A Case of COVID-19 Mimicking Acute Appendicitis in Multi-System Inflammatory Syndrome

Children's naive immune systems allow for a unique course of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus when compared to adults. In multi-system inflammatory syndrome in children (MIS-C), a current or recent SARS-CoV-2 infection can cause fever and elevated inflammatory markers in individuals under the age of 21. Similar to Kawasaki disease, Kikuchi disease, systemic lupus erythematosus, toxic shock syndrome (TSS), and macrophage activation syndrome (MAS), there is an influx of inflammation associated with MIS-C that creates this pathologic state. Because MIS-C affects numerous organ systems, its presentation varies substantially, thus making it difficult to diagnose and treat in a timely fashion. In our case, a previously healthy four-year-old African American female initially presented to the emergency department (ED) with high fever, abdominal pain, and headache after recent SARS-Co-V-2 exposure. After initially being diagnosed with a urinary tract infection (UTI), she returned with a myriad of symptoms, including persistent fever, abdominal pain, and conjunctivitis. Her initial SARS-CoV-2 test returned positive, and she was admitted and placed on broad-spectrum antibiotics then requiring vasopressors, mechanical ventilation, and an appendectomy. Her workup revealed elevated inflammatory markers, elevated brain natriuretic peptide (BNP), anemia, thrombocytopenia, pyuria, and hypercoagulability meeting the criteria for MIS-C. In addition to antibiotics, her treatment included IV immunoglobulin and methylprednisolone until the patient was stabilized for discharge. As more is learned about SARS-CoV-2, it will become increasingly important to consider the development and implications of MIS-C. Educating providers on the wide range of MIS-C presentations can lead to more effective preventative measures and treatments.