MIS-C-Implications for the Pediatric Surgeon: An Algorithm for Differential Diagnostic Considerations

Abstract

Background: multisystem inflammatory syndrome in children (MIS-C) is a new disease associated with a recent infection with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Affected children can present predominantly with abdominal symptoms, fever and high inflammatory parameters that might lead to a consult by the pediatric surgeon and an indication for surgery. Methods: clinical data of three patients with MIS-C that underwent surgery were collected. Histopathological analysis of the appendix was performed. Results: we present the clinical course of three children with fever, abdominal pain and vomiting for several days. Clinical examination and highly elevated inflammation markers led to indication for laparoscopy; appendectomy was performed in two patients. Because of intraoperative findings or due to lack of postoperative improvement, all patients were reevaluated and tested positive for MIS-C associated laboratory parameters and were subsequently treated with corticosteroids, intravenous immunoglobulins, acetyl salicylic acid and/or light molecular weight heparin. Conclusions: we discuss the implications of MIS-C as a new differential diagnosis and stress the importance of assessing the previous medical history, identifying patterns of symptoms and critically surveilling the clinical course. We implemented an algorithm for pediatric surgeons to consider MIS-C as a differential diagnosis for acute abdomen that can be integrated into the surgical workflow.

Imaging findings in acute pediatric coronavirus disease 2019 (COVID-19) pneumonia and multisystem inflammatory syndrome in children (MIS-C)

“…Some researchers have suggested that the localized right lower quadrant findings in a mesenteric adenitis pattern is due to the abundant lymphoid tissue in the terminal ileum (Peyer patches), which is vulnerable to vasculitis and necrotizing lymphadenitis caused by the systemic hyperinflammatory illness [ 38 , 78 , 102 , 105 ]. The appendix can appear radiologically normal or abnormal, and imaging cannot always clearly distinguish between MIS-C and acute appendicitis [ 38 , 79 , 101 , 104 , 106 – 108 ]. Therefore, these findings must be considered in light of multiorgan involvement and laboratory data that would support a diagnosis of MIS-C.

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Analysis of 21 appendices from children with multisystem inflammatory syndrome compared to specimens of acute appendicitis – a new insight into MIS-C pathology

“…[1][2][3][4]9 Gastrointestinal involvement (nausea, vomiting, diarrhea, and abdominal pain) is particularly common during MIS-C. 2,3,5,9 A combination of severe abdominal pain and peritoneal signs sometimes leads to surgical interventions for the 'acute abdomen' before the final diagnosis is made. 1,5,[10][11][12] MIS-C is an effect of immune dysregulation, involving activation of macrophages, dendritic cells and neutrophils, profound peripheral lymphopenia and a 'cytokine storm', triggered by SARS-CoV-2.…”

“…There are only single case reports or small case series presenting histologic findings of the selected tissues from children with this new entity. 10,11,[19][20][21] We aimed to examine appendectomy specimens obtained during MIS-C and analyze the pathomorphological features of the disease and the presence of SARS-CoV-2 antigens in the affected tissue.…”

“…1–4,9 Gastrointestinal involvement (nausea, vomiting, diarrhea, and abdominal pain) is particularly common during MIS-C. 2,3,5,9 A combination of severe abdominal pain and peritoneal signs sometimes leads to surgical interventions for the ‘acute abdomen’ before the final diagnosis is made. 1,5,10–12…”

“…There are only single case reports or small case series presenting histologic findings of the selected tissues from children with this new entity. 10,11,19–21…”