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Determination of Factors to Distinguish MIS-C from Acute Appendicitis in Children with Acute Abdominal Pain
Introduction The aim of this study was to make the differential diagnosis between acute appendicitis and multisystem inflammatory syndrome in children (MIS-C) for patients presenting with the complaint of acute abdominal pain (AAP) and to identify the determining factors for the diagnosis of MIS-C.
Materials and Methods Eighty-one children presenting with AAP/suspected AAP were evaluated. Of these, 24 (29.6%) were included in the MIS-C group (MIS-C/g) and 57 were included in the suspected appendicitis group (S-A/g), which consisted of two subgroups: appendicitis group (A/g) and control observation group (CO/g).
Results Comparing MIS-C/g, A/g, and CO/g, duration of abdominal pain (2.4, 1.5, 1.8 days), high-grade fever (38.8, 36.7, 37°C), severe vomiting, and severe diarrhea were higher in MIS-C/g. Lymphocytes count (LC) was lower, while values of C-reactive protein (CRP), ferritin, and coagulopathy were higher in MIS-C/g (p < 0.05). The optimal cutoffs for the duration of abdominal pain was 2.5 days; the duration of fever, 1.5 days; peak value of fever, 39°C; neutrophil count, 13,225 × 1,000 cell/µMoL; LC, 600 × 1,000 cell/µMoL; ferritin, 233 µg/L; and D-dimer, 16.4 mg/L (p < 0.05). The optimal cutoff for CRP was 130 mg/L (sensitivity 88.9, specificity 100%, positive predictive value 100%, NPV, negative predictive value 92.5%, p < 0.001). All patients in MIS-C/g tested positive by serology by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Conclusion The duration of abdominal pain, presence of high-grade and prolonged fever, and evaluation of hemogram in terms of high neutrophil count and low LC exhibit high sensitivity and negative predictive value for MIS-C presenting with AAP. In case of doubt, inflammatory markers such as CRP, ferritin, D-dimer, and serology for SARS-CoV-2 should be studied to confirm the diagnosis.
Keywordsacute appendicitis - multisystem hyperinflammatory syndrome in children (MIS-C) - COVID-19 - acute abdominal pain
Level III evidence.
Received: 20 May 2021
Accepted: 10 June 2021
23 July 2021 (online)
© 2021. Thieme. All rights reserved.
Georg Thieme Verlag KG
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- 1 Frenkel L, Gomez F, Bellanti JA. COVID-19 in children: pathogenesis and current status. Allergy Asthma Proc 2020; DOI: 10.2500/aap.2020.42.200104.
- 2 Periyakaruppan M, Kumar S, Kandasamy S. et al. COVID abdomen: SARS-CoV-2 infection presenting as ‘Acute Abdomen’in a child. Indian J Pediatr 2021; 88 (03) 299-300
- 3 Verdoni L, Mazza A, Gervasoni A. et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet 2020; 395 (10239): 1771-1778
- 4 Levin M. Childhood multisystem inflammatory syndrome—a new challenge in the pandemic. N Engl J Med 2020; 383: 393-395 DOI: 10.1056/NEJMe2023158.
- 5 Rowley AH. Understanding SARS-CoV-2-related multisystem inflammatory syndrome in children. Nat Rev Immunol 2020; 20 (08) 453-454
- 6 Almaramhy HH. Acute appendicitis in young children less than 5 years: review article. Ital J Pediatr 2017; 43 (01) 15
- 7 Anderson JE, Bickler SW, Chang DC, Talamini MA. Examining a common disease with unknown etiology: trends in epidemiology and surgical management of appendicitis in California, 1995-2009. World J Surg 2012; 36 (12) 2787-2794
- 8 Guanà R, Pagliara C, Delmonaco AG. et al. Multisystem inflammatory syndrome in SARS-CoV-2 infection mimicking acute appendicitis in children. Pediatr Neonatol 2021; 62 (01) 122-124 DOI: 10.1016/j.pedneo.2020.09.007.
