We present a 6-year-old boy. He received a resection of the urine bladder and a channeled ileal conduit four years before because of a rhabdomyosarcoma of the bladder. In July 2020 he had symptoms of COVID-19 including loss of taste. There was no regular antigen or PCR testing at that time.

At time of presentation in January 2022 no vaccine was accepted for children of that age in Germany. The predominating virus types in Europe at that time were the wild type virus variant B and the variant BA.1.

At presentation in the evening hours, the boy had suffered from vomiting for four days. He was in a reduced dehydrated condition, had petechiae on the trunk, the abdomen was soft without signs for peritonitis. He had a tachycardia of 119 /min, a decrease of sodium of 124 mmol/l, c-reactive protein (CRP) value was 95.2 mg/l, leucocytes 4.5 /nl, lactate 3.1 mml/l, LDH 202 U/l, d-dimer levels increased from 1.95 to 3.71 mg/l within 7 hours, IL-6 9309 pg/ml. His temperature was 36.6 degrees, blood pressure 114/72 mmHg and oxygen saturation 97%. The conduit was vital, urinary excretion was reduced.

In the next morning, he was disoriented, respiratory and cardio circularly unstable (tachypnea > 50 /min, tachycardia 180 /min) and hypotensive (82/35 mmHg). Oxygen saturation was 98%. An emergency surgical intervention was indicated under the suspicion of a mechanical ileus.

During the anesthesiologic induction, the boy had a desaturation and circulatory arrest due to vomiting and bile aspiration. After 8 minutes of cardio-respiratory resuscitation and the necessary drugs he returned to spontaneous circulation.

During the following surgery, the mesentery of the small intestine showed scarring changes at the basis allegedly to the previous operation. Some vessels were thrombotic. More than 60cm the small intestine presented complete ischemic next to vital areas. There was no sign for a volvulus. In hope to preserve a longer distance bowel resection, an enterostomy about 60cm apart the Treitz Band was prepared with a planned second look operation. Due to the patient’s poor condition, the second look surgery was performed on the next day. Nothing of the bowel did recover, so about 65cm of the small intestine had to be resected (Figures 1-4).

At day 39, the enterostomy was relocated due to the now cachectic condition of the patient in hope for gaining weight besides the parenteral nutrition. The postoperative course was uneventful, and the boy left the hospital in a good condition.

Because of a suspected MIS-C, the boy was treated with immunoglobulins since day three after admission. Table 1 shows this medication. He was extubated five days after the operation. Afterwards he received non-invasive ventilation therapy because of a pneumonia while rising SARS-CoV-2 antibodies and a PCR testing clarified a now acute COVID 19 infection. Table 2 shows the timeline of the PCR testing and the testing for spike (S) and nucleocapsid (N) antibodies.

On day 17 after admission, he developed scaling of the fingertips (Figure 5) and repeated fever of unknown origin. On day 20, he showed a palmar exanthema (Figure 6).

One month after admission the respiratory support was stopped. Under the suspicion of MIS-C because of persisting subfebrile temperatures without rising infection values and without a clear focus, the boy received immunoglobulins (2g/kg) again and methylprednisolone 300mg/d for three days as recommended.

The cardiac function was measured as well functioning repeatedly.

The histopathological examination of the resected bowel showed a long-distancing and full-thickness hemorrhagic infarction of the bowel up to the edges of the resection (Figures 7, 8a, 8b). There was no vasculitis but multiple fibrin thrombi in the boundary zone of the blood vessels (Figures 9a, 9b). No virus was found in the ischemic bowel. There was no sign for recurrence of the malignancy.