Multisystem inflammatory syndrome in children. An emerging clinical challenge for pediatric surgeons in the COVID 19 era

Abstract

Background/purpose Multisystem inflammatory syndrome in children (MIS-C) is a potentially life-threatening condition occurring 2–6 weeks after Coronavirus disease 2019 (COVID-19) in previously healthy children and adolescents, characterized by clinical and laboratory evidence of multiorgan inflammation. We reported the case of a 6-year-old child presented with acute abdomen and then diagnosed with MIS-C. In addition, to better portray this new entity, we performed a systematic review of MIS-C gastrointestinal features and particularly on those mimicking surgical emergencies. Methods We described the clinical presentation, the diagnostic approach and the therapeutic outcomes of our MIS-C patient. Parallel to this, we conducted a systematic literature search using Google Scholar, PubMed, EMBASE, Scopus, focusing on gastrointestinal MIS-C. Results Our patient was initially assessed by the surgical team due to his query acute abdomen. Following the diagnosis of MIS-C with myocarditis, intravenous methylprednisolone (2 mg/Kg/day) and intravenous immunoglobulins (2 gr/Kg single infusion) were promptly started, leading to clinical improvement. According to our literature search, patients with MIS-C have a high rate of severe abdominal symptoms resembling surgical emergencies (appendicitis, obstruction, etc.) and a not negligible number of those patients have been surgically explored with variable findings. Conclusions We encourage pediatric surgeons in the upcoming months of COVID-19 pandemic to evaluate myocardial function prior to surgical abdominal exploration. In children with query acute abdomen, MIS-C should be promptly ruled out in order to avoid unnecessary surgeries that could worsen the already frail outcome of this new syndrome. Nevertheless, it should be considered that MIS-C might well encompass complications (e.g. appendicitis, segmental intestinal ischemia) which need swift surgical treatment.

Abdominal manifestation of multisystemic inflammatory syndrome in children

“…Between 95% and all of the patients with this entity have abdominal pain, vomiting or diarrhea [ 11 ]. Comparing gastrointestinal manifestations in adults with SARS CoV-2 infection, they are present in less than 15%, in children between 10 and 20% and in children or adolescents with a diagnosis of MIS-C, between 80 and 100% [ 2 , 8 , 17 ]. In the study by Miller et al, 84.1% had gastrointestinal symptoms (abdominal pain, vomiting and diarrhea), and 100% of the children under study had fever (N: 44), which is very similar to that described by Shema et al, in a description of 35 patients where 86% presented gastrointestinal involvement.…”

“…The SARS CoV-2 pandemic, declared by the World Health Organization (WHO) on March 11, 2020, since the beginning has had a differential behavior between children and adults, mainly due to the type of involvement, clinical manifestations and severity. Thus, in mid-May 2020, European researchers reported cases of patients with symptoms of severe inflammation and multisystemic involvement that was initially associated with a syndrome similar to Kawasaki disease [ [1] , [2] , [3] , [4] ]. From this description and the issue of the criteria both by the WHO and the Center for Disease Control and Prevention (CDC) a new differential diagnosis has been established in children with gastrointestinal symptoms and surgical abdomen [ 1 , 3 , [5] , [6] , [7] , [8] ].…”

“…The multisystemic inflammatory syndrome, developed by patients as a complication of SARS CoV-2 infection, is a rare entity but one that can involve important organs of the body's economy in a variety of ways [ 2 , [9] , [10] , [11] , [12] ]. The clinical manifestations at abdominal level can lead to suspicion of surgical abdomen pathology, mainly acute appendicitis, without documentation of macroscopic or pathological findings in some cases that explain this entity [ 2 , 3 , 9 , 13 ].…”

Pediatric Multisystem Inflammatory Syndrome in Children as a Challenging Problem for Pediatric Surgeons in the COVID 19 Pandemic—A Case Report

“…Valitutti et al based on their own experience, encourages the assessment of the activity of the heart muscle before the operation of exploring the abdominal cavity. A preliminary assessment of troponin, BNP, D-Dimer, ferritin and echocardiography can help to establish a precise differential diagnosis in children with acute abdomen, especially when in MIS-C evolution toward cardiogenic shock should not be neglected (14). Another recomendation is presented by Khesrani et al They advice that in atypical abdominal pain syndrome during this pandemic an abdominal CT angio-scan should be performer to look for vascular damages in order to establish an appropriate medical treatment (immunoglobulins, corticoids) (15).…”

A Novel and Severe Clinical Picture Related to COVID-19: Multi-Inflammatory Syndrome in Children

“…44 Therefore, to prevent unnecessary surgical operations during the pandemic, it has been suggested that pediatric surgeons perform a myocardial evaluation and rule out the MIS-C in children who presented with acute abdomen. 45 Although any segment of the gastrointestinal tract can be compromised, there is a predominance of ileal and colonic inflammation among the patients. Progressive bowel obstruction which mainly recovers with medical treatment may occur.…”