LAUSR

It was one of those busy days in the children’s emergency department (ED) in December 2021. Omicron was the dominant virus. Along came an 18-month-old girl, whose mother gave a history that she was unsettled for 5 days with upper respiratory symptoms, constipation, and abdominal pain. She was being treated for constipation. She would not allow the junior doctor to examine her, but made friends with the consultant after extensive bribery involving bubbles, stickers, colouring and choice of movie. Clinical observations and examination were normal when done whilst watching the aforesaid movie. Her abdomen was soft and non-tender. A period of observation was decided on, given the history. At the same time, there was a 15-year-old boy in ED with fever and abdominal pain. Appendicitis was suspected; the surgical team got ready to take him to theatre. The ED team expressed concerns as he looked relatively well but with a raised serum C Reactive Protein (CRP) of 202 mg/L. Abdominal ultrasound was reported as showing ileitis. Negotiations between both teams were started, facilitated by the ED consultant. The toddler, in the Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2, decided that more food supplies were in order after consuming personal supplies of Hula Hoops, and approached the consultant. She departed into the waiting room after procuring biscuits and orange juice. Attention returned to the 15-year-old; it was decided that he should be admitted and observed. Once this was settled, further history taken from the mother revealed that over the past 3 days her daughter woke up at night screaming with pain, so much so that neighbours would call and ask if all was well. A peculiar history of neighbours checking in the great city of London was notable. It was decided to perform an abdominal ultrasound, based on the history. Extensive negotiations with the radiology team commenced and 2 h later it was agreed the ultrasound would be done at a sister hospital. The toddler had in the meantime spent 3 h in ED eating and drinking and enjoying the facilities. Hula Hoops were removed from the toddler’s fingers by the consultant, on account of the fact that she was requesting an ultrasound for intussusception and did not want to look foolish (the consultant not the toddler). The toddler amicably ate the removed Hula Hoops and set off after waving a cheerful goodbye. ED became busy and numerous children were seen. Two hours later the radiologist called – abdominal ultrasound showed a doughnutshaped mass, an ileocolic intussusception. At the receiving hospital, a fresh bag of Hula Hoops was removed from the toddler who showed great anger at this turn of events, especially as this was followed by cannulation. Bloods showed a non-specific CRP of 11 mg/L. The toddler was transferred to a tertiary centre where an air enema resulted in resolution of the intussusception. As it turned out she was also COVID positive on nasopharyngeal swabs. She was discharged home and is subsequently living happily ever after. As for the 15-year-old, he too was COVID positive, diagnosed as having Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS). He continued to spike fevers, was started on IV methylprednisolone and had a good outcome. PIMS-TS is notably a great masquerader, mimicking appendicitis on this occasion. The toddler was unique: 5 days of varied symptoms, normal examination and an excellent appetite. The clue was in the history. In the COVID-19 pandemic, when our concentration is on the obviously sick children, along comes one who teaches us an unforgettable lesson. What we see in ED is a snapshot, the movie is evolving at home, hence history is the key. Paediatrics is a speciality like no other, extraordinary learning interspersed with magic.