key: cord-0763489-rjrrnjzd authors: Bazuaye-Ekwuyasi, Eseosa Amy; Camacho, Alvin C.; Saenz Rios, Florentino; Torck, Andrew; Choi, Woongsoon John; Aigbivbalu, Ebelosele E.; Mehdi, Mohammed Q.; Shelton, Kyle J.; Radhakrishnan, Geetha L.; Radhakrishnan, Ravi S.; Swischuk, Leonard E. title: Intussusception in a child with COVID-19 in the USA date: 2020-10-06 journal: Emerg Radiol DOI: 10.1007/s10140-020-01860-8 sha: 79b2d22f51e01ebaae0b5c69f5e88a57ad318b23 doc_id: 763489 cord_uid: rjrrnjzd COVID-19, caused by the novel coronavirus strain SARS-CoV-2 that emerged in late 2019, has resulted in a global pandemic. COVID-19 was initially believed to occur less frequently in children with relatively mild disease. However, severe disease and varied presentations have been reported in infected children, one of such being intussusception. There have only been three reported cases of intussusception in the pediatric population infected with COVID-19. In this paper, we will discuss the management and treatment of a novel fourth case of COVID-19-associated intussusception. This case is the first reported in the USA and suggests that COVID-19 may be implicated in the development of intussusception. Pediatricians should consider the possibility of intussusception when a child with COVID-19 presents with abdominal pain. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus first appeared in late 2019 and is responsible for the global coronavirus 2019 (COVID-19) pandemic. Unlike in the adult population where respiratory symptoms are characteristic, few infected children are symptomatic with only about half presenting with fever or cough. Additionally, gastrointestinal (GI) symptoms have been documented to occur more commonly in children than in adults. Intussusception is a possible but rare GI manifestation of COVID-19 infection with only three other reported cases worldwide [1] [2] [3] , making this case the first of its kind to be reported in the USA. A 9-month-old Hispanic male initially presented to the outpatient clinic on June 27, 2020, with complaints of increased fussiness, congestion, cough, and sneezing for 4 days and Two days following the initial outpatient visit, the patient presented to the emergency room with complaints of vomiting, episodic abdominal pain, decreased oral intake, and blood streaked stool. Signs of dehydration were noted on physical examination, but the abdominal exam was unremarkable. Urinalysis revealed ketonuria (80 mg/dl) and proteinuria (30 mg/dl). Complete blood count was significant for decreased lymphocytes at 1.6 × 10 3 μl. Abdominal radiograph (AXR) and abdominal ultrasound confirmed the presence of ileocolic intussusception (Fig. 1) . Non-surgical management with fluoroscopy-guided hydrostatic reduction of the intussusception was performed using a solution of saline and Gastrografin® (diatrizoate meglumine and diatrizoate sodium solution) contrast material. Successful reduction was achieved in a single attempt without complications (Fig. 2) . The patient remained stable and was discharged home the following day. COVID-19 refers to the infection caused by the novel 2019 coronavirus strain, SARS-CoV-2, that emerged in late 2019 and has been subsequently declared a global pandemic by the World Health Organization (WHO) on March 2, 2020. As of July 11, 2020, the virus has resulted in more than 12 million infections and over half a million deaths worldwide. The USA accounts for a quarter of these infections with more than 3 million cases and over 130,000 deaths [4] . Initially, COVID-19 was believed to be less frequent and not as virulent in Multi-system involvement including at least two of the following: a. Gastrointestinal (e.g., nausea, vomiting, diarrhea) b. Renal (e.g., elevated creatinine, proteinuria) c. Cardiac (e.g., elevated pro-BNP, elevated troponin, positive echocardiographic is findings) d. Mucocutaneous inflammation (e.g., palms, soles of feet, conjunctiva, oral mucosa) e. Coagulopathy (e.g., elevated PT, aPTT, D-dimer) f. Hypotension/shock 5 No alternative diagnosis or explanation for signs of inflammation 6 Current or recent positive COVID-19 with at least one of the following: a. PCR b. Serology c. Antigen d. Unprotected COVID-19 exposure within the last 4 weeks Tmax maximum temperature children. However, reports from Europe and the USA have emerged depicting an association between COVID-19 infection in children and a condition called multisystem inflammatory syndrome in children (MIS-C) [5] . The Center for Disease Control's (CDC) case definition of this syndrome is outlined in Table 1 . Intussusception is the most common abdominal emergency in young children [6] and the most common cause of intestinal obstruction in children between 3 months and 6 years [7] . There have been three reported cases of intussusception associated with COVID-19 worldwide [1] [2] [3] with ours being the fourth case and the first in the USA. A comparison of our case with the other documented cases is included in Table 2 . Most pediatric intussusceptions are idiopathic with a precipitating lesion detected in only about 10-25% of cases [6, 8] . Nonetheless, several factors have been implicated in its pathophysiology. Viral infections are the most prevalent etiologic factor [9] with the most commonly implicated virus being non-enteric adenoviruses [9] . In the limited cases with identifiable lead points, lymphoid hyperplasia of Peyer's Patches within the ileum was the most common instigating lead point [8] . Although the pathogenesis of COVID-19-related intussusception is not fully understood, it can be inferred to parallel the other viral associated intussusception cases. This involves an alteration in the peristaltic movement of the bowel wall which enables the telescoping of adjacent loops of bowel into each other, manifesting as intussusception [6] . Notably, the widespread immune activation that has been shown to be prevalent in COVID-19 may result in hypertrophy of the intestinal Peyer's patches thereby inciting intussusception. Of the four reported cases of COVID-19-related intussusception, there has been one mortality. This contrasts with the mortality rate of less than 1% in intussusception associated with other viruses. The heightened mortality in COVID-19associated intussusception is dependent on the association with MIS-C as seen in the case in Wuhan, China [2] who developed multiple organ failure and eventually died. Hence, prompt testing, institution of appropriate precautions, and preparation for possible complications are of vital importance in patients with COVID-19-related intussusception. Our case, however, did not meet the diagnostic criteria for MIS-C as outlined in Table 1 . The gold standard for management of intussusception in children is non-surgical reduction by hydrostatic or pneumatic enema under fluoroscopic or sonographic guidance with surgery reserved for complicated cases or after failure of nonsurgical reduction. All reported cases of COVID-19associated intussusception had successful non-surgical reduction, even the patient who eventually died. Hence, enema reduction should be attempted in uncomplicated cases of COVID-19-associated intussusception, as prescribed by current guidelines. Our case report suggests that COVID-19 may be implicated in the development of intussusception. Hence, it is important that pediatricians consider the possibility of intussusception when a COVID-19 patient presents with abdominal pain. Also, as children infected with SARS-CoV-2 are more likely to be asymptomatic or exhibit non-respiratory symptoms, we propose that children with intussusception during this pandemic should be tested for SARS-CoV-2. This is imperative as timely diagnosis is crucial for the successful management of COVID-19 and avoidance of potentially severe complications, including MIS-C. Intussusception in an infant as a manifestation of COVID-19 Clinical characteristics of 5 COVID-19 cases with non-respiratory symptoms as the first manifestation in children COVID-19 infection is a diagnostic challenge in infants with ileocecal intussusception COVID-19) cases and deaths in the US Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease Intestinal intussusception Failed intussusception reduction in children: correlation between radiologic, surgical, and pathologic findings Association of viral isolates from stool samples with intussusception in children Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Conflict of interest The authors declare that they have no conflict of interest.