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ABSTRACTS: ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—SMALL INTESTINE

S2794 A Rare and Unusual Gastrointestinal Manifestation of COVID-19

Rehman, Mahin DO1; Gondal, Amlish MD2; Yousef, Mohammad MD3; Khan, Salman MD3; Suwal, Kriti MD3; Rehman, Najeeb MD, MHA3; Molina, Jaime MD3; Georgetson, Michael J. MD, FACG3

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The American Journal of Gastroenterology: October 2020 - Volume 115 - Issue - p S1461
doi: 10.14309/01.ajg.0000713224.63531.ce
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INTRODUCTION:

COVID-19 typically presents with a febrile illness and respiratory symptoms. There are some reports of mild gastrointestinal involvement but no cases have been reported on severe gastrointestinal symptoms, especially in the immunosuppressed host.

CASE DESCRIPTION/METHODS:

A 72-year-old male with a past medical history of poorly differentiated adenocarcinoma of the lower esophagus and gastroesophageal junction (Stage III) is undergoing cancer treatment with a curative intent via neoadjuvant chemoradiation (carboplatin and taxol) weekly. He presents with nausea, vomiting, bloody diarrhea, hypotension and a fever of 104° Fahrenheit. He was pancytopenic and his absolute neutrophil count (ANC) was low at 1.64 K/µL. CT Chest/Abdomen/Pelvis with contrast revealed a significant amount of new portal venous gas with abnormal mucosal enhancement and edema in the ileum, cecum, and ascending colon in conjunction with air seen within the mesenteric vessels; this was highly concerning for bowel ischemia. The CT scan showed completely clear lungs. His abdominal pain and distension worsened; surgery was necessary. Prior to surgery, SARS-CoV-2 virus testing was required, and he tested positive. Repeat CT scan showed spontaneous resolution of portal venous gas within hours of his initial CT. The exploratory laparotomy showed a 90 cm long thickened ileus, consistent with neutropenic enterocolitis. A complete infectious work up yielded negative results; only the COVID-19 test was positive and he did not improve with IV antibiotics. Thus, we diagnosed him with COVID-19 induced neutropenic enterocolitis, which is typically associated with a bacterial superimposed infection.

DISCUSSION:

COVID-19 manifests primarily as a respiratory disease. There have been no reports of bloody diarrhea and/or neutropenic enterocolitis as a manifestation of COVID-19, making this a novel presentation. Additionally, studies show that neutropenic enterocolitis develops with an ANC < 500/µL and it is extremely rare to develop this with an ANC >1000/µL, which our patient had. To add to the rarity of this presentation, he had extensive portal venous gas concerning for bowel ischemia which spontaneously resolved on its own. This case highlights that immunosuppressed individuals are at greatest risk of morbidity and mortality with regards to COVID-19 and that atypical and non-respiratory manifestations of COVID-19 in immunosuppressed individuals may occur.

Figure 1A.
Figure 1A.:
Coronal view of CT abdomen showing the site of neutropenic enterocolitis and gas in paracolic gutter (red arrow). Figure 1B: Transverse view of CT abdomen showing the site of neutropenic enterocolitis (white arrow). Figure 1C: Transverse view of CT abdomen showing significant portal venous gas that eventually spontaneously resolved within hours on repeat CT abdomen (yellow arrow).
© 2020 by The American College of Gastroenterology