key: cord-1015553-9aiy98k2 authors: Díaz-Ruiz, Renato; Ponce-de-León-Lovatón, Paula; Delgado-Seminario, Paulo; Urrunaga-Pastor, Diego title: Spontaneous resolution of intussusception after COVID-19 infection found at laparoscopy in a 6-year-old date: 2022-04-09 journal: J Pediatr Surg Case Rep DOI: 10.1016/j.epsc.2022.102273 sha: 881c2cce01954bfc4c0e77c911f5f1dab78b1f42 doc_id: 1015553 cord_uid: 9aiy98k2 The incidence of intussusception is 2.5 per 1000 live births, and infants between 4 and 10 months of age represent the highest frequency peak. Cases of intussusception with acute COVID-19 infection have been reported in infants under one year of age and with one death associated with MIS-C. However, we have not found reports of intussusception in schoolchildren. We report the case of a 6-year-old male with two days of illness that began with a sensation of temperature rise, headache, abdominal pain, liquid stools with mucus and no blood, hyporexia, chills, and food vomiting. He presented a negative result for the detection of SARS-CoV-2 antigen, negative SARS-CoV-2 IgM/IgG serology positive (lateral flow immunochromatography test), in addition to total IgM/IgG antibodies in 11.88 COI by means of a test of electrochemiluminescence. An abdominal ultrasound was performed that concluded invagination, for which an exploratory laparoscopy was performed and the patient evolved favorably. 13 cases of intussusception associated with acute COVID-19 infection have been described in this group. However, no reports of intussusception have been described after COVID-19 infection in school age. We recommend ruling out active or past SARS-CoV-2 infection in children with gastrointestinal symptoms and, if it exists, ruling out invagination by means of abdominal ultrasound. The incidence of intussusception is 2.5 per 1,000 live births and infants between 4 and 10 months of age represent the maximum frequency peak 1 and it is considered the main cause of intestinal obstruction in infants [2] [3] [4] [5] [6] [7] [8] [9] . Although most are idiopathic 2,6-10 ,30% are associated with previous viral infection 4, 8 being the most common etiological factor 1,2,4 . Adenoviruses and rotaviruses represent 50% of cases associated with viral infection 2-5 , although poliovirus , enterovirus, parechovirus , and norovirus have also been found 4, 8 . 6% of cases of intussusception are due to Meckel's diverticulum, Henoch-Schonlein purpura , intestinal duplication, polyp or lymphoma 8 , with a precipitating lesion found in 10% to 25% of cases 2 . 10% of children with COVID-19 present gastrointestinal symptoms 8 being more common than in adults 2, 8 . It increases up to 18% in some reports 1 and manifests as abdominal pain, diarrhea and vomiting 3, 4, 6, 10 . Cases of intussusception with acute COVID-19 infection have been reported in infants under one year of age and with one death associated with MIS-C 1-12 . Although there are cases of intussusception in infants with active SARS-CoV-2 infection, we have not found reports of intussusception in schoolchildren who have presented the disease. A 6-year-old male with two days of illness that began with a sensation of temperature rise, headache, and abdominal pain. Subsequently, liquid stools with mucus are added, without blood, hyporexia, chills and food vomiting. He goes to a private clinic where he is treated and discharged. The abdominal pain intensifies the next day, for which he returns to the private clinic, where laboratory tests are requested (Table 1) , he is given treatment (not specified by relatives) and when the crampy pain in the mesogastrium and epigastrium increases, accompanied by feeling nauseous, they request voluntary withdrawal and come to our institution due to an emergency. Physical examination revealed pain on deep palpation in the mesogastrium. An abdominal ultrasound was performed that concluded intussusception, so surgical intervention was decided (figure 1a). During surgery, mesenteric adenitis, non-invaginated ileum, appendix without significant alterations and liver with change in color were observed (figure 1b, 1c and 1d). An appendectomy was performed using a laparoscopic technique and a postoperative liver profile was requested (Table 1) . Given a presumptive diagnosis of MIS-C, the pediatrician requested laboratory tests (Table 1 ) and the cardiologist suggested continuing management by pediatric surgery. The patient evolved with mild and occasional pain, for which he was discharged on the second day after the operation, with analgesic. The patient came to the office 8 days after the operation and without symptoms. Control laboratory tests (Table 1) and echocardiography were taken, finding mild tricuspid regurgitation. In addition, the urinalysis did not present alterations, however, the functional coprology was positive for thevenon. The incidence of intussusception is 2.5 per 1,000 live births, affecting infants in most cases 1 . 13 cases of intussusception associated with COVID-19 infection have been described in infants with a positive active infection test, although one of them had already J o u r n a l P r e -p r o o f been diagnosed with COVID-19 three weeks before the intussusception 9 . However, no reports of intussusception have been found after COVID-19 infection in school age. 10 months 1,2,4-8,10-12 . However, cases have also been described in infants aged 2 months and 2.5 months 3,9 . We have not found cases in school-age children like the one we have presented who do not have an active SARS-CoV-2 infection. The generalized immune activation that exists during COVID-19 can cause hypertrophy of Peyer's patches 2 , the virus binds to the angiotensin II converting enzyme and enters the cell of the intestinal tract, altering peristalsis and could cause invagination 8 . We believe that the mechanism by which our patient presented intussusception is the same as in the cases of infants reported to date, since despite being of school age, we did not find a mechanical cause, but we did find mesenteric adenitis. The clinical picture was characterized by intermittent colicky abdominal pain, hyporexia, fever, vomiting and liquid stools. Some of the symptoms were present in the previous cases and although our patient did not present bloody stools, red blood cells were found in the stools and urine before surgery. Most of the cases published to date do report the presence of bloody stools and some report palpation of an abdominal mass, which was not found in our patient (Table 2 ). The image of choice to reach the diagnosis of intussusception is ultrasound. In most of the reported cases, ultrasound has also been used and in other cases, radiography and tomography. On the other hand, although the treatment of choice is non-surgical reduction, we opted for exploratory laparoscopy as it is a useful and valid diagnostic and treatment option with fewer complications than laparotomy. In addition, we did not have the necessary resources to do an emergency pneumatic or hydrostatic reduction. Most of the cases presented in the literature have been resolved non-surgical, others reached laparotomy after failure of non-surgical treatment, some performed laparotomy in the first instance and none attempted to resolve the case by laparoscopy. In conclusion, in children with gastrointestinal symptoms, it is necessary to rule out an active or past COVID-19 infection and rule out the presence of associated invagination through ultrasound. If the diagnosis of intussusception is confirmed, laparoscopy offers Novel Coronavirus Infection in an Infant with Intussusception Intussusception in a child with COVID-19 in the USA. emerge radiol COVID-19 presenting as intussusception in infants: A case report with literature review Intussusception in an infant as a manifestation of COVID-19 COVID-19 Infection Is a Diagnostic Challenge in Infants With Ileocecal Intussusception. Pediatric Emergency Care Can Cause Severe Intussusception in Infants: Case Report and Literature Review An Infant with COVID-19-Associated Intussusception Intussusception and SARS-CoV-2 infection Pediatric Covid-19 mesenteric lymphoid hyperplasia associated intussusception: A case report and literature review Global Reports of Intussusception in Infants With SARS-CoV-2 Infection Intussusception in 2 Children With Severe Acute Respiratory Syndrome Coronavirus-2 Infection Unusual presentation of COVID-19 as intussusception