A catastrophic case of Multisystem inflammatory syndrome (MIS-C) with small bowel obstruction

ABSTRACT

There is no definitive guideline to distinguish multisystem inflammatory syndrome in children (MIS-C) associated with gastrointestinal symptoms from surgically-based pathologies such as volvulus. A 9-year-old boy presented with periumbilical abdominal pain and non-bilious vomiting. A week prior, he and his family had fever. He arrived at the emergency department dehydrated and in shock. His abdomen was soft, non-tender and non-distended. Abdominal x-ray showed faecal loading and no dilated bowel while ultrasound showed features of enterocolitis. The polymerase chain reaction was positive for SARS-CoV-2. He was treated for MIS-C and intravenous immunoglobulin and methylprednisolone were administered. Later, there was progressive abdominal distention where CT angiography of abdomen demonstrated ascites and generalized small bowel dilatation and thickening. Exploratory laparotomy found small bowel volvulus and anomalous bands (AB). SARS-CoV- 2 has been speculated to trigger dysregulation of the immune response resulting in multiorgan failure. Around 68.3% - 73.7% of MIS-C patients had gastrointestinal symptoms. Small bowel obstruction secondary to AB is a rare entity contributing only about 3% of the total cases2. AB may be acquired as a result of an infection or inflammatory condition, or it may be congenital. The diagnosis of obstructed congenital AB was based on the exclusion of acquired cause 3. Recent SARS-CoV-2 infection may have contributed to this patient's condition. As immunomodulatory therapies are required, it is crucial to consider MIS-C in the diagnostic process. This case illustrates the complexity in attaining a diagnosis. COVID-19 can cause a myriad of inflammatory dysregulation which in turn, present as a multitude of symptoms. Physicians in all time should always think of other possible causes of the symptoms to ensure the best course of management for the patient.