Pseudomembranous colitis in patients with COVID-19 (review)

AIM: to estimate the features of pseudomembranous colitis in patients with COVID-19, diagnostics, conservative treatment and surgery for complications. PATIENTS AND METHODS: a retrospective analysis of 396 patients with pseudomembranous colitis (PMC) in patients with new coronavirus infection was carried out for the period from March 2020 to November 2021. Among them there were 156 (39.3%) males, females - 240 (60.6%), moderate and severe forms of COVID-19 occurred in 97.48%. The diagnosis of PMC was established due to clinical picture, laboratory, instrumental methods (feces on Cl. difficile, colonoscopy, CT, US, laparoscopy). RESULT(S): the PMC rate in COVID-19 was 1.17%. All patients received antibiotics, 2 or 3 antibiotics - 44.6%, glu-cocorticoids were received by all patients. At 82.8%, PMC developed during the peak of COVID-19. To clarify the PMC, CT was performed in 33.8% of patients, colonoscopy - 33.08%, laparoscopy - in 37.1% (to exclude bowel perforation, peritonitis). Conservative treatment was effective in 88.8%, 76 (19.1%) patients had indications for surgery (perforation, peritonitis, toxic megacolon). Most often, with peritonitis without clear intraoperative confir-mation of perforation, laparoscopic lavage of the abdominal cavity was performed (60 patients - 78.9%, mortality - 15.0%), colon resection (n = 6 (7.9%), mortality - 66.6%), ileo-or colostomy (n = 8 (10.5%), mortality - 37.5%), colectomy (n = 2 (2.6%), mortality - 50.0%). The overall postoperative mortality rate was 22.4%, the incidence of surgical complications was 43.4%. In addition, in the postoperative period, pneumonia was in 76.3%, thrombosis and pulmonary embolism in 22.3% of patients. In general, the overall mortality in our patients with PMC was 11.4%, with conservative treatment - 8.8%. CONCLUSION(S): pseudomembranous colitis is a severe, life-threatening complication of COVID-19. In the overwhelm-ing majority of patients, conservative therapy was effective, but almost 1/5 of patients developed indications for surgery, the latter being accompanied by high mortality and a high morbidity rate. Progress in the treatment of PMC, apparently, is associated with early diagnosis, intensive conservative therapy, and in the case of indications for surgery, their implementation before decompensation of the patient's condition and the development of severe intra-abdominal complications and sepsis.Copyright © 2022, Association of Coloproctologists of Russia. All rights reserved.

Disease clearance: A potential target for management of patients with Ulcerative Colitis

Background: Disease clearance defined by the absence of symptoms and intestinal inflammation at endoscopic and histological examination, is proposed as a target in the evaluation of the ulcerative colitis (UC) course. The purpose of this study was to evaluate disease remission on the UC evolution according to disease clearance concept. Method(s): Between January 2020 - March 2022, 79 patients with UC were evaluated clinically, laboratory testing, endoscopically and histologically. Patients positive for COVID and CDI were not included in the study. Disease remission, in accordance with the concept of disease clearance it is defined as clinical (partial Mayo score <=2), endoscopic (endoscopic Mayo score <=1) and histological (Nancy Index) remission. Disease clearance was measured at inclusion in the study and during follow-up after 12 months. Results were compared in patients who did or did not achieve disease clearance. Result(s): The patients were divided into 2 groups according to disease clearence: Group 1: 35 out of 79 patients with UC evaluated, were considered with disease clearance at the initial moment of the evaluation. Group 1 did not present complications and did not require surgical interventions during the follow-up period, compared to group 2: Nondisease clearence patients, 44 out of 79 patients (0.0% vs. 31.8%, p=0.03, OR=23.1). During follow-up, 38.6% patients (N=17 pts, Incidence Rate=0.3864) from group 2 obtained clinical remission, of which 15.9% patients obtained endoscopic remission, 6.81% patients obtained histological remission (p=0.025) and 27.2% patients were under biological therapy. A total of 27 patients from both groups required hospitalization, significantly shorter for patients with initial values of fecal calprotectin below 200 mug/mg, and without endoscopic and/or histological activity (8.57% vs. 54.54%, p=0.002, OR=0.57, RR=0.224). 51.8% patients presented severe forms of disease with surgical and non-surgical complications (35.7% vs. 64.2%, p=0.91, OR=1.07). Surgical complications include toxic megacolon (N=2 pts, 14.2%), colonic perforation (N=1 pts, 7.1%), gastrointestinal hemorrhage (N=1 pts, 7.1%) and stricture with bowel obstruction (N=1 pts, 7.1%). Non-surgical complications include gastrointestinal hemorrhage (N=6 pts, 42.8%), venous thrombosis (N=1 pts, 7.1%) and colorectal cancer (N=2 pts, 14.2%). No deaths were reported. Conclusion(s): According to the concept of disease clearance, our data indicate that UC patients in clinical, endoscopic and histological remission present a significantly lower risk of hospitalization, complications and surgical intervention.

