Sex: M
Vaccine: DTP, HIBV, IPV, RV1, UNK
Symptoms: Blood bicarbonate, Blood chloride decreased, COVID-19, Decreased activity, Explorative laparotomy
Clinical narrative: Ileocolic intussusception; 2 episodes of blood in stool/ Brown, normal-colored stool mixed with some blood / currant jelly stool; Decreased intake of formula in 24 hrs; Only 1 wet diaper in 24 hrs; Brown, normal-colored stool mixed with some blood and mucus/ mucus and blood in diaper; Lethargic; Not engaging actively as would be normal; Abdominal discomfort; Rigidity; Hypochloremia; Mild metabolic acidosis; SARS-CoV-2 was positive; intussusception with some internal vascularity within the lesion; Dilated loops of bowel; Paucity of rectal gas; This case was reported in a literature article and described the occurrence of ileocolic intussusception in a 4-month-old male patient who received Rota (Rotarix) for prophylaxis.   Co-suspect products included DTP (A or W not known) (DTP vaccine) for prophylaxis, Haemophilus influenzae type b vaccine for prophylaxis, INACTIVATED POLIO VACCINE for prophylaxis and PNEUMOCOCCAL CONJUGATE VACCINE 13 for prophylaxis.   On an unknown date, the patient received Rotarix, DTP vaccine, Haemophilus influenzae type b vaccine, INACTIVATED POLIO VACCINE and PNEUMOCOCCAL CONJUGATE VACCINE 13. On an unknown date, between 1 and 2 weeks after receiving Rotarix, DTP vaccine and Haemophilus influenzae type b vaccine and an unknown time after receiving INACTIVATED POLIO VACCINE, the patient experienced ileocolic intussusception (serious criteria hospitalization, GSK medically significant and clinically significant/intervention required), blood in stool (serious criteria hospitalization and GSK medically significant), oral intake reduced (serious criteria hospitalization), urine output decreased (serious criteria hospitalization), mucus stools (serious criteria hospitalization), lethargy (serious criteria hospitalization), hypoactive (serious criteria hospitalization), abdominal discomfort (serious criteria hospitalization), abdominal rigidity (serious criteria hospitalization), hypochloremia (serious criteria hospitalization), metabolic acidosis (serious criteria hospitalization), sars-cov-2 infection (serious criteria hospitalization), gastric mucosal lesion (serious criteria hospitalization), intestinal dilatation (serious criteria hospitalization) and gas (serious criteria hospitalization). The patient was treated with intravenous fluid (nos) (Intravenous Fluid Therapy (Nos)) and barium (Barium Enema). On an unknown date, the outcome of the ileocolic intussusception was recovering/resolving and the outcome of the blood in stool, oral intake reduced, urine output decreased, mucus stools, lethargy, hypoactive, abdominal discomfort, abdominal rigidity, hypochloremia, metabolic acidosis, sars-cov-2 infection, gastric mucosal lesion, intestinal dilatation and gas were unknown.   The reporter considered the ileocolic intussusception, blood in stool, oral intake reduced, urine output decreased, mucus stools, lethargy, hypoactive, abdominal discomfort, abdominal rigidity, hypochloremia, metabolic acidosis, gastric mucosal lesion, intestinal dilatation and gas to be possibly related to Rotarix. The reporter considered the sars-cov-2 infection to be related to Rotarix. It was unknown if the reporter considered the ileocolic intussusception, blood in stool, oral intake reduced, urine output decreased, mucus stools, lethargy, hypoactive, abdominal discomfort, abdominal rigidity, hypochloremia, metabolic acidosis, sars-cov-2 infection, gastric mucosal lesion, intestinal dilatation and gas to be related to DTP vaccine and Haemophilus influenzae type b vaccine.     Additional Information: GSK Receipt Date: 04-APR-2022 Author comment: The patient with no past medical history and born at term 39 weeks 3 days presented to the emergency department (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 physicians, which appeared to be "currant jelly" stool.  The patient received 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. No additional significant findings were noted on examination, and all other systems were grossly normal. During the initial hospital course, he was started on intravenous fluid therapy and was ordered nothing by mouth in anticipation of potential operative intervention. Laboratory studies revealed an elevated total leukocyte count of 15.08 × 103/mcl (reference range, 7.91-13.41 × 103/mcl) with neutrophil predominance and an elevated platelet count of 649 × 103/mcl (reference range, 215-448 × 103/mcl). Serum chemistry revealed significant hypochloremia of 96 mmol/L (reference range, 98-107 mmol/L), mild metabolic acidosis with bicarbonate level of 21 mmol/L (reference range, 22-29 mmol/L), and anion gap of 19 mEq/L (reference range, 6-18 mEq/L). A nasopharyngeal polymerase chain reaction swab for SARS-CoV-2 was positive and procalcitonin elevated to 0.32 ng/ml (reference range, 0.02-0.08 ng/ml). Additional laboratory studies were within the normal reference range. An abdominal radiograph (Figure 1) revealed multiple dilated loops of bowel measuring up to 2.9 cm in the mid and left abdomen with a paucity of rectal gas; there was no radiographic evidence of pneumoperitoneum. Ultrasound of the abdomen demonstrated apparent bowel within bowel forming a "doughnut sign" and measuring approximately 6.7 × 2.8 × 3.7 cm in the mid-pelvic region posterior to the bladder. The area was described as a hyperechoic center and hypoechoic wall that likely represents intussusception with some internal vascularity within the lesion. After confirming the diagnosis on ultrasound, a barium enema was performed and demonstrated partial reduction of ileocolic intussusception up to the level of the hepatic flexure without evidence of further reduction beyond the hepatic flexure. At this time the patient was taken for an exploratory laparotomy by the pediatric surgery team. 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 eventually advanced to a liquid diet and was discharged home on hospital day 5.  "There have been many studies attempting to determine the natural course of the SARS-CoV-2 infection and possible long-term effects, but the studies are ongoing. Initially, the pediatric population was thought to be minimally affected by SARS-CoV-2; however, multisystem inflammatory syndrome in children first seen in April 2020 has demonstrated the wide range of inflammatory effects the virus can have especially in the pediatric population. Based on the postulated pathogenesis of intussusception and the likelihood that COVID-19 directly affects the GI tract more in children than adults, it is not surprising that intussusception is a possible presentation or complication of SARS-CoV-2 infection. In addition, the patient had received the routine scheduled rotavirus (Rotarix) vaccine in the week before presentation, which has long been thought to be associated with an increased likelihood of developing intussusception. Based on the concomitant presence of the SARS-CoV-2 infection, it is not clear which cause superseded in the development of intussusception or if both contributed equally." Conclusion: The author presented a rare case of intussusception in the setting of acute SARSCoV- 2 infection in an infant less than 6months 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.  Additional Supportive Information: This article is not available for regulatory reporting due to copyright restriction.