Case Presentation: A previously healthy 4-month-old male was admitted with vomiting, diarrhea and dehydration associated with COVID-19 infection. Three days prior to admission he developed fever to 102.1, cough, and was seen in an urgent care where he tested positive for COVID-19. Forty-eight hours prior to admission non-bloody diarrhea began with multiple episodes per day. Nonbilious emesis began on the day of admission with nine episodes over 24 hours. He had multiple sick contacts at home; his father had respiratory symptoms and tested positive for COVID-19 the week prior and his sister had respiratory symptoms but had not yet been tested for COVID-19. On physical examination, our patient presented pale and ill-appearing and was difficult to arouse. Vital signs revealed tachycardia to the 150s, apyrexia, normal blood pressure and normal pulse oximetry. Lungs were clear and there was no rhinorrhea. Mucous membranes appeared moist and capillary refill was less than two seconds. Abdomen was soft without distension or tenderness and normal bowel sounds were present. Admission laboratory testing showed a normal white blood cell count, renal, liver function tests and electrolytes were normal as well. Urinalysis was consistent with dehydration but showed no signs of urinary tract infection. Blood and urine cultures were sent. Following Zofran and a 20 ml/kg saline bolus the patient had additional nonbilious emesis and was admitted for rehydration. Over the first 12 hours of hospitalization a lack of improvement in both tachycardia and clinical exam findings with intravenous rehydration prompted abdominal xray and ultrasound imaging. These revealed a massive ileocolic intussusception with fluid-filled dilated small bowel loops. A subsequent contrast enema, using Gastrografin diluted with saline, was successfully performed reducing the invagination. No complications occurred during the procedure. Respiratory symptoms remained mild with no shortness of breath and nonproductive cough. Following reduction of the intussusception, emesis and diarrhea resolved. Our patient was observed overnight, and prior to discharge was tolerating his normal diet and appeared clinically improved.
Discussion: Through the course of the COVID-19 pandemic it has been noted that children may have an asymptomatic or mild clinical presentation of infection. Gastrointestinal symptoms including diarrhea and vomiting have been frequently reported as presenting symptoms in children (1). Intussusception is the most common pediatric cause of gastrointestinal obstruction. Prompt reduction of intussusception is imperative to prevent bowel ischemia, necrosis and bowel perforation (2). A strong causal association of intussusception with viral illnesses has been described (3). Emerging data describes an association between COVID-19 infection and intussusception, with intussusception the presenting symptom particularly in infants.
Conclusions: We report a case of a male infant admitted to the hospital with vomiting, diarrhea and dehydration with COVID-19 infection, subsequently found to have ileocolic intussusception. This report adds to growing evidence of an association between COVID-19 infection and intussusception in children. Given the potential morbidity associated with delayed diagnosis and treatment of intussusception, it is prudent to consider intussusception in children admitted to the hospital with COVID-19 infection and gastrointestinal symptoms.