SARS-CoV-2 identification in an acute appendicitis case: Acute abdomen as manifestation of Multisystem Inflammatory Syndrome in a child with COVID-19

Acute Abdomen as a Clinical Presentation of COVID-19-Associated Multisystem Inflammatory Syndrome in Children

Background

On December 2019, a novel coronavirus disease (COVID-19) spread worldwide and became a pandemic. Multisystem inflammatory syndrome in children (MIS-C) due to cytokine release syndrome following COVID-19 presents with various manifestations. We hypothesize that one of the rare manifestations is acute abdomen. Case Presentation. In this case series, eight cases (five girls and three boys) of gastrointestinal (GI) involvement and acute abdomen were reported to be associated with the cytokine storm due to COVID-19 infection. All patients were of Iranian nationality (Caucasian ethnicity), with a mean age of 8.9 years (range 3.5-14). They all presented with fever and acute abdominal pain. Additionally, maculopapular rash and edema of the extremities were common presentations. Free fluid on abdominal ultrasound or computerized tomography (CT) scan was observed in all patients. All cases tested positive for COVID-19. In six cases, laparotomy or abdominal surgery was performed for a diagnosis of acute abdomen, but appendicitis was confirmed in only one case. None of the cases presented with phlegmon. Elevated serum lipase and amylase levels were noted in two cases. Seven patients received corticosteroid pulse therapy. Clinical symptoms improved after one or two doses, and all patients were discharged after 4 weeks of follow-up with no mortality or morbidity.

Conclusion

Patients experiencing unexplained acute abdominal pain along with fever, skin rash, and peripheral edema, who had a history of COVID-19 infection prior to or during the episode of acute abdomen symptoms, should be considered to have MIS-C. Furthermore, methylprednisolone pulse therapy could be a safe treatment option, reducing hospitalization duration in this patient population.

Pathologic Analysis of Twenty-one Appendices From Children With Multisystem Inflammatory Syndrome Compared to Specimens of Acute Appendicitis: A Cross-sectional Study

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C) is a rare, severe complication of coronavirus disease 2019, commonly involving the gastrointestinal tract. Some children with MIS-C undergo appendectomy before the final diagnosis. There are several hypotheses explaining the pathomechanism of MIS-C, including the central role of the viral antigen persistence in the gut, associated with lymphocyte exhaustion. We aimed to examine appendectomy specimens from MIS-C patients and assess their pathologic features, as well as the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antigens.

METHODS

In this cross-sectional study we included 21 children with MIS-C who underwent appendectomy. The control group included 21 sex- and age-matched children with acute appendicitis (AA) unrelated to SARS-CoV-2 infection. Histologic evaluation of appendiceal specimens included hematoxylin and eosin staining and immunohistochemical identification of lymphocyte subpopulations, programmed cell death protein-1 (PD-1) and SARS-CoV-2 nucleocapsid antigen.

RESULTS

Appendices of MIS-C patients lacked neutrophilic infiltrate of muscularis propria typical for AA (14% vs. 95%, P < 0.001). The proportion of CD20+ to CD5+ cells was higher in patients with MIS-C (P = 0.04), as was the proportion of CD4+ to CD8+ (P < 0.001). We found no proof of SARS-CoV-2 antigen presence, nor lymphocyte exhaustion, in the appendices of MIS-C patients.

CONCLUSIONS

The appendiceal muscularis of patients with MIS-C lack edema and neutrophilic infiltration typical for AA. SARS-CoV-2 antigens and PD-1 are absent in the appendices of children with MIS-C. These findings argue against the central role of SARS-CoV-2 persistence in the gut and lymphocyte exhaustion as the major triggers of MIS-C.

Differentiating abdominal pain due to COVID-19 associated multisystem inflammatory syndrome from children with acute appendicitis: a score system

PURPOSE

Differentiating abdominal pain due to coronavirus disease (COVID-19)-associated multisystem inflammatory syndrome (MIS-C) in children with acute appendicitis (AA) can cause diagnostic dilemmas. This study aimed to evaluate the efficacy of a previously described scoring system and improve its diagnostic ability in differentiating between these diseases.

METHODS

This study was conducted between March 2020 and January 2022. Patients who had MIS-C with gastrointestinal system (GIS) involvement and patients who underwent surgery for appendicitis were included. First, all patients were evaluated using the new scoring system (NSS). The groups were compared by adding new MISC-specific parameters to NSS. The scoring system was evaluated using propensity score matching (PSM).

RESULTS

A total of 35 patients with abdominal pain due to GIS involvement in MIS-C (group A) and 37 patients with AA who had ALT, PRC, and D-dimer results at their first admission (group B) were included in the study. The mean age of patients in group A was lower than that of patients in group B (p < 0.001). False NSS positivity was found in 45.7% of the patients with MIS-C. Lymphocyte (p = 0.021) and platelet counts (p = 0.036) were significantly lower in the blood count and serum D-dimer (p = 0.034), C-reactive protein (CRP) (p < 0.001), and procalcitonin (p < 0.001) were significantly higher in the MIS-C group. We created a scoring system called the Appendicitis-MISC Score (AMS) using the NSS and new parameters. The sensitivity and specificity of AMS diagnostic scores were 91.9% and 80%, respectively.

