Acute appendicitis in pediatric patients with Coronavirus Disease 2019 (COVID-19): A case series from a developing country's tertiary hospital

Abstract

Introduction and importance: A common gastrointestinal presentation of both COVID-19 and multisystem inflammatory syndrome in children (MIS-C) is acute abdominal pain, which sometimes mimics appendicitis. Literature describing children with COVID-19 infection and concurrent acute appendicitis is growing, and understanding these patients’ clinical picture is necessary for their proper treatment. Case presentation We present a case series of six healthy children before they developed classic symptoms of appendicitis. At the same time, they were also found to have confirmed COVID-19. All patients had fever and right lower abdominal pain. Four of six children having Alvarado score above seven had surgical treatment, while the others only received systemic antibiotic and antiviral medication. Surgical results of two patients revealed perforated appendicitis. No mortality occurred among them. Clinical discussion There is increasing recognition of gastrointestinal involvement in patients with COVID-19 and MIS-C. There are several postulates to explain appendicitis in COVID-19. First, inflammatory response is exaggerated in SARS-CoV-2 infected patients. Second, obstruction of the appendiceal lumen is caused by mesenteric adenopathy, which in turn, is caused by COVID-19 infection, not fecalith. Third, hyperinflammatory response in MIS-C triggers inflammation in appendix. Conclusion Clinicians must recognize that abdominal pain with fever could be the presenting symptoms of COVID-19 with MIS-C. MIS-C, which has severe presentations with gastrointestinal manifestations and high mortality rate, should be considered as a differential diagnosis for a patient with appendicitis-like symptoms and a positive SARS-CoV-2 infection.

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

“…As in the present case, Sturgill et al 21 presented a series of three children diagnosed with appendicitis and MIS-C related to SARS-CoV-2; all patients were initially admitted with a diagnosis of appendicitis and had an appendectomy before the further diagnosis of MIS-C. One and two cases from two-case series reported from South Africa and Indonesia, respectively, were treated nonsurgically and only received systemic antibiotics and antiviral medication. 22 , 23 …”

“…As in the present case, Sturgill et al 21 presented a series of three children diagnosed with appendicitis and MIS-C related to SARS-CoV-2; all patients were initially admitted with a diagnosis of appendicitis and had an appendectomy before the further diagnosis of MIS-C. One and two cases from two-case series reported from South Africa and Indonesia, respectively, were treated nonsurgically and only received systemic antibiotics and antiviral medication. 22,23 Tullie et al 24 presented a case series and highlighted that children with MIS-C associated with COVID-19 may exhibit clinical characteristics suggesting appendicitis. Using advanced radiological procedures, however, a differential diagnosis was made for the children in the London series, and operative intervention was subsequently abounded.…”

A critical appraisal on the treatment of acute appendicitis in pediatric population during the COVID-19 pandemic

“…A systematic review revealed that 18.7% of patients with MIS-C presented with an acute abdomen 50 . Even though the presentation of both MIS-C and acute appendicitis may be similar 51 , however, the treatment modality is different MIS-C patients usually receive nonoperative management, while patients with acute appendicitis require appendectomy 35 , 47 , 50 . Yock-Corrales et al .…”

Reasons for Delayed Diagnosis of Pediatric Acute Appendicitis during the COVID-19 Era: A Narrative Review

“…Prior infection or contact with a positive SARS-CoV-2 case and lack of an alternative diagnosis are among the criteria for establishing a diagnosis of MIS-C [85]. MIS-C abdominal pain can be severe and can mimic appendicitis [84,86,87]. MIS-C can also manifest with severe gastrointestinal diagnoses including appendicitis [88].…”