Pseudo-Appendicitis in an Adolescent With COVID-19

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Abstract

Coronavirus disease 2019 (COVID-19) pandemic is a global health emergency in 2020. Patients with COVID-19 may present with variable clinical features, involving pulmonary, gastrointestinal, neurological, and cardiovascular symptoms. Notwithstanding, the acute abdomen as a presentation of COVID-19 is rare. We report an adolescent with confirmed COVID-19, initially presented with acute abdominal pain mimicking appendicitis. Our case highlights the inaccuracy of using clinical diagnosis for surgical abdomen in the COVID-19 era. Clinicians should perform screening COVID-19 tests in patients presenting with acute abdominal pain before admitting the patients to implement proper preventive measures in order to reduce viral transmission to other patients and healthcare professionals. Confirmed COVID-19 patients with acute abdomen may need proper imaging tests before surgery to avoid iatrogenic complications.

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Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding

Roujian Lu, Xiang Zhao, Juan Li … (2021)

Summary Background In late December, 2019, patients presenting with viral pneumonia due to an unidentified microbial agent were reported in Wuhan, China. A novel coronavirus was subsequently identified as the causative pathogen, provisionally named 2019 novel coronavirus (2019-nCoV). As of Jan 26, 2020, more than 2000 cases of 2019-nCoV infection have been confirmed, most of which involved people living in or visiting Wuhan, and human-to-human transmission has been confirmed. Methods We did next-generation sequencing of samples from bronchoalveolar lavage fluid and cultured isolates from nine inpatients, eight of whom had visited the Huanan seafood market in Wuhan. Complete and partial 2019-nCoV genome sequences were obtained from these individuals. Viral contigs were connected using Sanger sequencing to obtain the full-length genomes, with the terminal regions determined by rapid amplification of cDNA ends. Phylogenetic analysis of these 2019-nCoV genomes and those of other coronaviruses was used to determine the evolutionary history of the virus and help infer its likely origin. Homology modelling was done to explore the likely receptor-binding properties of the virus. Findings The ten genome sequences of 2019-nCoV obtained from the nine patients were extremely similar, exhibiting more than 99·98% sequence identity. Notably, 2019-nCoV was closely related (with 88% identity) to two bat-derived severe acute respiratory syndrome (SARS)-like coronaviruses, bat-SL-CoVZC45 and bat-SL-CoVZXC21, collected in 2018 in Zhoushan, eastern China, but were more distant from SARS-CoV (about 79%) and MERS-CoV (about 50%). Phylogenetic analysis revealed that 2019-nCoV fell within the subgenus Sarbecovirus of the genus Betacoronavirus, with a relatively long branch length to its closest relatives bat-SL-CoVZC45 and bat-SL-CoVZXC21, and was genetically distinct from SARS-CoV. Notably, homology modelling revealed that 2019-nCoV had a similar receptor-binding domain structure to that of SARS-CoV, despite amino acid variation at some key residues. Interpretation 2019-nCoV is sufficiently divergent from SARS-CoV to be considered a new human-infecting betacoronavirus. Although our phylogenetic analysis suggests that bats might be the original host of this virus, an animal sold at the seafood market in Wuhan might represent an intermediate host facilitating the emergence of the virus in humans. Importantly, structural analysis suggests that 2019-nCoV might be able to bind to the angiotensin-converting enzyme 2 receptor in humans. The future evolution, adaptation, and spread of this virus warrant urgent investigation. Funding National Key Research and Development Program of China, National Major Project for Control and Prevention of Infectious Disease in China, Chinese Academy of Sciences, Shandong First Medical University.

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Novelty in the gut: a systematic review and meta-analysis of the gastrointestinal manifestations of COVID-19

Vishnu Charan Suresh Kumar, Samiran Mukherjee, Prateek Suresh Harne … (2020)

Background The COVID-19 epidemic has affected over 2.6 million people across 210 countries. Recent studies have shown that patients with COVID-19 experience relevant gastrointestinal (GI) symptoms. We aimed to perform a systematic review and meta-analysis on the GI symptoms of COVID-19. Methods A literature search was conducted via electronic databases, including PubMed, Embase, Scopus, and Google Scholar, from inception until 20 March 2020. Data were extracted from relevant studies. A systematic review of GI symptoms and a meta-analysis comparing symptoms in severe and non-severe patients was performed using RevMan V.5.3. Results Pooled data from 2477 patients with a reverse transcription-PCR-positive COVID-19 infection across 17 studies were analysed. Our study revealed that diarrhoea (7.8%) followed by nausea and/or vomiting (5.5 %) were the most common GI symptoms. We performed a meta-analysis comparing the odds of having GI symptoms in severe versus non-severe COVID-19-positive patients. 4 studies for nausea and/or vomiting, 5 studies for diarrhoea and 3 studies for abdominal pain were used for the analyses. There was no significant difference in the incidence of diarrhoea (OR=1.32, 95% CI 0.8 to 2.18, Z=1.07, p=0.28, I2=17%) or nausea and/or vomiting (OR=0.96, 95% CI 0.42 to 2.19, Z=0.10, p=0.92, I2=55%) between either group. However, there was seven times higher odds of having abdominal pain in patients with severe illness when compared with non-severe patients (OR=7.17, 95% CI 1.95 to 26.34, Z=2.97, p=0.003, I2=0%). Conclusion Our study has reiterated that GI symptoms are an important clinical feature of COVID-19. Patients with severe disease are more likely to have abdominal pain as compared with patients with non-severe disease.

