\u003c/em\u003e):347\u0026ndash;358\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel JM (2022) \u003cem\u003eMultisystem Inflammatory Syndrome in Children (MIS-C). Curr Allergy Asthma Rep.\u003c/em\u003e doi: 10.1007/s11882-022-01031-4. Epub 2022 Mar 22. PMID: 35314921; PMCID: PMC8938222\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eCenter for Disease Control and Prevention. Multisystem infammatory syndrome in children (MIS-C) 2021.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/mis-c/cases\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/mis-c/cases\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 18 Mar 2022\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBi K, Chen Y, Zhao S, Kuang Y, John Wu CH (2018) \u003cem\u003eCurrent Visceral Leishmaniasis Research: A Research Review to Inspire Future Study. Biomed Res Int.\u003c/em\u003e doi: 10.1155/2018/9872095. PMID: 30105272; PMCID: PMC6076917\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Griensven J, Diro E (2012) \u003cem\u003eVisceral leishmaniasis. Infect Dis Clin North Am.\u003c/em\u003e doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.idc.2012.03\u003c/span\u003e\u003cspan address=\"http://10.1016/j.idc.2012.03\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003cem\u003e005. Epub 2012 Apr 24. PMID: 22632641.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlvar J, V\u0026eacute;lez ID, Bern C, Herrero M, Desjeux P, Cano J (2012), \u003cem\u003eJannin J, den Boer M; WHO Leishmaniasis Control Team. Leishmaniasis worldwide and global estimates of its incidence. PLoS One.\u003c/em\u003e doi: 10.1371/journal.pone.0035671. Epub 2012 May 31. PMID: 22693548; PMCID: PMC3365071\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBode SF, Bogdan C, Beutel K, Behnisch W, Greiner J, Henning S et al (2014) \u003cem\u003eHemophagocytic lymphohistiocytosis in imported pediatric visceral.\u003c/em\u003e leishmaniasis in a nonendemic area. J Pediatr 165(1):147\u0026ndash;153e141\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMottaghipisheh H, Kalantar K, Amanati A, Shokripour M, Shahriari M, Zekavat OR, Zareifar S, Karimi M, Haghpanah S, Bordbar M (2021) \u003cem\u003eComparison of the clinical features and outcome of children with hemophagocytic lymphohistiocytosis (HLH) secondary to visceral.\u003c/em\u003e leishmaniasis and primary HLH: a single-center study. BMC Infect Dis 21(1):732. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12879-021-06408-w\u003c/span\u003e\u003cspan address=\"10.1186/s12879-021-06408-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34340686; PMCID: PMC8330039\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElshikh ESS, El Sanousi H, El Amin E, Mohammed N, Verdonck A, Jacobs K, Boelaert J, Chappuis M (2018) \u003cem\u003eCase Report: Visceral Leishmaniasis with Salmonella Paratyphi and Brucella melitensis Coinfection as a Cause of Persistent Fever in a Patient from.\u003c/em\u003e Sudan. Am J Trop Med Hyg 99(5):1150\u0026ndash;1152. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4269/ajtmh.18-0466\u003c/span\u003e\u003cspan address=\"10.4269/ajtmh.18-0466\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30255832; PMCID: PMC6221239 \u003cem\u003eF.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZ\u0026uuml;mr\u0026uuml;tdal A, Erken E, Turun\u0026ccedil; T et al Delayed and overlooked diagnosis of an unusual opportunistic infection in a renal transplant recipient: visceral leishmaniasis. Turkiye Parazitol Derg (2010) ; \u003cem\u003e34\u003c/em\u003e(\u003cem\u003e4\u003c/em\u003e): 183\u0026ndash;185\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSundar S, Rai M (2002). Laboratory diagnosis of visceral leishmaniasis. Clin Diagn Lab Immunol \u003cem\u003e9\u003c/em\u003e: 951\u0026ndash;958\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChappuis F, Rijal S, Jha UK, Desjeux P, Karki BM, Koirala S, Loutan L, Boelaert M. \u003cem\u003eField validity, reproducibility and feasibility of diagnostic tests for visceral leishmaniasis in rural Nepal. Trop Med Int Health. 2006.\u003c/em\u003e Jan;11(1):31\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1365-3156.2005.01533.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-3156.2005.01533.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 16398753\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Dijk NJ, Hagos DG, Huggins DM, Carrillo E, Ajala S, Chicharro C, Kiptanui D, Solana JC, Abner E, Wolday D (2024) \u003cem\u003eSchallig HDFH. Simplified molecular diagnosis of visceral leishmaniasis: Laboratory evaluation of miniature direct-on-blood PCR nucleic acid.\u003c/em\u003e lateral flow immunoassay. PLoS Negl Trop Dis 18(5):e0011637. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pntd.0011637\u003c/span\u003e\u003cspan address=\"10.1371/journal.pntd.0011637\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38713648; PMCID: PMC11075898\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Griensven J, Diro E (2019) \u003cem\u003eVisceral Leishmaniasis: Recent Advances in Diagnostics and Treatment Regimens. Infect Dis Clin North Am.\u003c/em\u003e doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.idc.2018.10\u003c/span\u003e\u003cspan address=\"http://10.1016/j.idc.2018.10\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003cem\u003e005. PMID: 30712769.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUral S, Kaptan F, Sezak N, El S, \u0026Ouml;rmen B, T\u0026uuml;rker N et al (2015) Evaluation of clinical and laboratory findings of adult visceral leishmaniasis cases Mikrobiyol Bul. doi: 10.5578/mb.9780\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Dicle University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multisystem İnflammatory Syndrome In Children, Visceral leishmenia","lastPublishedDoi":"10.21203/rs.3.rs-7469493/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7469493/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMultisystem inflammatory syndrome (MIS) is a rare but serious condition associated with SARS-CoV-2, the virus that causes COVID-19, in which different internal and external body parts become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, gastrointestinal tract.\u003c/p\u003e\u003cp\u003eIn this report, a female patient who presented with complaints of fever, abdominal pain, headache and fatigue lasting for seven days and whose systemic examination revealed positive findings of meningeal irritation is presented. The patient was initially evaluated as MIS-C due to the presence of hematological, gastrointestinal and central nervous system involvement along with fever and Covid antibody positivity, and was diagnosed with Visceral leishmenia in further examinations.\u003c/p\u003e","manuscriptTitle":"Rare disease mimicking Multisystem İnflammatory Syndrome In Children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 10:30:17","doi":"10.21203/rs.3.rs-7469493/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9fe744a5-0340-4da8-9590-d99fa8a98ba8","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":53771044,"name":"Pediatrics"}],"tags":[],"updatedAt":"2025-09-01T10:30:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 10:30:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7469493","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7469493","identity":"rs-7469493","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}