Researchers at the University of Virginia have recently presented a case series pointing to a potential association between infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the development of acute appendicitis in children.
SARS-CoV-2 is the agent responsible for the coronavirus disease 2019 (COVID-19) pandemic that continues to pose a risk to global public health, putting healthcare services under pressure to focus resources on COVID-19-related care.
Writing in the Journal of Pediatric Surgery Case Reports, Debbie-Ann Shirley and colleagues describe four cases of children (aged 11 to 17 years) presenting with acute appendicitis symptoms who were also found to be infected with the SARS-CoV-2 virus.
The team says healthcare providers should consider testing for SARS-CoV-2 in pediatric patients presenting with severe gastrointestinal symptoms in order to inform transmission control measures.
The researchers also say the reporting of such cases would improve understanding of how SARS-CoV-2 infection manifests in children.
COVID-19 symptoms usually milder among children than among adults
Since the COVID-19 outbreak began in Wuhan, China, late last year (2019), studies have found that SARS-CoV-2 generally appears to cause milder disease among children than among adults.
The most common symptoms in children are fever and respiratory conditions, although gastrointestinal symptoms and skin conditions have also been reported.
“Severe disease can occur in children less frequently, but the full scope is yet to be elucidated,” says Shirley and colleagues.
A potential link between SARS-CoV-2 and appendicitis in children
Now, the researchers have described four cases of children presenting with acute appendicitis who were also found to be infected with SARS-CoV-2, suggesting a potential association.
The patients included an 11-year-old girl presenting with abdominal pain, vomiting and fever; a 13-year-old boy with abdominal pain, nausea and vomiting; a 17-year-old male with abdominal pain, nausea and vomiting and a 14-year-old boy with abdominal pain, vomiting and diarrhea.
In all four cases, computed tomography of the pelvis revealed a dilated and fluid-filled appendix and fat stranding consistent with edema and acute inflammation. Polymerase-chain-reaction (PCR) testing of nasopharyngeal swab samples revealed that all patients were infected with SARS-CoV-2.
“During the time period of presentation of these patients, 4 out of 13 patients (31%) with acute appendicitis tested positive for COVID-19,” writes the team. “Interestingly, this rate of COVID-19 in children with appendicitis was much higher than the 8% positivity rate for all children tested at our institution.”
The researchers suspect a link for several reasons
The researchers say there are several reasons they suspect that acute appendicitis may be associated with COVID-19 in children.
Firstly, gastrointestinal symptoms occur frequently in children with COVID-19, and gastrointestinal involvement is increasingly becoming recognized among SARS-CoV-2-infected children.
Secondly, a persistent viral infection of the gastrointestinal tract has been observed in cases of COVID-19. For example, one study conducted earlier this year (2020) found that one-fifth of SARS-CoV-2-infected patients had detectable viral RNA in their fecal samples, even following negative conversion of viral RNA in the respiratory tract.
In addition, researchers studying an animal model of SARS-CoV-2 infection detected a higher level of viral RNA in the gastrointestinal tract than in the respiratory tract.
The evidence to date also suggests that SARS-CoV-2 can be secreted by infected intestinal cells.
Third, the host cell receptor for SARS-CoV-2, called angiotensin-converting enzyme 2 (ACE2), is expressed at high levels in the intestinal lining.
Furthermore, “as ACE2 is present on glandular cells in the appendix, the appendix is also a viral target of SARS-CoV-2,” writes the team.
The team encourages SARS-CoV-2 testing of children with severe gastrointestinal symptoms
The researchers say that following this case series of children with COVID-19 and appendicitis, they would like to draw attention to a potential association between the two conditions.
“We encourage consideration of testing for SARS-CoV-2 in pediatric patients presenting with severe gastrointestinal symptoms to inform mitigation strategies for transmission and monitor for respiratory decompensation,” they say.
“Reporting of these observations will help further our understanding of disease manifestations in children,” concludes the team.
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