Diagnostics and treatment of complications of SARS-CoV-2 infection in the pediatric surgery department. An analysis based on seven clinical cases and literature review.

<b> Introduction:</b> Pediatric inflammatory multisystem syndrome - temporally associated with SARS-CoV-2 (PIMS-TS) is a new disease, the first cases of which were observed in the spring of 2020. It affects children who have been infected with SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus 2) and children who have been in direct contact with patients suffering from COVID-19 (coronavirus disease 2019). The disease is characterized by a wide spectrum of symptoms and the development of generalized inflammation of different organs and systems. One of the numerous symptoms may be severe abdominal pain. </br></br> <b>Aim:</b> The aim of this study was to review the available literature and analyze the results of patients treated at the Department of Pediatric Surgery, Traumatology and Urology in Poznan in whom PIMS-TS imitated acute surgical abdominal disease. </br></br> <b>Materials and methods:</b> material for the study was collected on the basis of medical records of patients treated at the Department of Pediatric Surgery, Traumatology and Urology of the Poznan University of Medical Sciences in the period between March 2020 and February 2021. </br></br> <b>Results:</b> TDuring this period, seven patients met the PIMS-TS criteria and three children were qualified for surgical treatment. Only one patient had an acute surgical cause of abdominal pain. </br></br> <b>Discussions:</b> The guidelines of the expert group at the Polish Pediatric Society and the National Consultant in the field of Pediatrics indicate the need to exclude acute surgical abdominal disease as a criterion for the diagnosis of PIMS-TS syndrome. In patients with acute abdominal pain, imaging and laboratory tests are sometimes diagnostically inconclusive, therefore exploratory laparoscopy is worth considering in order to differentiate PIMS-TS from acute surgical abdominal disease.

COVID-19 and abdominal pain: a pediatric case report and a point of view in pediatric emergency medicine.

COVID-19 is to date a global pandemic that can affect all age groups; gastrointestinal symptoms are quite common in patients with COVID-19 and a new clinical entity defined as Multisystem Inflammatory Syndrome in Children (MIS-C) has been described in children and adolescents previously affected by COVID-19. Presenting symptoms of this new disease include high fever and severe abdominal pain that can mimic more common causes of abdominal pain; patients can rapidly deteriorate presenting severe cardiac dysfunction and multiorgan failure. Some fatalities due to this serious illness have been reported. We describe the case of a ten-year-old patient presenting with persistent high fever associated with continuous and worsening abdominal pain. Various hypotheses were performed during his diagnostic workup and an initial appendectomy was performed in the suspect of acute appendicitis. As his clinical picture deteriorated, the child was subsequently diagnosed and successfully treated as a case of MIS-C. The objective of this case report and brief review of abdominal pain in children throughout the age groups is to provide the emergency pediatrician with updated suggestions in diagnosing abdominal pain in children during the COVID-19 pandemic.

Imaging as an alternate diagnostic modality in a presumptive case of abdominopelvic TB in a COVID-19 patient.

A 30-year-old, multiparous widow, with postpolio residual paralysis, presented with complaints of dull aching abdominal pain for 15 days. Ultrasound showed a mixed echogenic right adnexal mass with free fluid in the pelvis and abdomen. CT abdomen and pelvis revealed partially defined peripherally enhancing collection in lower abdomen and right adnexa suggestive of tubo-ovarian abscess. There was mild ileal wall thickening and few enlarged mesenteric lymph nodes. Ascitic fluid did not show acid fast bacilli and cultures were sterile. Extensive diagnostic laboratory work was done which was inconclusive. Diagnostic laparoscopy could not be performed due to non-availability of elective operation theatre in the COVID-19 pandemic. Presumptive extrapulmonary tuberculosis was clinically and radiologically diagnosed. She was started on daily anti tuberculosis treatment. This case shows us the importance of imaging as a diagnostic tool and as an alternative for laparoscopy in COVID-19 pandemic to diagnose abdomino-pelvic tuberculosis.

The gut microbiome: a missing link in understanding the gastrointestinal manifestations of COVID-19?