CONCLUSION

MIS-C with GIS involvement may present as acute abdomen. It is difficult to differentiate this condition from acute appendicitis. AMS has been shown to be useful for this differentiation.

Coincidental or mimicking acute appendicitis secondary to MIS-C associated with SARS-CoV-2: A case report

The predominant organic system involved in multisystem inflammatory syndrome in children associated with COVID-19 is the gastrointestinal system, which is observed in almost 90% of patients. Gastrointestinal symptoms can mimic acute appendicitis. There have been a few cases of misdiagnosed multisystem inflammatory syndrome in children associated with SARS-CoV-2 as appendicitis, and a few concomitant cases of a multisystem inflammatory syndrome associated with acute appendicitis during the COVID-19 pandemic. Here, we present the case of an 11-year-old girl who presented to our Intensive Care Unit with a 2-day history of fever, generalized abdominal pain, and vomiting. The clinical findings resulted in a clinical suspicion of acute appendicitis and subsequent surgery. While postoperatively, she became critically ill, and she was diagnosed with the multisystem inflammatory syndrome in children associated with COVID-19. When diagnosing children with acute appendicitis, healthcare professionals, especially pediatricians and surgeons, must pay attention to the multisystem inflammatory syndrome linked to the SARS-CoV-2 infection.

Does Multisystem Inflammatory Syndrome Only Mimic Acute Appendicitis in Children or Can It Coexist: When Should We Suspect MIS-C?

Background and Objectives: Acute abdominal pain in children has been noticed to be a primary reason to seek medical attention in multisystem inflammatory disorder (MIS-C), which can prevail separately or together with acute appendicitis. Our aim was to distinguish regular appendicitis cases from MIS-C and to suggest the best clinical and laboratory criteria for it. Materials and methods: Cases of patients, admitted to the Pediatric Surgery Department over a six-month period in 2021, were retrospectively analyzed. Confirmed MIS-C or acute appendicitis cases were selected. MIS-C cases were either separate/with no found inflammation in the appendix or together with acute appendicitis. Acute appendicitis cases were either regular cases or with a positive COVID-19 test. Four groups were formed and compared: A-acute appendicitis, B-MIS-C with acute appendicitis, C-MIS-C only and D-acute appendicitis with COVID-19. Results: A total of 76 cases were overall analyzed: A-36, B-6, C-29 and D-5. The most significant differences were found in duration of disease A—1.4 days, B—4.5 days, C—4 days, D—4 days (p < 0.0001), C reactive protein (CRP) values A-19.3 mg/L B-112.5 m/L, C-143.8 mg/L and D-141 mg/L (p < 0.0001), presence of febrile fever A-13.9%, B-66.7%, C-96.6% and D-40% (p < 0.0001) and other system involvement: A 0%, B 100%, C 100% and D 20%. A combination of these factors was entered into a ROC curve and was found to have a possibility to predict MIS-C in our analyzed cases (with or without acute appendicitis) with an AUC = 0.983, p < 0.0001, sensitivity of 94.3% and specificity of 92.7% when at least three criteria were met. Conclusions: MIS-C could be suspected even when clinical data and performed tests suggest acute appendicitis especially when at least three out of four signs are present: CRP > 55.8 mg, symptoms last 3 days or longer, febrile fever is present, and any kind of other system involvement is noticed, especially with a known prior recent COVID-19 contact, infection or a positive COVID-19 antibody IgG test.

SARS-CoV-2 Infection Is Not Associated With Pediatric Appendicitis

Although case reports have suggested an association between severe acute respiratory distress syndrome coronavirus 2 and appendicitis, we found that the overall incidence of appendicitis was stable throughout the pandemic at our tertiary pediatric hospital. Furthermore, we did not find evidence of CoV2 infection in 9 appendicitis tissues. Therefore, we conclude that severe acute respiratory distress syndrome coronavirus 2 infection of the appendix is not a common etiologic cause of pediatric appendicitis.

Angiotensin-Converting Enzyme 2 and Furin Expression in the Appendix of Children with COVID-19

Background: The sudden outbreak of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has resulted in more than 261 million infections and an estimated 5.1 million deaths. Some vital organs such as the kidneys, heart, intestines, and lungs could be damaged by SARS-CoV-2. Questions remain regarding the effect of SARS-CoV-2 on the mucous membrane of the appendix in children. The aim of this study was to evaluate the knowledge of cytologic processes in appendix tissue in children with coronavirus disease 2019 (COVID-19). Patients and Methods: Fragments of the appendices of children with confirmed COVID-19 (n = 42) were studied by real-time polymerase chain reaction (PCR) to determine the expression of SARS-CoV-2 RNA and genes encoding protein complexes: ACE-2 and Furin. Results: We found traces of coronavirus genetic material in the appendices of children with COVID-19. We also found increased expression of ACE-2 and Furin in the tissue, which indicates favorable conditions for coronavirus infection. Conclusions: Viral load in the appendices of children can be reported based on the results of real-time PCR for SARS-CoV-2 and the expression of ACE-2 and Furin.