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Case Reports
. 2021 Aug:71:101913.
doi: 10.1016/j.epsc.2021.101913. Epub 2021 May 19.

COVID-19-associated multisystem inflammatory syndrome in children (MIS-C) presenting as appendicitis with shock

Jamie E Anderson  1 , Julie A Campbell  2 , Lindsey Durowoju  3 , Sarah L M Greenberg  1 , Samuel E Rice-Townsend  1 , Kenneth W Gow  1 , Jeffrey Avansino  1
Affiliations
Case Reports

COVID-19-associated multisystem inflammatory syndrome in children (MIS-C) presenting as appendicitis with shock

Jamie E Anderson et al. J Pediatr Surg Case Rep. 2021 Aug.

Abstract

Multisystem inflammatory syndrome in children (MIS-C) is an identified complication of the COVID-19 infection. A common presentation of both COVID-19 and MIS-C is acute abdominal pain, sometimes mimicking appendicitis. We report two cases of patients initially diagnosed with appendicitis who either presented with or developed signs of shock and were found to have MIS-C. An 8-year-old girl who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) presented with fever, abdominal pain, and shock with ultrasound findings consistent with acute appendicitis. After being treated for MIS-C, she underwent appendectomy and improved. Final pathology was consistent with acute appendicitis. A 9-year-old girl who tested negative for COVID RT-PCR presented with uncomplicated appendicitis and underwent laparoscopic appendectomy, but developed post-operative fever and shock. Antibody testing was positive and she responded to treatment for MIS-C. Histology showed lymphohistiocytic inflammation within the muscularis propria, mesoappendix and serosa without the typical neutrophil-rich inflammation and mucosal involvement of acute appendicitis. The diagnosis was MIS-C, not appendicitis. Given the new reality of the COVID-19 pandemic, pediatric surgeons must be aware of MIS-C as a possible diagnosis and should understand the diagnostic criteria and current treatment guidelines.

Keywords: Acute abdomen; Appendicitis; COVID-19; Coronavirus; Multisystem inflammatory syndrome in children (MIS-C); SARS-CoV-2.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Pathology findings of perforated acute appendicitis. A: Transmural neutrophilic inflammation with H&E stain (4x), B: Mucosal ulceration with H&E stain (10x), C: Negative anti-SARS- CoV-2 antibody immunostain shows non-specific staining of goblet cells and mucin (20x), D: Positive control on lung tissue with anti-SARS- CoV-2 antibody immunostain (20x).
Fig. 2
Fig. 2
Hematoxylin and eosin stained appendix. A: Intact mucosa and prominent Peyer's patches without neutrophilic inflammation (10x), B: Muscularis propria with lymphohistiocytic inflammation (20x), C: Mesoappendix with histiocytic aggregates (10x), D: Possible perivascular or vascular fibrin deposition with intermixed lymphohistiocytic inflammation (20x).
Fig. 3
Fig. 3
Immunohistochemical studies. A: CD163 stain highlights increased histiocytes within the mesoappendix (10x), B: Myeloperoxidase stain demonstrates prominent granular cytoplasmic staining of histiocytes (10x), C: CD3 stain shows T lymphocytes within the muscularis propria and mesoappendix (10x), D: Negative anti-SARS- CoV2 with non-specific staining of goblet cells and mucin (20x).
See this image and copyright information in PMC

References

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