A Case of Multisystem Inflammatory Syndrome in Children Mimicking Acute Appendicitis in a COVID-19 Pandemic Area

Abstract

The outbreak of the novel coronavirus (2019-nCoV) began in Wuhan, China and spread rapidly throughout the world. As of now, there have been numerous reports demonstrating clinical, radiological and pathological findings in adults. In children, the disease has essentially been seen as mild and self-limiting. However, more recently, children have been presenting with findings reminiscent of Kawasaki’s disease. And secondary to this, the benign nature of COVID-19 disease in children is beginning to be challenged. This phenomenon is now referred to as multisystem inflammatory syndrome in children (MIS-C). Further understanding the clinical course in MIS-C and its temporal association with coronavirus disease 2019 will be paramount for treatment and public health decision making. This correspondence describes a case of MIS-C with gastrointestinal manifestations mimicking acute appendicitis in a child presenting from a COVID-19 endemic area.

Multisystem inflammatory syndrome in children. An emerging clinical challenge for pediatric surgeons in the COVID 19 era

“…Moreover, a diagnosis of mesenteric adenitis in MIS-C has been accounted by 8 case-series, with a prevalence of 9–20% of the abdominal imaging studies [ 6 , 8 , 13 , 16 , 23 , 27 , 31 , 32 ]. In addition, the latter condition has been also described in six recent case-reports from different geographic areas [ 9 , 25 , 26 , 30 , 33 , 34 ]: notably, in one of those patients mesenteric lymphadenitis was even confirmed on surgical specimens by pathologists [ 9 ].…”

“…When focusing on severe abdominal manifestations, we found nine patients affected by MIS-C who underwent exploratory laparotomies: two children with a healthy appendix as finding (“pseudo appendicular syndrome”) [ 16 , 17 ], one with aseptic peritonitis [ 18 ], four with appendicitis [ 19 ] and two with mesenteric lymphadenitis [ 20 ]. Appendicitis was initially suspected in roughly 5–30% [ 16 , 18 , [20] , [21] , [22] , [23] , [24] ] of the reviewed case series and in four case reports [ 9 , 17 , 25 , 26 ]. Three patients underwent intestinal resection with re-anastomosis due to segmental inflammation with necrosis of terminal ileum [ 9 , 17 , 27 ].…”

“…Appendicitis was initially suspected in roughly 5–30% [ 16 , 18 , [20] , [21] , [22] , [23] , [24] ] of the reviewed case series and in four case reports [ 9 , 17 , 25 , 26 ]. Three patients underwent intestinal resection with re-anastomosis due to segmental inflammation with necrosis of terminal ileum [ 9 , 17 , 27 ].…”

“…Some children have been noted to have mesenteric adenitis, terminal ileitis and/or colitis on abdominal imaging [ [6] , [7] , [8] ]. An increasing number of children referred for suspected appendicitis or acute abdomen are subsequently diagnosed as MIS-C, often after undergoing surgery or after needing intensive care [ 9 , 10 ]. Cardiac involvement includes ventricular dysfunction, coronary artery dilation or aneurysm, and arrhythmias [ 11 ].…”

Acute Appendicitis in Multisystem Inflammatory Syndrome

“…MIS-C can mimic acute appendicitis leading to delayed diagnosis. Moreover, acute appendicitis can be a part of the multisystem inflammation in MIS-C [1][2][3][4]. SARS-CoV-2induced inflammation and vasculitis through angiotensinconverting enzyme 2 receptors in the terminal ileum are the suspected mechanisms [1].…”