Abstract
Background
A 69-year-old man presented with small intestinal abscesses during the weeks immediately following respiratory COVID-19 recovery, confirmed via nasopharyngeal testing.
Summary
The patient is a 69-year-old man who presented with severe abdominal pain two weeks after a positive COVID-19 test and associated symptoms. His follow-up nasopharyngeal COVID-19 test was negative. CT demonstrated enteritis and microperforation, and he was managed conservatively with antibiotics and discharged after three days. However, he returned the following week with worsening abdominal pain and peritoneal signs. Follow-up CT showed a jejunal abscess and was drained by interventional radiology. Despite drainage, peritoneal signs persisted, and surgical intervention was indicated. Exploratory laparotomy was performed with drainage of abscess, resection of the jejunal mass, and primary jejunojejunal anastomosis. He recovered symptomatically, but the development of an enterocutaneous fistula complicated his postop course.
Since the outbreak of the novel coronavirus disease 2019 (COVID-19) in December 2019, various acute clinical manifestations and chronic complications have been reported worldwide. While there is a prevalence of acute gastrointestinal symptoms such as diarrhea, abdominal pain, and vomiting in COVID-19 patients, long-term gastrointestinal complications have not been well documented.
Conclusion
COVID-19-related complications are still being investigated. We present a case of severe gastrointestinal complications in the weeks immediately following COVID-19 infection, potentially suggesting a causal relationship between SARS-CoV-2 infection and the complications. Therefore, attentive surveillance and evaluation for gastrointestinal symptoms following the acute course of COVID-19 infection is recommended.
Key Words
COVID-19; SARS-CoV-2; abscess; perforation
Case Description
With the outbreak of COVID-19 in December 2019, efforts to understand this disease have gained rapid momentum. An increase in gastrointestinal symptoms such as diarrhea rose from 20% to 53% after March 2020.1
A genetic study on in vitro infectivity of SARS-CoV-2 demonstrated the viral affinity for angiotensin-converting enzyme II (ACE2) as the site of attachment allowing for viral entry.2 It is also shown that ACE2 proteins are expressed in the intestinal mucosa, and these cells were confirmed to replicate SARS-CoV-2.3 Furthermore, SARS-CoV-2 RNA can be isolated from stool samples in 53.42% of infected patients, with up to 23.39% of patients having persistently positive stool RNA following negative nasopharyngeal tests.4 These results indicate SARS-CoV-2 infiltration in the intestinal tract and suggest the possibility for dissemination in time for an infectious presentation.
A few case reports suggested severe gastrointestinal complications during an active COVID-19 infection, including but not limited to small and large bowel perforations and splenic abscesses.5–7 Given the evidence of gastrointestinal involvement and variability in SARS-CoV-2 clearance in different organ systems, we suspect implications of gastrointestinal complications in the period immediately following recovery from respiratory SARS-CoV-2.
A 69-year-old man who presented with shortness of breath, cough, abdominal pain, nausea, vomiting, and diarrhea tested positive for SARS-CoV-2. He was treated conservatively as an outpatient. Two weeks later, he returned to the ED for worsening left lower and middle quadrant pain for three days. A nasopharyngeal COVID-19 test was negative on this encounter. A physical exam showed abdominal distension with tenderness but no acute peritoneal signs. CT abdomen and pelvis found free intraperitoneal air suggesting micro-perforation (Figure 1A). Patchy diffuse ground-glass infiltrates were seen in the lungs, likely secondary to previous COVID-19 infection. Conservative management with IV piperacillin-tazobactam was adequate in alleviating his symptoms, and he was discharged after three days with outpatient oral amoxicillin-clavulanic acid.
However, the patient returned to the ED a week later with excruciating abdominal pain, and his abdomen was diffusely tender with guarding. Abdominal CT showed a 5 cm interval abscess next to the jejunum, a progression from previously imaged micro-perforations (Figure 1B).
Interventional radiology drained the abscess the following day, and cultures were positive for MRSA and normal skin flora. Vancomycin was started. However, over the week, the drain began to yield enteric content and localized peritoneal signs developed. An exploratory laparotomy with extensive lysis of adhesions, drainage of abscess, mobilization of the splenic flexure of the colon, and resection of the jejunal mass with primary jejunojejunal anastomosis was performed one week later. Histological examination demonstrated granulation tissue and inflammatory changes consistent with a perforated abscess and no evidence of malignancy. His symptoms improved over several days, and he was subsequently discharged.
The patient was then readmitted for a newly developed high-output enterocutaneous fistula after surgical staple removal. He was managed conservatively outpatient as the fistula outputs dwindled.
Figure 1. CT With Contrast. Published With Permission