- 9 Jackson RJ, Chavarria HD, Hacking SM. A case of multisystem inflammatory syndrome in children mimicking acute appendicitis in a COVID-19 pandemic area. Cureus 2020; 12 (09) e10722
- 10 Meyer JS, Robinson G, Moonah S. et al. Acute appendicitis in four children with SARS-CoV-2 infection. J Pediatr Surg Case Rep 2021; 64: 101734
- 11 Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132 (05) 910-925
- 12 Gruber CN, Patel RS, Trachtman R. et al. Mapping systemic inflammation and antibody responses in multisystem inflammatory syndrome in children (MIS-C). Cell. 2020; 183 (04) 982-995.e14
- 13 Blumfield E, Levin TL, Kurian J, Lee EY, Liszewski MC. Imaging findings in multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19). AJR Am J Roentgenol 2021; 216 (02) 507-517
- 14 Gonzalez DO, Lawrence AE, Cooper JN. et al. Can ultrasound reliably identify complicated appendicitis in children?. J Surg Res 2018; 229: 76-81
- 15 Radia T, Williams N, Agrawal P. et al. Multi-system inflammatory syndrome in children & adolescents (MIS-C): a systematic review of clinical features and presentation. Paediatr Respir Rev 2021; 38: 51-57 DOI: 10.1016/j.prrv.2020.08.001.
- 16 Bonadio W. Time to appendectomy and risk of complicated appendicitis and adverse outcomes in children. JAMA Pediatr 2018; 172 (01) 94-94
- 17 Carlin RF, Fischer AM, Pitkowsky Z. et al. Discriminating multisystem inflammatory syndrome in children requiring treatment from common febrile conditions in outpatient settings. J Pediatr 2021; 229: 26-32.e2 DOI: 10.1016/j.jpeds.2020.10.013.
- 18 Becker T, Kharbanda A, Bachur R. Atypical clinical features of pediatric appendicitis. Acad Emerg Med 2007; 14 (02) 124-129
- 19 Kulik DM, Uleryk EM, Maguire JL. Does this child have appendicitis? A systematic review of clinical prediction rules for children with acute abdominal pain. J Clin Epidemiol 2013; 66 (01) 95-104
- 20 Gross I, Siedner-Weintraub Y, Stibbe S. et al. Characteristics of mesenteric lymphadenitis in comparison with those of acute appendicitis in children. Eur J Pediatr 2017; 176 (02) 199-205
- 21 Cheng VC, Hung IF, Tang BS. et al. Viral replication in the nasopharynx is associated with diarrhea in patients with severe acute respiratory syndrome. Clin Infect Dis 2004; 38 (04) 467-475
- 22 Lee J-H, Han H-S, Lee JK. The importance of early recognition, timely management, and the role of healthcare providers in multisystem inflammatory syndrome in children. J Korean Med Sci 2021; 36 (02) e17
- 23 Vella L, Giles JR, Baxter AE. et al. Deep immune profiling of MIS-C demonstrates marked but transient immune activation compared to adult and pediatric COVID-19. medRxiv September 27 2020; DOI: 10.1101/2020.09.25.20201863.
- 24 Kaushik S, Aydin SI, Derespina KR. et al. Multisystem inflammatory syndrome in children associated with severe acute respiratory syndrome coronavirus 2 infection (MIS-C): a multi-institutional study from New York City. J Pediatr 2020; 224: 24-29
- 25 Nakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. Multi-system inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection: review of clinical presentation, hypothetical pathogenesis, and proposed management. Children (Basel) 2020; 7 (07) 69
- 26 Belot A, Antona D, Renolleau S. et al. SARS-CoV-2-related paediatric inflammatory multisystem syndrome, an epidemiological study, France, 1 March to 17 May 2020. Euro Surveill 2020; 25 (22) 2001010
- 27 Anderson EM, Diorio C, Goodwin EC. et al. SARS-CoV-2 antibody responses in children with MIS-C and mild and severe COVID-19. J Pediatric Infect Dis Soc 2021; 10 (05) 669-673 DOI: 10.1093/jpids/piaa161.
- 28 Arnold MR, Wormer BA, Kao AM. et al. Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial. Pediatr Surg Int 2018; 34 (12) 1257-1268
- 29 Lishman J, Kohler C, de Vos C. et al. Acute appendicitis in multisystem inflammatory syndrome in children with COVID-19. Pediatr Infect Dis J 2020; 39 (12) e472-e473
- 30 Aronoff SC, Hall A, Del Vecchio MT. The Natural History of SARS-Cov-2 Related Multisystem Inflammatory Syndrome in Children (MIS-C): A Systematic Review. J Pediatric Infect Dis Soc 2020; 9 (06) 746-751
- 31 Choi NH, Fremed M, Starc T. et al. MIS-C and cardiac conduction abnormalities. Pediatrics 2020; 146 (06) e2020009738