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Intussusception in the setting of severe acute respiratory syndrome coronavirus 2 infection following rotavirus vaccination

Abstract Most cases of intussusception are thought to be idiopathic, related to viral infections, structural abnormalities, or certain vaccinations. In this report, we present the development of intussusception in a pediatric patient who was coronavirus 2019 (COVID‐19) positive. Although the most common gastrointestinal symptoms of COVID‐19 virus are diarrhea and vomiting, there recently have been rare case reports of intussusception in patients throughout the world who are severe acute respiratory syndrome coronavirus 2 positive. This case is only the second known report in the United States and the second case reported globally that required surgical intervention for definitive management.


INTRODUCTION
Intussusception is a common abdominal emergency in early childhood with a mean age of 6 to 18 months with an incidence in the United States from 0.24 to 2.4 per 1000 live births. 1 It is an idiopathic condition in most instances, with ≈30% of cases having an identifiable cause such as Meckel's diverticulum, polyps, vaccines, or viral infections. 2 It is thought that the associated immune response to viral infections results in mesenteric lymphadenopathy, which serves as a lead point, creating the opportunity for the disease process. 3 The most common subtype is ileocolic intussusception, and this is likely secondary to the ileocecal anatomy as well as the abundance of lymphoid tissue found in the terminal ileum. 4 The understanding of this pathophysiology serves as a mechanism by which the coronavirus 2019 (COVID-19) virus may precipitate intussusception.

CASE PRESENTATION
A 4-month-old boy with no past medical history and born at term 39 weeks 3 days presented to the pediatric emergency department JACEP Open 2022;3:e12703. wileyonlinelibrary.com/journal/emp2 1 of 4 https://doi.org/10.1002/emp2.12703 (ED) accompanied by his mother for the complaint of 2 episodes of blood in stool that began 2-3 hours before presentation. According to the mother, the patient had decreased intake of formula during the preceding 24 hours with only 1 wet diaper in the same timeframe. The mother brought the patient to the ED after first noticing 1 episode of brown, normal-colored stool mixed with some blood and mucus followed by a second episode of only blood and mucus noted in the diaper.
On arrival, there was a third episode of mucus and blood in the diaper that was witnessed by the ED physicians, which appeared to be "currant jelly" stool. Additional history included the patient receiving routine scheduled immunizations 9 days before the ED visit that included inactivated polio vaccine (IPV); pneumococcal conjugate vaccine (PCV13); rotavirus (Rotarix); diphtheria, tetanus, and pertussis; and Haemophilus influenzae type b.
In the ED, initial vital signs were within normal limits, with exception of a heart rate of 153 beats per minute with a normal rhythm. On physical examination, he was awake, alert, and in no acute distress, but he did appear lethargic and was not engaging actively as would be normal for his age. An abdominal examination revealed discomfort to palpation diffusely without distension, rigidity, and no palpable masses. The surgical intervention was successful in locating ileocolic intussusception reaching the hepatic flexure, which was reduced without any areas of compromise requiring resection. After the procedure, the patient was observed as an inpatient for several days and was F I G U R E 1 Dilated loops of bowel measuring up to 2.9 cm with a paucity of rectal gas eventually advanced to a liquid diet and was discharged home on hospital day 5.

DISCUSSION
The SARS-CoV-2 virus that first appeared in late 2019 has resulted in Among the previously recorded cases of intussusception with SARS-

CONCLUSION
We present a rare case of intussusception in the setting of acute SARS-CoV-2 infection in an infant <6 months of age with no known exposure to COVID-19 and without any respiratory symptoms. After reviewing the 6 other case reports of intussusception in pediatric patients who were SARS-CoV-2 positive, it seems plausible that the virus has some direct effect on GI pathology. More studies need to be executed to better understand the mechanism of infectivity of gut epithelial or endothelial cells. Such studies could allow the Centers for Disease Control and Prevention and WHO to better protect the global pediatric and adult patient population throughout the pandemic.

PATIENT CONSENT
Consent was not obtained to publish this case report. The report does not contain personal information that could lead to the identification of the patient.