Complicated appendicitis in a COVID -19 positive child: A case report

Abstract

A ppendicitis is the most common surgical abdominal emergency seen in the casualty. Common complaints are fever, malaise, anorexia with pain in the abdomen, and vomiting. Diagnosis requires a high level of suspicion as less than 50% present with classical symptoms [1]. Ultrasonography (USG) and abdominal computerized tomography (CT) help clinch the diagnosis [2]. Delay in the diagnosis can lead to appendiceal perforation, peritonitis, septicemia, and even death. Appendicectomy remains the gold standard in the management of acute appendicitis (AA). Recent reports support a conservative approach in the management of AA with the use of intravenous (IV) antibiotics [3]. Reduced risks of surgery and anesthesia along with a shorter hospital stay and reduced cost of treatment are some other benefits of conservative management of AA [3-5]. Coronavirus disease (COVID)-19 infection presenting with gastrointestinal (GI) symptoms in the pediatric age group has been recently reported in a few studies [3-6]. Tullie et al. have reported a series of eight children presenting at a single center in the UK with COVID-19 infection [6]. Compromised lung function in a COVID-19-positive patient poses a high perioperative risk in addition to cytokine storm causing systemic inflammatory response syndrome and multiple organ dysfunction syndrome. The role of conservative management, particularly in COVID times, needs to be considered. We present the case of a COVID-19 positive child with AA, appendicular perforation, and abscess. The patient was successfully managed conservatively, supporting the role of non-operative management for AA in selected cases. CASE REPORT A 5-year-old male child was brought to the casualty with complaints of high-grade fever, gradually increasing pain in the abdomen in the past 3 days and vomiting since morning on the day of admission. The pain was gradual in onset, dull aching in nature, moderate to severe in intensity, localized over the right iliac fossa, aggravated by food, cough, or on walking, and relieved only after medications. There were four episodes of nonprojectile, non-bilious vomiting on the day of admission since morning. There was decreased oral intake due to vomiting and pain in the abdomen. There was no significant history of any illness or surgery. The patient belonged to a high-risk containment zone for COVID-19 though he had never come in direct contact with any COVID-19-positive patient. He had no symptoms other than fever and GI symptoms suggestive of COVID-19 infection. Examination of the patient was done after donning personal protective equipment. The child was ill looking but well nourished,

COVID-19 and Complicated Appendicitis: What is the Relationship?

“…This might have required screening investigations which are often not readily available, [15] with the result being a delay in referral and/or operative intervention and increased potential for developing complications. Thirdly, although appendicectomy is the gold standard in the management of acute uncomplicated appendicitis, [7,16] several centres are increasingly adopting conservative management of uncomplicated and even complicated appendicitis during the pandemic [17][18][19]. This might have been a strategy to reduce potential contact of the surgical team and operating room environment with the SARS CoV-2 virus.…”

“…Indeed, 4 (25%) of the patients presenting within the index period in this study had presented in other hospitals, where initial conservative management was attempted. There is a report of indicated surgery in a COVID-19 positive individual deferred on account of the patient's COVID-19 positive status [17]. Whether this should be an acceptable standard of care in the face of this pandemic is debatable.…”