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Children and adolescents with COVID-19 who developed multisystem inflammatory syndrome often exhibited marked gastrointestinal (GI) manifestations, sometimes confounding diagnosis by mimicking GI infections or inflammatory bowel disease (IBD), according to a recent case series.

In a chart review of 44 pediatric patients (ages 7 months to 20 years, 55% female) hospitalized for COVID-19-related MIS-C from April 18 to May 22, 2020, GI symptoms were prominent in 84.1% of cases and were commonly accompanied by fever (100%) and rash (70.5%), reported Kara Gross Margolis, MD, of Morgan Stanley Children's Hospital at Columbia University Irving Medical Center in New York City, and colleagues.

However, unlike adult patients, only 25% of the pediatric patients in the case series required supplemental oxygen, and only one required intubation, they stated in

Some 30% had within the past 7 days visited an emergency department or urgent care center for less severe symptoms, such as fever and GI symptoms mimicking viral gastroenteritis, including nausea, vomiting, and diarrhea. No other systemic symptoms were evident.

Of the 27% of patients who had an infectious polymerase chain reaction panel performed on stool, none had an identified infection. The majority of cases at admission had markedly elevated inflammatory markers: erythrocyte sedimentation rate (ESR) median of 59 and C-reactive protein (CRP) median of 146.5. They also had mildly decreased albumin (median 3.7), and 52.3% had elevated transaminases. Just one patient had lipase elevated to more than three times the upper limit of normal.

MIS-C, a condition involving systemic hyperinflammation with fever and multisystem organ dysfunction similar to the symptomatic profile of Kawasaki disease, should therefore be considered in patients who present with prominent GI symptoms, and a history of recent SARS-CoV-2 exposure, according to the authors. Long-term follow-up of possible organ dysfunction may warrant surveillance for IBD, they added.

"These data suggest that the vast majority of patients who develop this condition present with GI symptoms mimicking GI infection or even inflammatory bowel disease. MIS-C should thus be considered in patients with prominent GI symptoms and a history of recent SARS-CoV-2 exposure or infection," Margolis and team wrote.

In further tests, abdominal imaging in 15 patients revealed mesenteric adenitis (two cases), biliary sludge or acalculous cholecystitis (six), and ascites (six). In three cases, ultrasound or MRI revealed thickening of the bowel wall, which raised concern about possible IBD.

Of these patients, one had intense right lower quadrant abdominal pain, fever, and rash, with MRI findings of severe concentric mural thickening, edema, and hyper-enhancement of a short segment of terminal ileum with extensive mesenteric fat edema. Similar mural thickening appeared in the rectosigmoid colon (CRP 184.7, ESR 56, and albumin 3.7).

The two other patients had sonographic images showing nonspecific thickened bowel loops in the right lower quadrant with highly elevated CRP and mildly decreased to normal albumin levels.

Steroids (methylprednisolone and/or hydrocortisone) were administered to 42 patients. Other therapies included intravenous immunoglobulin and anakinra (Kineret), and 90.1% received anticoagulation. At the time of this report, all but one patient were discharged, none required mechanical circulatory support, and one required renal replacement therapy. The authors reported no deaths.

Though much less common in adults, GI symptoms are an increasingly recognized aspect of COVID-related MIS-C, starting with the description of MIS-C in eight , all of whom had GI symptoms. Similarly, in an six of 10 affected children with Kawasaki-like symptoms had GI issues.

These manifestations have the potential to confuse the diagnosis of MIS-C with common, less toxic, GI infections and even IBD, noted Andrew B. Grossman, MD, of the Center for Pediatric Inflammatory Bowel Disease at the Children's Hospital of Philadelphia.

"For any child with MIS-C whose GI symptoms and/or findings mimic inflammatory bowel disease, surveillance to confirm that this is self-limited will be critical," he told MedPage Today.

"We are seeing a similar presentation of MIS-C at our institution," said Grossman, who was not involved in the case series.

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