Kanwal Bains, MD1, Dong Joo Seo, MD1, Jason Wang, MD2; 1Roger Williams Medical Center, Providence, RI; 2Roger Williams Medical Center, Brooklyn, NY
Introduction: The effects of COVID-19 on the coagulation cascade are still being investigated. However, it is theorized that hypercoagulability caused by activation of widespread inflammatory pathways is occurring in a subset of patients. This hypercoagulability may lead to wide-spread microthrombi formation and/or endothelial injury leading to ischemic injury to various organs including lungs, heart, kidney, and in this case- bowels. We present a case of ischemic colitis in a patient diagnosed with SARS-CoV-2 infection coinciding with marked elevation of inflammatory markers.
Methods: 72 year old male nursing home resident with multiple comorbidities including type 2 diabetes, dementia, and hypertension was recently diagnosed with COVID-19 and sent to the ED with complaints of abdominal pain and bright red blood per rectum. On arrival he was febrile, tachycardic, and hypertensive but oxygenating well on room air. Exam was significant for abdominal distension. Lab work was significant for Hgb 10.3. His inflammatory markers were elevated with Ferritin 350, CRP 127, ESR 39, D-dimer >35, fibrinogen 465. He had an elevated PT and APTT with normal INR. Procalcitonin was 68. Imaging including CTA Chest, abdomen and pelvis showed wall thickening of descending and sigmoid colon along with cecal pneumatosis. No arterial or venous thrombosis were seen. Workup for infectious colitis included stool culture and clostridium difficile were negative. He was made NPO and intravenous fluids along with antibiotics were started. He was given 2 units of convalescent plasma and 1 dose of tocilizumab along with 5 doses of remdesivir. Surgical options were discussed but the family declined any intervention and the patient was made CMO. Discussion: Patients infected with SARS-CoV-2 have been shown to have hyperacute inflammatory response as evidenced by elevated inflammatory markers. Our patient presented with a D-dimer value of >35 on presentation which is likely associated with worse outcomes and vascular complications. Watershed areas of colon, namely the splenic flexure and rectosigmoid juncture are theorized to be most likely affected in patients with ischemic bowel injury from SARS-CoV-2. Elevated coagulation labs including prothrombin time and d-dimer may be seen with SARS-CoV-2 ischemic colitis.
CT abdomen pelvis showing cecal pneumatosis seen in ischemic colon.
Supine abdominal X-ray showing persistent moderate gaseous distention of the colon.
Trend of CRP and D-dimer values over time . Patient got convalescent plasma (day 2), Tocilizumab ( day 3) and Remdesivir (day 9-14).
Disclosures: Kanwal Bains indicated no relevant financial relationships. Dong Joo Seo indicated no relevant financial relationships. Jason Wang indicated no relevant financial relationships.