Toxic Megacolon Burdened with COVID-19 Coinfection-Worsening of an Unfavorable Diagnosis: A Single-Center Retrospective Study.

INTRODUCTION: This study primarily sought to evaluate the risk factors for toxic megacolon development and treatment outcomes in Clostridium difficile-positive COVID-19 patients, secondarily to determining predictors of survival. METHODS: During the second COVID-19 wave (May 2020 to May 2021), we identified 645 patients with confirmed COVID-19 infection, including 160 patients with a severe course in the intensive care unit. We selected patients with Clostridium difficile infection (CDI) (31 patients) and patients with toxic megacolon (9 patients) and analyzed possible risk factors. RESULTS: Patients who developed toxic megacolon had a higher incidence (without statistical significance, due to small sample size) of cancer and chronic obstructive pulmonary disease, a higher proportion of them required antibiotic treatment using cephalosporins or penicillins, and there was a higher rate of extracorporeal circulation usage. C-reactive protein (CRP) and interleukin-6 values showed significant differences between the groups (CRP [median 126 mg/L in the non-toxic megacolon cohort and 237 mg/L in the toxic megacolon cohort; p = 0.037] and interleukin-6 [median 252 ng/L in the group without toxic megacolon and 1127 ng/L in those with toxic megacolon; p = 0.016]). As possible predictors of survival, age, presence of chronic venous insufficiency, cardiac disease, mechanical ventilation, and infection with Candida species were significant for increasing the risk of death, while corticosteroid and cephalosporin treatment and current Klebsiella infection decreased this risk. CONCLUSIONS: More than ever, the COVID-19 pandemic required strong up-to-date treatment recommendations to decrease the rate of serious in-hospital complications. Further studies are required to evaluate the interplay between COVID-19 and CDI/toxic megacolon.

POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) IN RENAL TRANSPLANT PATIENTS WITH COVID-19

SESSION TITLE: Pulmonary Issues in Transplantation Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Post-transplant lymphoproliferative disorder (PTLD) is a life-threatening complication after transplantation. While there is evidence that hematologic malignancy is associated with increased severity in COVID-19 infection, there is little description of PTLD and COVID-19. CASE PRESENTATION: A 68-year-old man and a 68-year-old female, both of whom had prior renal transplantation, were admitted to the hospital with COVID-19 pneumonia. Both patients were vaccinated against COVID-19, though were negative for spike protein antibodies. The man was treated with remdesivir and the woman was treated with remdesivir and dexamethasone. Both patients improved and were discharged. Within a month, both had recurrent symptoms of dyspnea and fever requiring re-admission. They were hypoxic, the man requiring high flow nasal cannula and the woman requiring nasal cannula to maintain SpO2>90%. They had positive COVID-19 PCR tests, with cycle threshold lower than in their initial admissions, as well as chest imaging with bilateral infiltrates. The man had a pleural effusion with cytology consistent with PTLD and perinephric mass and retroperitoneal lymphadenopathy with biopsy confirming PTLD. The woman had a renal sinus mass with biopsy confirming PTLD. Both patients were treated with another 5 days of remdesivir and started on dexamethasone. The medical team discussed monoclonal antibody treatment, but the patients did not meet EUA criteria and compassionate use request was denied. To treat PTLD, both were initiated on Rituximab, Cyclophosphamide, Hydroxydaunomycin, Oncovin, and Prednisone (R-CHOP). Since then, both patients have had complicated and prolonged hospital courses. The woman developed renal failure and severe C.diff colitis complicated by toxic megacolon requiring total colectomy. The man developed renal failure, CMV viremia, and pseudomonas UTI. The patients were able to be weaned to room air, though ultimately the woman had to be intubated due to poor mental status and remains on low oxygen settings. Both patients continue to be persistently positive for COVID-19 by PCR. DISCUSSION: This case illustrates diagnosis and treatment of PTLD in two patients with COVID-19 infection. Of particular interest was the use of Rituximab, an anti-CD-20 antibody which impairs humoral immunity, in the treatment of PTLD, as the drug has been associated with increased risk of severe COVID-19 infection. Rituximab was particularly concerning as both patients had persistent COVID-19 without development of immunity despite prior vaccination, and both continue to be positive despite two months of active infection. The patients had improvement of their respiratory status, though have had poor and complicated clinical courses with renal and infectious complications. CONCLUSIONS: Treatment of PTLD in patient's with active COVID-19 may impair ability to clear virus, though impact on outcomes is unclear. Reference #1: Simpson-Yap, S., de Brouwer, E., Kalincik, T., Rijke, N., Hillert, J. A., Walton, C., Edan, G., Moreau, Y., Spelman, T., Geys, L., Parciak, T., Gautrais, C., Lazovski, N., Pirmani, A., Ardeshirdavanai, A., Forsberg, L., Glaser, A., McBurney, R., Schmidt, H., … Peeters, L. (2021). Associations of Disease-Modifying Therapies With COVID-19 Severity in Multiple Sclerosis. Neurology, 97(19). https://doi.org/10.1212/WNL.0000000000012753 Reference #2: Andersen, K. M., Bates, B. A., Rashidi, E. S., Olex, A. L., Mannon, R. B., Patel, R. C., Singh, J., Sun, J., Auwaerter, P. G., Ng, D. K., Segal, J. B., Garibaldi, B. T., Mehta, H. B., Alexander, G. C., Haendel, M. A… Chute, C. G. (2022). Long-term use of immunosuppressive medicines and in-hospital COVID-19 outcomes: a retrospective cohort study using data from the National COVID Cohort Collaborative. The Lancet Rheumatology, 4(1). https://doi.org/10.1016/S2665-9913(21)00325-8 Reference #3: Passamonti, F., Cattaneo, C., Arcaini, L. Bruna, R., Cavo, M., Merli, F., Angelucci, E., Krampera, M., Cairoli, R., della Porta, M. G., Fracchiolla, N., Ladetto, M., Gambacorti Passerini, C., Salvini, M., Marchetti, M., Lemoli, R., Molteni, A., Busca, A., Cuneo, A., … Corradini, P. (2020). Clinical characteristics and risk factors associated with COVID-19 severity in patients with haematological malignancies in Italy: a retrospective, multicentre, cohort study. The Lancet Haematology, 7(10). https://doi.org/10.1016/S2352-3026(20)30251-9 DISCLOSURES: No relevant relationships by Ian Mahoney No relevant relationships by Caroline Motschwiller

Toxic Megacolon After Irrational Antibiotic Treatment of Pregnant Patient With Covid 19: Case Report

