There is increasing recognition of gastrointestinal involvement in patients with COVID-19 and MIS-C. Several case reports describe patients who present with typical symptoms of appendicitis who are also found to be infected with SARS-CoV-2 virus or meet the diagnosis for MIS-C. Studies have demonstrated that most children with MIS-C will present with gastrointestinal (GI) symptoms. MIS-C should be high on the differential for patients who present with GI symptoms and a history of recent SARS-CoV-2 exposure or infection, even if findings seem consistent with other GI pathologies such as appendicitis, infection, or inflammatory bowel disease (IBD).
MIS-C can mimic acute appendicitis leading to delayed diagnosis. Moreover, acute appendicitis can be a part of the multisystem inflammation in MIS-C. SARS-CoV-2- induced inflammation and vasculitis through angiotensin converting enzyme 2 receptors in the terminal ileum are the suspected mechanisms.
Case presentation
A 10-year old female child was admitted with pain in the abdomen for 8 days, which did not relieve on taking medication. The child with MIS-C coexisting with perforated appendicitis, was requiring surgery besides medical management of MIS-C.
She had loose stools (5-6 episodes/ days) for 5 days, fever for 6 days. The child had a pulse- 120/min, BP- 100/60mmhg, Temp- 98.4F, SpO2:99% on room air and Resp.rate – 20/min. On systemic examination, she had localized guarding and tenderness over right iliac fossa and decreased bowel sounds. Investigations revealed raised total leukocyte count, D-dimer, LDH, and CRP. Anti SARS-CoV-2 IgG was elevated. Other tests like dengue NS1 antigen and dengue virus IgM antibodies and IgM against scrub typhus were negative. Electrolytes and urea, creatinine is within normal limits. USG abdomen & pelvis found features suggested of perforated appendix with lump formation. 2D ECHO showed mild pericardial effusion, with normal ejection fraction. Laparoscopic appendectomy was done by Dr S Mohanty and Dr H Tudu. Histopathologic examination of the specimen showed features suggestive of acute appendicitis with periappendicitis. Medical management consists of IVIG, antibiotics, management of electrolytes and nutrition. It was a coordinated treatment effort of the pediatric team, pediatric surgery team and PICU team who brought out the child from such a moribund condition to discharge home in good health.
The experience of the Operating Team further highlighted the suspected association between acute appendicitis, COVID-19, and MIS-c. This should always be considered particularly in children with clinical appendicitis who are PCR positive for SARS-CoV-2 at the time of presentation.
Parents were very happy to get their child diagnosed and treated properly in KIMS. They showered their blessing to the staff and doctors taking care of their kid. The pediatric team was thankful to the management for providing infrastructure and diagnostic facility to carry-out such strenuous work.
This case was managed by a pediatric team consisting of Prof SR Biswal, Prof. M Behera, Prof. Nirmal K. Mohakud, Associate Professor Sibabrata Patnaik & his PICU team and Postgraduates (Dr Vinod, Dr Praneeth, Dr Jenith) and other faculties of KIMS.