# Critical Intestinal Perforations in Pediatric Immunocompromised Patients: A Case-Based Review

## TL;DR

This paper discusses three cases of children with weakened immune systems who developed severe intestinal perforations without typical symptoms, highlighting the need for early imaging and careful monitoring.

## Contribution

The paper introduces the novel observation that immunomodulatory therapies can mask signs of intestinal perforation in pediatric patients.

## Key findings

- Three pediatric patients on immunomodulators developed intestinal perforation without classic symptoms like fever or pain.
- All patients survived after diagnosis through surgical findings and timely intervention.
- The paper emphasizes the importance of early imaging and multidisciplinary review in at-risk patients.

## Abstract

As survival rates for children with cancer and immune disorders have improved, clinical focus has shifted toward managing serious treatment-related complications. Intestinal perforation remains life-threatening and is typically diagnosed by signs of peritonitis and inflammation. This report presents three high-risk pediatric patients who developed severe intestinal perforation without the usual clinical symptoms. Each patient was receiving high-dose corticosteroids and/or targeted biologic immunomodulators (ruxolitinib, anakinra, tocilizumab, eculizumab). Classic indicators such as fever, leukocytosis, hemodynamic instability, and abdominal pain were absent, despite surgical findings of fecal contamination and bowel necrosis. All three patients survived to hospital discharge. These cases demonstrate that potent immunomodulatory therapies can mask the physiological response to perforation. Relying solely on traditional clinical signs may delay diagnosis. In this population, subtle findings such as persistent gastrointestinal bleeding, feeding intolerance, or minor imaging abnormalities should prompt consideration of perforation. Early imaging and multidisciplinary review are essential for timely intervention and improved outcomes.