PC2176: Infant with COVID-19: Progressive Bilious Emesis Due to Intussusception

Introduction: While COVID-19 is largely considered a respiratory disease, it is known to have multi-systemic effects. Infants are frequently asymptomatic or have only mild disease. In this case, we report an uncommon presentation: an infant with mild respiratory symptoms who presented with progressive bilious emesis due to intussusception.

Case Description: A former full term 4-month-old female presented to the emergency department with one day of episodic, progressively bilious emesis. Three days prior to presentation, the patient developed mild congestion, cough, and intermittent fussiness. Parents denied increased work of breathing, apnea, cyanosis, diarrhea, or blood/mucous in the stool. There were no known sick contacts, although the patient was in daycare. Upon examination, patient was well appearing, afebrile, and hemodynamically stable. She had scant clear congestion but no other respiratory abnormalities. During the exam, the patient was intermittently fussy and had an episode of small volume bilious emesis (Figure 1). Initial evaluation included an abdominal film, which showed a non-obstructive bowel gas pattern, and a SARS-CoV-2 nasopharyngeal PCR, which was positive. Due to the bilious emesis and concern for malrotation, an upper GI series was obtained but was normal. The patient was admitted for observation but continued to have bilious emesis with intermittent fussiness. A repeat abdominal film showed mildly dilated right lower quadrant loops of bowel. Given the persistent symptoms and new radiographic finding, an abdominal ultrasound was performed. It demonstrated ileocolic intussusception (Figure 2). Pediatric Surgery performed an air enema reduction. The patient’s fussiness and emesis subsequently resolved. The next day, a repeat ultrasound revealed mesenteric lymphadenopathy with a small amount of simple free fluid in the abdomen consistent with a reactive process. The intussusception did not recur. Our patient tolerated oral intake and was discharged later that day.

Discussion: Intussusception in the pediatric population is most commonly found to be idiopathic. Nevertheless, there is evidence that viral infections can trigger intussusception via hypertrophy of intestinal lymphatic tissue. As COVID-19 is known to infect the gastrointestinal tract and can result in mesenteric lymphadenitis, it is likely that the patient’s acute COVID-19 infection was the cause of her intussusception. This case supports the growing evidence that the SARS-CoV-2 virus can trigger intussusception.

Conclusion: This case highlights the association between COVID-19 infection and intussusception. In a COVID-19 positive pediatric patient with emesis and intermittent fussiness, intussusception should be high on the differential diagnosis.