We describe an 11-year-old well-grown boy, a single child from a nuclear family presented with fever, pain abdomen for five days, vomiting, loose stool for three days, transient non-itchy, maculopapular rashes on both feet. There were no respiratory symptoms. At admission, he had diffuse abdominal tenderness with guarding, raised doubt of an acute surgical abdomen. He was kept nil by mouth and started on intravenous fluid maintenance and ceftriaxone.
Abdominal ultrasound revealed thickening of terminal ileum and caecum with multiple lymph nodes in the right iliac fossa. Initial blood investigations showed Hemoglobin 11.6 g/dl; total leukocyte count (TLC) - 11,500 cells/mm3 with 90% neutrophils(N) and 9% lymphocytes(L), Platelets - 3.0Lakhs/mm3, CRP - 107 mg/L, hypoalbuminemia (2.6g/dl), INR 1.46, Ferritin 666ng/ml, LDH 233U/L with preserved renal function, lactate and transaminases. CXR was normal.
As a part of fever workup, COVID-19 RT-PCR was done (6th day of illness) from a nasopharyngeal sample and reported as negative. Due to persistent fever, abdominal pain, and the inability of USG to locate appendix, CECT abdomen was done showed normal appendix, diffuse mural wall thickening in the terminal ileum, ileo-caecal junction and ascending colon with adjacent significant mesenteric lymphadenopathy [Figure 1].
On day 3 of hospitalization i.e. 8th day of illness, the child developed features of compensated shock, required 40 ml/kg crystalloid fluid resuscitation. As there was resurfacing of shock on next day, shifted to PICU and received another 20 ml/kg fluid bolus and started on face mask oxygen. Given worsening clinical status, the antibiotic was upgraded to Piperacillin + Tazobactum, and Azithromycin was added. 2D ECHO was normal. Repeat investigation showed TLC- 13,730cells/mm3 (N-91%, L-06%), platelets - 5.05Lakhs/mm3, CRP increased to 142 mg/L, D-dimer was high (2.16mg/L) with negative pro-BNP and Troponin T. Due to worsening clinical condition, and negative yield in all other infective (leptospirosis, typhoid, scrub typhus) workup, nasopharyngeal and oropharyngeal swab were re-sent for COVID on 10th day of illness and reported as positive.
We have planned immunomodulation and chosen to start 2g/kg of IVIG over steroid for fear of intestinal perforation. He was also given iv thiamine and ascorbic acid as part of supportive therapy. Hydroxychloroquine was not added as the corrected QT was 470ms. Over the next 72 hours, his tachypnea improved, became afebrile, appetite improved and tolerated oral liquids and soft diet. Blood parameters also showed concurrent improvement with CRP coming down to 38 mg/L. Both parents were tested negative for COVID. The child was shifted to public healthcare facility for continuation care and discharged after seven days of observation and PCR negative status.