COVID-19-induced hemorrhagic colitis: A case series

ABSTRACT

Introduction: Little is known about the extent of GI tract involvement in acute COVID-19 infection. GI bleed (GIB) has been reported in COVID patients;the etiology is difficult to determine given that of confirmed COVID infection where patients, without prior medical history, presumably developed COVID induced HC, and it was their only presenting symptom. Case Description/Methods: Case 1 A 44 year old male presented with hematochezia, abdominal pain, and syncope and a drop in hemoglobin (Hb) from 15.3 to 12.6g/dL. COVID PCR was positive. Fecal calprotectin (FCP) elevated at 169ug/g (n, 49ug/g), with negative stool cultures (SCx). CT showed a long segment of circumferential wall thickening of the mid-distal descending colon with haustral thickening of the transverse colon. Patient declined treatment with remdesivir and dexamethasone Case 2 A 65 year old female presented with hematochezia and confirmed COVID infection. CBC revealed a drop in Hb 13.5 to 11.8g/dL, platelets 237 to 184K/uL. Negative SCx, elevated FCP 88ug/g, procalcitonin 0.31ng/nL, CRP 7.1mg/dL, and D-Dimer 740ng/mL. CT showed severe wall thickening of the transverse, descending and rectosigmoid colon with fat stranding. Given negative SCx, patient was started on methylprednisolone Case 3 A 38 year old male presented with painless hematochezia. Negative SCx, O&P, C. diff. Elevated FCP, ESR and CRP (ESR 80mmh/CRP 12.1mg/dL). COVID PCR positive. CT showed extensive colonic wall thickening in the rectum, sigmoid, descending colon and splenic flexure, increased vascularity around the inflamed colon and fat stranding. Given lack of clinical improvement with antibiotics and conservative management, patient was started on methylprednisolone with improvement Discussion: GI symptoms due to COVID occur from the expression of ACE2 receptors on intestinal epithelial cells that allow for binding and replication. This leads to a direct inflammatory state accounting for enteritis and HC. All patients presented had hematochezia without bleeding history, AC use or a source of bleeding, except for the colitis seen on CT. Confirmed HC in the setting of COVID infection has been documented twice;one case with a similar presentation who had colonoscopy with biopsy proven HC, another case with diffuse HC on endoscopic evaluation. Nonetheless, more research is needed to explore the effects of COVID on the GI tract. (Figure Presented).