Coronavirus disease 2019 (COVID-19), which is caused by infection with SARS-CoV-2, presents with a broad constellation of both respiratory and nonrespiratory symptoms, although it is primarily considered a respiratory disease. Gastrointestinal symptoms-including nausea, abdominal pain, vomiting, and diarrhea-rank chief among these. When coupled with the presence of viral RNA in fecal samples, the presence of gastrointestinal symptoms raises relevant questions regarding whether SARS-CoV-2 can productively infect the upper or lower gastrointestinal tract. Despite the well-documented prevalence of gastrointestinal symptoms and the high rate of SARS-CoV-2 fecal RNA shedding, the biological, clinical, and epidemiological relevance of these findings is unclear. Furthermore, the isolation of replication-competent virus from fecal samples has not been reproducibly and rigorously demonstrated. Although SARS-CoV-2 shedding likely occurs in a high proportion of patients, gastrointestinal symptoms affect only a subset of individuals. Herein, we summarize what is known about gastrointestinal symptoms and fecal viral shedding in COVID-19, explore the role of the gut microbiome in other respiratory diseases, speculate on the role of the gut microbiota in COVID-19, and discuss potential future directions. Taking these concepts together, we propose that studying gut microbiota perturbations in COVID-19 will enhance our understanding of the symptomology and pathophysiology of this novel devastating disease.

Atypical and novel presentations of Coronavirus Disease 2019: a case series of three children.

Typical presentations of Coronavirus Disease 2019 (Covid-19) including respiratory symptoms (cough, respiratory distress and hypoxia), fever and dyspnoea are considered main symptoms in adults, but atypical presentation in children could be a diagnostic challenge. We report three children whose initial presentation was gastrointestinal, and in whom Covid-19 infection was found, concluding that cases of acute appendicitis, mesenteric adenitis and flank tenderness may mask an infection with this virus, and should therefore be investigated.

Spontaneous portomesenteric thrombosis in a non-cirrhotic patient with SARS-CoV-2 infection.

Intra-abdominal thromboses are a poorly characterised thrombotic complication of COVID-19 and are illustrated in this case. A 42-year-old man with chronic hepatitis B (undetectable viral load, FibroScan 7.4 kPa) developed fever and cough in March 2020. 14 days later, he developed right upper quadrant pain. After being discharged with reassurance, he re-presented with worsening pain on symptom day 25. Subsequent abdominal ultrasound suggested portal vein thrombosis. CT of the abdomen confirmed portal and mid-superior mesenteric vein thromboses. Concurrent CT of the chest suggested COVID-19 infection. While reverse transcription PCR was negative, subsequent antibody serology was positive. Thrombophilia screen excluded inherited and acquired thrombophilia. Having been commenced on apixaban 5 mg two times per day, he is currently asymptomatic. This is the first case of COVID-19-related portomesenteric thrombosis described in the UK. A recent meta-analysis suggests 9.2% of COVID-19 cases develop abdominal pain. Threshold for performing abdominal imaging must be lower to avoid this reversible complication.

A 29-Year-Old Male Construction Worker from India Who Presented with Left- Sided Abdominal Pain Due to Isolated Superior Mesenteric Vein Thrombosis Associated with SARS-CoV-2 Infection.

BACKGROUND In corona virus disease 2019 (COVID-19), which emerged in December 2019 and is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), most case presentations have been related to the respiratory tract. Several recent studies reveal that angiotensin-converting enzyme 2 (ACE2), which was found in the target cells of the virus, is highly expressed in the lungs, small bowel, and vasculature. CASE REPORT A 29-year-old male construction worker from India presented with left-sided colicky abdominal pain. He tested positive for infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription-polymerase chain reaction (RT-PCR). Isolated superior mesenteric vein thrombosis was diagnosed by CT (computed tomography) scan. He was managed by anti-coagulants and clinically improved. CONCLUSIONS This case report indicates that isolated venous thrombosis of the abdominal vessels without concurrent arterial thrombosis can be a complication of the hyper-coagulability state in COVID-19 patients. Hence, early evaluation of abdominal vessels in covid-19 patients who present with any abdominal symptoms should be considered, especially when found to have an elevated D-dimer level, as early treatment of thrombosis with low-molecular-weight heparin can have a significant impact on the therapeutic outcome.

