Appendicitis likely to occur in children with COVID-19

Children infected with SARS-CoV-2, the causative agent of the coronavirus disease 2019 (COVID-19), may also develop acute appendicitis, according to a study.

The researchers postulate that “it may represent a postinfectious hyperinflammatory complication of SARS-CoV-2 infection occurring 2 weeks after the early manifestation of acute pneumonia disease in children.”

This retrospective analysis included 48 paediatric patients (aged ≤25 years) with confirmed SARS-CoV-2 infection admitted between 29 March and 26 July 2020. The researchers reviewed the medical charts of patients to obtain the date of admission, medical history, demographic variables, presenting signs and symptoms, admitting laboratory values, diagnostic imaging, diagnosis, treatment modalities, and outcomes including length of stay and disease severity.

Seven patients were asymptomatic and were thus excluded from further analysis. Of the remaining 41 patients, 16 were diagnosed with SARS-CoV-2 pneumonia, 10 with appendicitis, 10 with multisystem inflammatory syndrome in children (MIS-C), and five with unconventional symptoms.  [Pediatr Infect Dis J 2021;40:e49-e55]

SARS-CoV-2 pneumonia tended to present early during the first 4­–6 weeks (11 of 16 patients). About 2 weeks after the peak in reported SARS-CoV-2 cases, cases of pneumonia declined while admission for MIS-C and acute appendicitis in association with a diagnosis of COVID-19 increased. Ten appendicitis cases and nine of 10 MIS-C cases occurred during the final 12 weeks.

Of the patients with a radiologic diagnosis of appendicitis, five had a ruptured appendix. Only one of eight had radiologic evidence of mesenteric adenopathy. Eight patients underwent an appendectomy, and the rest were medically managed.

The major presenting clinical findings were fever, nausea, vomiting, and abdominal pain. Six children underwent chest radiography, and three had abnormal findings (ie, unilateral or bilateral basilar opacity). None of them had respiratory symptoms. In addition, three of the seven appendicitis patients were either overweight or obese.

“The cause of appendicitis is unknown, although obstruction of the lumen of the appendix secondary to an initiating factor such as appendicolith formation or mesenteric adenopathy is suspected,” the researchers said. [Acta Chir Scand 1983;149:789-791]

“All three of our patients with rupture who were screened for appendicoliths were positive, compared with two of five patients without rupture. Mesenteric lymphadenopathy was noted in one of three with rupture and none of the patients without rupture,” they added.

In previous studies, patients with COVID-19 presented with gastrointestinal signs and symptoms suggestive of acute appendicitis but subsequently ruled out by abdominal computed tomography. In contrast, the current study showed that appendicitis could occur in children with SARS-CoV-2 infection. [Lancet Child Adolesc Health 2020;4:e19-e20; ID Cases 2020;21:e00860; J Visc Surg 2020;203:S63-S64]

“To the best of our knowledge, this is the first report of a temporal association of SARS-CoV-2 infection with multiple cases of acute appendicitis in children,” the researchers said. “Although our numbers are small and more studies are needed to verify this association, clinicians should be made aware of the possibility that appendicitis can present as a postinfectious manifestation of SARS-CoV-2 infection in children.”