Pediatric COVID-19 and Appendicitis: A Gut Reaction to SARS-CoV-2?

Abstract

Background: We describe the temporal pattern of COVID-19 admissions to a tertiary care children’s hospital in central New Jersey during the SARS-CoV-2 surge, covering the time period from March 29 to July 26, 2020. Methods: Medical charts were reviewed for the date of admission, past medical history, and demographic variables, presenting signs and symptoms, admitting laboratory values, diagnostic imaging, diagnosis, treatment modalities, and outcomes including length of stay and disease severity. Results: Patients with symptomatic SARS-CoV-2 infection tended to present with pneumonia early during the study period, which coincided with the early surge in New Jersey cases. Approximately 2 weeks after the peak in reported SARS-CoV-2 cases in New Jersey, we began to see fewer pneumonia cases and an increase in admissions for Multi-Inflammatory Syndrome in Children and cases of acute appendicitis in association with a diagnosis of SARS-CoV-2 infection. Conclusions: We present a novel association of acute appendicitis in children infected with SARS-CoV-2 and postulate that it may represent a postinfectious hyperinflammatory complication of SARS-CoV-2 infection occurring 2 weeks after the early manifestation of acute pneumonia disease in children.

Characteristics of Hospitalized Children Positive for SARS-CoV-2: Experience of a Large Center

“…13 In our potentially symptomatic category, 37% of patients had appendicitis. It has been hypothesized that SARS-CoV-2 can make patients more susceptible to developing appendicitis [16][17][18] ; however, no mechanism for this has been described. Given the fact that patients with appendicitis universally have abdominal pain, it seems likely that a positive SARS-CoV-2 test result in this instance is coincidental rather than causative.…”

Acute appendicitis in children with multisystemic inflammatory syndrome associated to SARS-CoV-2 (MIS-C). A complication to consider

“…This suggested the possibility of an association between the multisystemic inflammatory syndrome in children (MIS-C), SARS-CoV-2 infection and acute appendicitis. 2 , 3 , 4 …”

“…In the case of MIS-C, it is suspected that the inflammatory changes that lead to the occlusion of the appendiceal lumen, and in turn to acute appendicitis, could be secondary to reactive lymphoid hyperplasia resulting from viral colonization of the bowel (and made possible by the abundance of ACE-2 receptors in the intestine) and/or the vasculitis produced in MIS-C, which causes ischaemia-reperfusion events 6 that could damage the appendiceal artery. 2 , 3 …”

Finding a place for non-operative management of acute appendicitis: COVID-19 as an example

“…The authors hypothesized that AA in children with SARS-COV-2 infection may represent a postinfectious hyperinflammatory complication of the infection that can occur two weeks after the early manifestation of the disease. 6 The impact of COVID-19 pandemic on the management of AA was explored in a population-based analysis in Germany. The analysis found an overall reduction by 12.9% of patients presenting with AA and this reduction was mainly relevant to decreased rates of uncomplicated AA, rather than complicated appendicitis.…”