Question normal

Authors: Ali Ammar MD, Alex Baronowsky MD, Mai H Vo MD, William S Havron MD, Timothy W Jones MD, Rumi A Khan MD

Date of Presentation: April 4th 2020

Case Presentation: This is a 60 year old obese male with hypertension who presented with two days of fever, dyspepsia, fatigue, myalgias, and scant hemoptysis. He was found to be SAR-CoV-2 positive and hydroxychloroquine and azithromycin were initiated. Over the following three days he developed progressive dyspnea, and bilateral infiltrates on chest X-Ray, and was subsequently admitted to our facility’s COVID-Intensive Care Unit. The following day, his respiratory failure progressed and required intubation and placed on APRV mode to facilitate adequate oxygenation. The following day he developed septic shock, requiring norepinephrine, and his abdominal exam was concerning for obstruction. Abdominal X-Ray was ordered and surgical team was consulted after patient was placed on norepinephrine 0.2mcg/kg/min and lactic acid was only mildly elevated. We performed serial abdominal exams and monitored bladder pressures, however his condition deteriorated. He was rushed to the operating room for a total abdominal colectomy and small bowel resection. Intraoperative findings were consistent with necrotic bowel which began 40cm distal to the ligament of Trietz and ended at the proximal rectum. Total colon was send to the laboratory for pathologic analysis. In addition, an intraoperative pericardiocentesis was performed due to boggy and hypokinetic appearance of the heart, however there was no return of fluid. The patient was left in discontinuity with planned temporary abdominal closure. Unfortunately, the patient went into cardiac arrest due to pulseless electrical activity, and the patient expired despite CPR.

Pertinent Physical exam:
General: GCS 3, sedated. Warm to touch, Temperature: 39C
Cardiac: s1s2, tachycardia. No murmurs,
Pulmonary: Poor air entry bilaterally, with coarse rhonchi as well as fine crackles throughout the lung fields.
Abdomen: Hard, tense, distended abdomen. No bowel sounds appreciated throughout entire abdomen.
Extremities: 1+ pulses, 1+ pitting edema
Neuro: heavily sedated, GCS 3, pupils equal and reactive.

Pertinent Laboratory values
Leukocytes: 5,100 gradually trended up to 18,400/uL
Lymphopenia: 700/uL (low),
Lactic Acid: 2.3, 5.4, 5.9, 14.1 mmol/L
C-reactive protein: 274.6 mg/L
Creatinine: 4.6 mg/dL
ABG: pH: 6.97, PCO2: 78 mmHg, PO2: 45 mmHg, Ventilation with FiO2: 100%
Pertinent Imaging:
Abdominal X-Ray showing massively distended bowel.

Treatment:
Supportive. Mechanical Ventilation. Hydroxychloroquine, Azithromycin. Vasopressors. Total colectomy and small bowel resection.

Outcomes: Death.

Lessons Learned:
This case serves as a reminder to the medical community, despite adequate bowel regiment, ischemic bowel can occur in patients who are critically ill, on vasopressors and heavy sedation. Gastrointestinal (GI) symptoms are more commonly being reported in COVID patients [1]. It is unclear if SARS-CoV-2 directly attacks receptors in the GI tract which subsequently causes bowel necrosis. We suspect that the virus’s inflammatory condition prompted a hypercoagulable state which likely thrombosed the super mesenteric artery leading to this degree of acute thrombosis. The final pathology report was consistent with extensive necrosis of the small and large intestine, with areas of transmural necrosis and bacterial infiltration. This is an interesting case we decided to share, because it this possibly resulted from the thrombosis of the SMA due to the hypercoaguloable state. Or possibly an infiltration of the virus into the intestine, what are your thoughts?

Citations:
Tian Y, Rong L, Nian W, He Y. Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission. Aliment Pharmacol Ther. 2020;