Early reports of COVID-19 in pediatric populations emphasized a mild course of 
disease with severe cases disproportionately affecting infant and comorbid 
pediatric patients. After the peak of the epidemic in New York City, in late 
April to early May, cases of severe illness associated with COVID-19 were 
reported among mostly previously healthy children ages 5-19. Many of these cases 
feature a toxic shock-like syndrome or Kawasaki-like syndrome in the setting of 
SARS-CoV-2 positive diagnostic testing and the CDC has termed this presentation 
Multisystem Inflammatory Syndrome (MIS-C). It is essential to disseminate 
information among the medical community regarding severe and atypical 
presentations of COVID-19 as prior knowledge can help communities with 
increasing caseloads prepare to quickly identify and treat these patients as 
they present in the emergency department. We describe a case of MIS-C in a child 
who presented to our Emergency Department (ED) twice and on the second visit was 
found to have signs of distributive shock, multi-organ injury and systemic 
inflammation associated with COVID-19. The case describes two ED visits by an 
11- year-old SARS-CoV-2-positive female who initially presented with fever, rash 
and pharyngitis and returned within 48 hours with evidence of cardiac and renal 
dysfunction and fluid-refractory hypotension requiring vasopressors and PICU 
admission.