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Covid‐19 may present with acute abdominal pain

U. Saeed, H. B. Sellevoll, V. Young … (2020)

Editor Coronavirus disease 2019 (COVID‐19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is typically characterized by respiratory tract symptoms and fever1. Less focus has been on abdominal pain. There are however some reports on COVID‐19 presenting similar to pancreatitis2. In our experience, patients have presented with abdominal pain as a main complaint without having findings of abdominal disease, but Covid‐19 infection. We conducted a retrospective analysis of medical records of patients over the age of 18 years admitted to our department between 17 March and 1 April 2020 due to acute abdominal pain. Patients who were diagnosed with COVID‐19 during diagnostic work‐up were included. All patients underwent routine screening for COVID‐19 before entering hospital. Patients with suspected COVID‐19 were isolated and tested for SARS‐CoV‐2. In total, 76 patients were admitted with acute abdominal pain as their main complaint. Nine patients (11·8 per cent) were diagnosed with COVID‐19 and were included in this study. Median age (range) was 48 (31–81) years. Patient findings from the work‐up are shown in Table 1. Following a positive COVID‐19 test, patients were re‐evaluated for respiratory tract symptoms, which they denied having experienced. In five patients, suspicion of COVID‐19 was made from pulmonary findings on acute CT performed for abdominal symptoms. All five subsequently tested positive for SARS‐CoV‐2. The remaining four patients were diagnosed directly using reverse‐transcription polymer chain reaction on oro‐ and nasopharyngeal swabs. Six patients had no findings on abdominal CT while showing typical findings of COVID‐19 on chest CT. All patients were discharged to self‐isolation at home. No patient needed ICU treatment. Table 1 Clinical, laboratory and radiologic data from nine patients with acute abdominal pain diagnosed with COVID‐19 CT Patient Abdominal pain region Other GI symptoms Fever O2 satuaration (%) C‐reactive protein (mg/l) White blood cell count (× 109/l) Abdomen Chest Follow‐up (days) 1 Epigastric Nausea, vomiting No 94 67 3·4 Normal Bilateral ground‐glass opacities 18 2 Epigastric Nausea, vomiting Yes 95 123 4·3 Normal Bilateral ground‐glass opacities 17 3 Global Nausea Yes 95 140 7·2 Normal Bilateral ground‐glass opacities 17 4 Left iliac fossa Nausea, vomiting Yes 94 111 7·4 Normal Unilateral ground‐glass opacities 16 5 Right iliac fossa Nausea Yes 97 43 7·6 Normal Bilateral ground‐glass opacities 21 6 Global Nausea, vomiting No 97 7·7 2·6 Normal Bilateral ground‐glass opacities 9 7 Right iliac fossa Nausea, vomiting No 90 350 23·8 Cholecystitis Normal 8 8 Right iliac fossa Diarrhoea Yes 100 82 4·6 Appendicitis Normal 9 9 Umbilical Nausea No 99 < 0·6 7·7 Ileus Normal 12 GI, gastrointestinal. Although causal relationship between SARS‐CoV‐2 and abdominal pain cannot be deducted from our limited observations, findings indicate that COVID‐19 can present with abdominal pain without respiratory symptoms. A potential explanation could be the presence of cellular angiotensin‐converting enzyme 2 (ACE2) in several abdominal organs3, making them susceptible to viral infection as SARS‐CoV‐2 binds to ACE24. In the initial phase of the pandemic, our screening criteria for COVID‐19 did not include symptoms of abdominal pain. Several patients were first isolated and tested after CT raised suspicion, forcing numerous health professionals into quarantine. CT is performed in the acute setting for these patients and may identity those with unestablished COVID‐19 early. However, since three of nine chest CTs were negative, our limited data indicate a low sensitivity for CT as a screening tool for COVID‐19. There are several recommendations on safe practice to reduce the risk of infection during surgery2, 5, however abdominal pain as a symptom in acute surgical patients is not discussed in detail. From our limited experience, we believe awareness of acute abdominal pain as a potential symptom of COVID‐19 could reduce the risk of viral transmission to healthcare providers and spread of the infection within hospitals. Modifications have been made to our institutional protocols for acute admission and diagnostic work‐up of patients with abdominal pain during the pandemic6. Droplet isolation and testing for COVID‐19 are now performed on all patients with upper abdominal pain, all patients with abdominal pain (irrespective of location) and fever, and all patients presenting with abdominal pain during quarantine. CT of the chest is performed routinely in all adults undergoing CT of the abdomen for acute abdominal pain.

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Journal ID (nlm-ta): Cureus

Journal ID (iso-abbrev): Cureus

Journal ID (issn): 2168-8184

Title: Cureus

Publisher: Cureus (Palo Alto (CA) )

ISSN (Electronic): 2168-8184

Publication date (Electronic, pub): 25 July 2020

Publication date (Electronic, collection): July 2020

Volume: 12

Issue: 7

Electronic Location Identifier: e9394

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[1 ] Internal Medicine, Lincoln Medical Center, New York City, USA

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Kulachanya Suwanwongse kulachanya.suwanwongse@ 123456gmail.com

Article

DOI: 10.7759/cureus.9394

PMC ID: 7449643

SO-VID: afc7186c-427c-4fc4-b9a3-a58b0b1c79cf

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Pseudo-Appendicitis in an Adolescent With COVID-19

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Novel Coronavirus Disease COVID-19

Most cited references 5

Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding

Novelty in the gut: a systematic review and meta-analysis of the gastrointestinal manifestations of COVID-19

Covid‐19 may present with acute abdominal pain

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