Multisystem Inflammatory Syndrome in Children Presenting

Multisystem Inflammatory Syndrome in Children Presenting as Subacute Intestinal Obstruction

To the Editor: A 9-y-old girl was admitted with fever and vomiting for 3 d, not passing stools for 2 d, abdominal pain and fullness for 1 d. She was febrile (105 °F), dehydrated, and tachycardic; there was abdominal distension with gen- eralized tenderness and sluggish bowel sounds. Abdominal radiograph showed multiple air fuid levels in the abdomen suggestive of intestinal obstruction. She was kept nil by mouth with continuous nasogastric tube aspiration which showed minimal bilious aspirates. She was started on intra- venous fluids and empirical antibiotics pending cultures.

Blood investigations showed neutrophilic leukocytosis, mild thrombocytosis, and elevated erythrocyte sedimenta- tion rate (ESR – 60 mm/h) and C-reactive protein (CRP – 31 mg/dL); urinalysis was normal. Serum lipase and amyl- ase were mildly raised and transaminases were normal. RT-PCR for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was negative. Serology for SARS-CoV-2 showed elevated IgG titer (538 AU/mL). Further investiga- tion revealed elevated troponin-T, N-terminal prohormone of brain natriuretic peptide (NT pro-BNP) and D-dimer. Echocardiography showed mild left ventricular dysfunction. Dengue serology and Typhidot IgM were negative. Blood culture was sterile. A diagnosis of multisystem infamma- tory syndrome in children (MIS-C) was made as she ful- flled the WHO criteria [1]. She was treated with intravenous immunoglobulin (IVIG), low-dose methyl-prednisolone and aspirin. Her symptoms resolved gradually. Repeat infam- matory markers and echocardiography were normal at 2 wk follow-up.

Gastrointestinal (GI) symptoms like vomiting, diarrhea, and abdominal pain have been reported in up to 90% chil- dren with MIS-C [2]. However, there are only a few case reports of MIS-C presenting with features of intestinal obstruction [3, 4]. To the best of our knowledge, this is the frst case of MIS-C presenting with features of intestinal obstruction reported in India. We believe MIS-C should be considered in the differential diagnosis of children present- ing with features of intestinal obstruction, especially during the ongoing pandemic.

References

1. WHO. Multi system inflammatory syndrome in children and adolescents temporally related to COVID-19. Accessed on 5 July 2021.

2. Feldstein LR, Tenforde MW, Friedman KG, et al. Character- istics and outcomes of US children and adolescents with mul- tisystem inflammatory syndrome in children (MIS-C) com- pared with severe acute COVID-19. JAMA. 2021;325:1074–87.

3. Sahn B, Eze OP, Edelman MC, et al. Features of intestinal disease associated with COVID-related multisystem inflammatory syn- drome in children. J Pediatr Gastroenterol Nutr. 2021;72:384–7.

4. Morparia K, Park MJ, Kalyanaraman M, McQueen D, Bergel M, Phatak T. Abdominal Imaging findings in critically Ill chil- dren with multisystem inflammatory syndrome associated with COVID-19. Pediatr Infect Dis J. 2021;40:E82–3.

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