Terminal Ileitis as the Exclusive Manifestation of COVID-19 in Children

Abstract

The clinical presentation, organ involvement, and severity of disease caused by SARS-CoV-2 are highly variable, ranging from asymptomatic or mild infection to respiratory or multi-organ failure and, in children and young adults, the life-threatening multisystemic inflammatory disease (MIS-C). SARS-CoV-2 enters cells via the angiotensin-converting enzyme-2 receptor (ACE-2), which is expressed on the cell surfaces of all organ systems, including the gastrointestinal tract. GI manifestations have a high prevalence in children with COVID-19. However, isolated terminal ileitis without other manifestations of COVID-19 is rare. In March 2023, two previously healthy boys (aged 16 months and 9 years) without respiratory symptoms presented with fever and diarrhea, elevated C-reactive protein levels, and low procalcitonin levels. Imaging studies revealed marked terminal ileitis in both cases. SARS-CoV-2 (Omicron XBB.1.9 and XBB.1.5 variants) was detected by nucleic acid amplification in throat and stool samples. Both patients recovered fast with supportive measures only. A differential diagnosis of acute abdominal pain includes enterocolitis, mesenteric lymphadenitis, appendicitis, and more. During SARS-CoV-2 epidemics, this virus alone may be responsible for inflammation of the terminal ileum, as demonstrated. Coinfection with Campylobacter jejuni in one of our patients demonstrates the importance of a complete microbiological workup.

Keywords: COVID-19; Oxford nanopore technology; SARS-CoV-2; children; nucleic acid amplification; terminal ileitis.

Figure 1

Sonographic imaging of a large conglomerate of lymph nodes with increased blood flow shown by a Color Doppler ultrasound in the right lower abdomen (a,b). MRI showing extensive lymphadenopathy in the right lower and middle abdomen (c,d) and the thickened, diffusion-impaired terminal ileum (e,f), as highlighted within the orange dashed line in the lower right corner of the images (case 1).

Figure 1

Sonographic imaging of a large conglomerate of lymph nodes with increased blood flow shown by a Color Doppler ultrasound in the right lower abdomen (a,b). MRI showing extensive lymphadenopathy in the right lower and middle abdomen (c,d) and the thickened, diffusion-impaired terminal ileum (e,f), as highlighted within the orange dashed line in the lower right corner of the images (case 1).

Figure 2

An abdominal ultrasound showing thickening of the intestinal wall of the terminal ileum (orange arrows in (a)) and the ileocecal valve (orange arrow in (b)—cross-section, and (c)—longitudinal section) (case 2).