Lung base CT findings in COVID-19 adult patients presenting with acute abdominal complaints: case series from a major New York City health system.

OBJECTIVE: To describe demographic, clinical, and lung base CT findings in COVID-19 patients presenting with abdominal complaints. METHODS: In this retrospective study, 76 COVID-19 patients who underwent abdominal CT for abdominal complaints from March 1 to April 15, 2020, in a large urban multihospital Health System were included. Those with positive abdominal CT findings (n = 14) were then excluded, with 62 patients undergoing final analysis (30M/32F; median age 63 years, interquartile range (IQR) 52-75 years, range 30-90 years). Demographic and clinical data were extracted. CT lung base assessment was performed by a cardiothoracic radiologist. Data were compared between discharged and hospitalised patients using Wilcoxon or Fisher's exact tests. RESULTS: The majority of the population was non-elderly (56.4%, < 65 years) and most (81%) had underlying health conditions. Nineteen percent were discharged and 81% were hospitalised. The most frequent abdominal symptoms were pain (83.9%) and nausea/vomiting/anorexia (46.8%). Lung base CT findings included ground-glass opacities (95.2%) in a multifocal (95.2%) and peripheral (66.1%) distribution. Elevated laboratory values (when available) included C-reactive protein (CRP) (97.3%), D-dimer (79.4%), and ferritin (68.8% of males and 81.8% of females). Older age (p = 0.045), hypertension (p = 0.019), and lower haemoglobin in women (p = 0.042) were more frequent in hospitalised patients. There was no difference in lung base CT findings between discharged and hospitalised patients (p > 0.165). CONCLUSIONS: COVID-19 patients can present with abdominal symptoms, especially in non-elderly patients with underlying health conditions. Lung base findings on abdominal CT are consistent with published reports. Radiologists should be aware of atypical presentations of COVID-19. KEY POINTS: • COVID-19 infected patients can present with acute abdominal symptoms, especially in non-elderly patients with underlying health conditions, and may frequently require hospitalisation (81%). • There was no difference in lung base CT findings between patients who were discharged and those who were hospitalised. • Lung base CT findings included multifocal and peripheral ground-glass opacities, consistent with published reports.

COVID-19 presenting as severe, persistent abdominal pain and causing late respiratory compromise in a 33-year-old man.

A 33-year-old man presented repeatedly with severe abdominal pain and diarrhoea. Renal colic was suspected, and he was admitted for pain management. Questioning elicited an additional history of sore throat and mild, dry cough. Inflammatory markers were mildly raised (C reactive protein (CRP) 40 mg/L). Initial nasopharyngeal swabs were negative for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by PCR. CT of the kidneys, ureters and bladder (CT KUB) was normal; however, CT of the thorax showed multifocal bilateral peripheral areas of consolidation consistent with COVID-19 infection. He developed respiratory compromise and was transferred to the intensive care unit (ICU). Sputum was positive for SARS-CoV-2 by PCR, and culture grew Yersinia enterocolitica He recovered following supportive management and treatment with piperacillin-tazobactam.

COVID-19 presenting with diarrhoea and hyponatraemia.

COVID-19 is a viral disease with a high infectivity rate. The full spectrum of the disease is not yet understood. This understanding may help in limiting potential exposure. We present a young man with diarrhoea, abdominal pain and hyponatraemia who turned out to be positive for COVID-19.

Acute complicated type B aortic dissection during the New York City COVID-19 surge.

The impact of the coronavirus disease 2019 (COVID-19) pandemic in New York City (NYC) is dramatic. COVID-19 cases surged, hospitals expanded to meet capacity, and NYC remains the global epicenter of this pandemic. During this unprecedented time, a young woman with known Marfan syndrome presented with an acute complicated type B aortic dissection to our Aortic Center. Using the provisional extension to induce a complete attachment technique, we treated this patient and quickly discharged her the next day to decrease the risk of COVID-19 infection. Her progress was monitored using frequent phone calls and one office visit at two weeks.