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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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Year : 2021  |  Volume : 26  |  Issue : 6  |  Page : 468-469

Primary peritonitis with subacute intestinal obstruction: An unusual presentation of multisystem inflammatory syndrome in children

1 PICU Consultant, VMCC Hospital, Pune, Maharashtra, India
2 Pediatric Surgeon, Dr. DY Patil Medical College Hospital and Research Center, Pune, Maharashtra, India
3 Pediatric consultant, Department of Pediatrics, VMCC Hospital, Pune, Maharashtra, India

Date of Submission29-May-2021
Date of Decision02-Aug-2021
Date of Acceptance12-Aug-2021
Date of Web Publication12-Nov-2021

Correspondence Address:
Dr. Vipulkumar Vijay Gandhi
Department of Pediatrics, VMCC Hospital, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.jiaps_108_21

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How to cite this article:
Gandhi VV, Hegde A, Kavade S, Gore S. Primary peritonitis with subacute intestinal obstruction: An unusual presentation of multisystem inflammatory syndrome in children. J Indian Assoc Pediatr Surg 2021;26:468-9

How to cite this URL:
Gandhi VV, Hegde A, Kavade S, Gore S. Primary peritonitis with subacute intestinal obstruction: An unusual presentation of multisystem inflammatory syndrome in children. J Indian Assoc Pediatr Surg [serial online] 2021 [cited 2022 Aug 8];26:468-9. Available from: https://www.jiaps.com/text.asp?2021/26/6/468/330356

Multisystem inflammatory syndrome in children (MIS-C) is one of the well-established post-COVID complications noted in the pediatric population in this pandemic. Almost 80% of MIS-C cases presented with gastrointestinal (GI) symptoms as compared to around 10% of patients with primary COVID-19 infection. Usual GI manifestations in MIS-C are abdominal pain, diarrhea, and vomiting.[1],[2] To the best of our knowledge, this is the first reported case of MIS-C with an unusual presentation of primary peritonitis with subacute intestinal obstruction from India. A 5-year-old male child was presented with fever, nonbilious vomiting, severe abdominal pain, and lethargy for 2 days. On admission, the child has significant guarding and rigidity with sluggish bowel sounds and mild abdominal distention. On admission child was in compensated shock which responded well to fluid resuscitation. Investigations revealed neutrophilia, raised inflammatory markers, and deranged coagulopathy (raised D-dimer) with sterile blood culture. Coronavirus disease 2019 (COVID-19) immunoglobulin G antibodies were positive 22.69 AU/ml (<1.00), and reverse transcription–polymerase chain reaction was negative. Abdominal ultrasonography and computed tomography showed findings of primary peritonitis associated with subacute obstruction of the small intestine. Echocardiography noted mildly dilated coronaries with a high Z score >2.5. Z score of <2 which is a standard deviation of mean coronary artery diameter for the same age and sex group is considered normal. The child was managed conservatively and treated with ceftriaxone, amikacin, metronidazole, pulse dose methylprednisolone, and immunoglobulins. Posttreatment, his inflammatory markers normalized, bowel sounds improved, and subacute intestinal obstruction gradually subsided. On day 5 of admission, he was started on an oral diet which he tolerated well and was subsequently discharged. Repeat echocardiography on day 7 of illness showed normalization of coronary Z scores. The differential diagnosis considered acute appendicitis, volvulus, and acute pancreatitis which were ruled out.

Angiotensin-II-converting enzyme (ACE2) plays a pivotal role in SARS-CoV-2 viral uptake and its spread in the human body. Terminal ileum which is a home for a highly dense population of these ACE2 receptors explains the higher GI symptoms in the patients with MIS-C.[3] However, it is still unclear the underlying roles of viral-induced lymphoid hyperplasia or systemic cytokine storm lead end-organ damage responsible for the acute abdomen presentation in MIS-C.

Considering the risk of rapid deterioration as well as the need for specific treatment modalities such as steroids and intravenous immunoglobulin, we recommend pediatricians and pediatric surgeons should consider MIS-C as one of the differentials while managing acute abdomen cases in this pandemic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Ahmed M, Advani S, Moreira A, Zoretic S, Martinez J, Chorath K, et al. Multisystem inflammatory syndrome in children: A systematic review. EClinicalMedicine 2020;26:100527.  Back to cited text no. 1
Miller J, Cantor A, Zachariah P, Ahn D, Martinez M, Margolis KG. Gastrointestinal symptoms as a major presentation component of a novel multisystem inflammatory syndrome in children that is related to coronavirus disease 2019: A single center experience of 44 cases. Gastroenterology 2020;159:1571-4.e2.  Back to cited text no. 2
Sahn B, Eze OP, Edelman MC, Chougar CE, Thomas RM, Schleien CL, et al. Features of intestinal disease associated with COVID-related multisystem inflammatory syndrome in children. J Pediatr Gastroenterol Nutr 2021;72:384-7.  Back to cited text no. 3


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