Nikolas St. Cyr, MD, Sarah Singh, DO, Aaron Douen, MD, Neera Sinha, MD, Anastasiya Pigal, MD, Vera Platsky, MD, John W. Trillo, MD; Coney Island Hospital, Brooklyn, NY
Introduction: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) patients commonly present with respiratory symptoms; however, the incidence of gastrointestinal symptoms is rising. We submit a case of cecal perforation in a SARS-CoV-2 infected patient, highlighting a life-threatening complication of the virus.
Methods: A 65-year-old with past medical history of atrial fibrillation on anticoagulation presents with fever and dyspnea. Initial observation showed an obese male on supplemental oxygen, with a benign abdominal exam. He tested SARS-CoV-2 positive and began Remdesivir therapy. While hospitalized, he had regular bowel movements but worsening abdominal distension and tenderness to palpation. CT of the abdomen revealed peritoneal free air signifying bowel perforation (Figure 1), which required emergent exploratory laparotomy and a right hemicolectomy. Biopsy of the perforation site showed acute inflammation and vascular congestion (Figure 2b). After an uneventful postoperative period, he was discharged. Discussion: SARS-CoV-2 infection often arises with respiratory symptoms. However, as the pandemic ensues, gastrointestinal symptoms(GI) such as vomiting, abdominal pain and diarrhea, are emerging. Our case examines bowel perforation in a SARS-CoV-2 infected patient. The virus downregulates expression of the Angiotensin converting enzyme 2 (ACE2), found most abundantly in lung, intestinal and vascular tissue. Suppression in the intestinal tissue may cause an inflammatory response, thereby weakening the intestinal wall leading to bowel perforation.Similarly, the virus may induce complement-mediated inflammatory damage to the vascular endothelium and systemic coagulopathy causing vascular and microvascular thrombi formation. We postulate that by these mechanisms, SARS-CoV-2 begets intestinal ischemia and eventual bowel perforation. Our case also highlights a significant clinical issue regarding Remdesivir. In vitro, it inhibits Multi drug resistance associated protein 4 (MRP4), which partakes in cell proliferation. This may lead to reduced integrity of the epithelial barrier, causing bowel perforation. Further studies to elicit the adverse effects of Remdesivir are warranted. With few reports of bowel perforation in SARS-CoV-2 patients, our case magnifies potential GI symptoms and complications of this novel virus. Moreover, with growing Remdesivir use as a SARS-CoV-2 therapy, it is vital to investigate its adverse effects.
Figure 1a. CT abdomen sagittal view- free intra-peritoneal air
Figure 1b. CT abdomen transverse view, with arrows showing irregular contour of bowel indicating area of perforation
Figure 2a.-Sloughed epithelium, atrophic microcysts, hyalinization of lamina propria, acute inflammation. Figure 2b-Marked surface injury, loss in atrophic crypts, hyalinization of lamina propria, residual glands appear more closely spaced, vascular congestion and acute inflammation
Disclosures: Nikolas St. Cyr indicated no relevant financial relationships. Sarah Singh indicated no relevant financial relationships. Aaron Douen indicated no relevant financial relationships. Neera Sinha indicated no relevant financial relationships. Anastasiya Pigal indicated no relevant financial relationships. Vera Platsky indicated no relevant financial relationships. John Trillo indicated no relevant financial relationships.