Introduction: Optimal management of toxic megacolon as a consequence of Cl. difficile colitis is still matter of controversy, as well as timing of available therapeutic modalities. In this article we report a case of severe C. difficile colitis associated with toxic megacolon in a pregnant patient with Covid 19, who was successfully treated conservatively. Case Report: A 33-years old pregnant woman contracted SARS-CoV-2 in the 32nd week of pregnancy. She was admitted to regional hospital and treated extensively by wide-spectrum antibiotics. After the delivery she developed severe form of Cl. difficile colitis with toxic megacolon. In spite of severe clinical picture, the patient was treated conservatively, with high initial oral doses of vancomycin, with subsequent tapering. The outcome of the treatment was complete recovery and colonic functions were regained completely. Conclusion: In conclusion, our case shows that in younger patients, who were fit before occurrence of Cl. difficile colitis and toxic megacolon, conservative therapy should be tried as long as possible before turning to colectomy, since chances for cure without surgery are considerable. (English) [ FROM AUTHOR] Uvod: Optimalno upravljanje toksičnim megakolonom kao posledicom Cl. difficile kolitis je još uvek predmet kontroverzi, kao i vreme kada su dostupni terapijski modaliteti. U ovom članku izveštavamo o slučaju teškog kolitisa C. difficile povezanog sa toksičnim megakolonom kod trudnice sa Covid-om 19, koja je uspešno lečena konzervativno. Prikaz slučaja: Trudnica stara 33 godine zarazila se SARS-CoV-2 u 32. nedelji trudnoće. Primljena je u regionalnu bolnicu i intenzivno lečena antibioticima širokog spektra. Nakon porođaja razvila je teški oblik Cl. difficile kolitis sa toksičnim megakolonom. I pored teške kliničke slike, pacijent je lečen konzervativno, visokim početnim oralnim dozama vankomicina, uz naknadno smanjivanje. Ishod lečenja je bio potpuni oporavak i potpuno su vraćene funkcije debelog creva. Zaključak: U zaključku, naš slučaj pokazuje da kod mlađih pacijenata, koji su bili u formi pre pojave Cl. difficile kolitisa i toksičnog megakolona, konzervativnu terapiju treba pokušavati što je duže moguće pre nego što se pređe na kolektomiju, pošto su šanse za izlečenje bez operacije znatne. (Bosnian) [ FROM AUTHOR] Copyright of Hospital Pharmacology: International Multidisciplinary Journal is the property of Serbian Medical Society, Section for Clinical Pharmacology and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Severe Clostridium difficile colitis as potential late complication associated with COVID-19.

Spain has been one of the most affected countries by the COVID-19 outbreak. After the high impact of the pandemic, a wide clinical spectrum of late complications associated with COVID-19 are being observed. We report a case of a severe Clostridium difficile colitis in a post-treatment and recovered COVID-19 patient. A 64-year-woman with a one-month hospital admission for severe bilateral pneumonia associated with COVID-19 and 10 days after discharge presented with diarrhoea and abdominal pain. Severe C. difficile-associated colitis is diagnosed according to clinical features and CT findings. An urgent pancolectomy was performed due to her bad response to conservative treatment. Later evolution slowly improved to recovery. C. difficile-associated colitis is one of the most common hospital-acquired infections. Significant patient-related risk factors for C. difficile infection are antibiotic exposure, older age, and hospitalisation. Initial therapeutic recommendations in our country included administration broad-spectrum antibiotics to all patients with bilateral pneumonia associated with SARS-CoV-2. These antibiotics are strongly associated with C. difficile infection. Our patient developed a serious complication of C. difficile due to the use of broad-spectrum antibiotics. The appearance of late digestive symptoms in patients diagnosed and treated for COVID-19 should alert clinicians to the possibility of C. difficile infection. The updated criteria for severe colitis and severe C. difficile infection should be considered to ensure an early effective treatment for the complication.