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AmJTropMedHyg10342020pp1600doi104269ajtmh200894Copyrig
AmJTropMedHyg10342020pp1600doi104269ajtmh200894Copyrig

AmJTropMedHyg10342020pp1600doi104269ajtmh200894Copyrig - PDF document

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AmJTropMedHyg10342020pp1600doi104269ajtmh200894Copyrig - Description

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Am.J.Trop.Med.Hyg.,103(4),2020,pp.1600doi:10.4269/ajtmh.20-0894Copyright©2020byTheAmericanSocietyofTropicalMedicineandHygieneCaseReport:ParalyticIleus:APotentialExtrapulmonaryManifestationofSevereCOVID-19YassminS.Ibrahim,GowriKaruppasamy,*JessiyaV.Parambil,HussamAlsoub,andShaikhaD.Al-ShokriInternalMedicineDepartment,HamadMedicalCorporation,Doha,Qatar;InfectiousDiseaseDepartment,HamadMedicalCorporation,Doha,Qatar *AddresscorrespondencetoGowriKaruppasamy,InternalMedicineDepartment,HamadMedicalCorporation,AlRayyanRoad,POBox3050,Doha,Qatar.E-mail:gkaruppasamy@hamad.qa cantinvestigationsincludedlipaseof�1,200U/L,am-ylase390U/L,ALT187U/L,andAST125U/L.Hewasnotedtohavederangedelectrolytes,withpotassiumof2.2mmol/Landcalcium0.96mmol/L.HisnasopharyngealRT-PCRwaspositiveforSARS-CoV-2.BilateralpneumonicpatcheswereobservedonthechestX-ray(Figure1C).Hewasintubatedandurgenthemodialysiswasinitiated,andhewasadmittedtotheintensivecareunitasacaseofsevereCOVID-19pneumonia,renalfailure,andacutepancreatitis.Ultrasoundabdomenrevealedhealthygallbladderbutnoteddilatedbowelloopsintheleftlowerabdomen.Hewasextubatedonday5ofadmission.Twodaysafterextubation,thepatientdevelopedbiliousvomitingandabdominaldiscomfort.Hedidnothavebowelmovementsforthepreceding4daysbutwasatus.Onexamination,hehadadistendedabdomenwithnoguarding,butbowelsoundsweresluggish.AbdominalX-rayshowingdiffusedilatationofthesmallandlargebowelloops(Figure1D).Computedtomographyscanoftheabdo-menshoweddiffuselydistendedlargebowel,fromtheanustothececum,lledwithuid,andairuidlevelsextendingto 1.RadiographsforpatientsdiagnosedwithCOVID-19pneumonia.()Chestradiographforcase1showingbilateralfreeairunderthediaphragmand()abdominalradiographshowingdistendedbowelloops.()Chestradiographforcase2showingbilateralpatchyinltratesand(abdominalradiographshowingdiffusedilatationofthesmallandlargebowelloops.ILEUSINCOVID-19 involvethesmallbowelproximallyuptothethirdpartoftheduodenum.Therewasnotransitionalzoneofnarrowing,mass,orbowelwallthickening.Minimalperipancreaticfatstrandingwasnotedwithnouidcollection.Bothkidneysweresmallinsize,andanincidentalndingofsofttissuelesionattherightupperpolewasnoted(Figure2B).Hewasevaluatedbythesurgeryteam,whoadvisedconservativemanagementwithanasogastrictubeinsertionandcor-rectionofelectrolytes.Thepatientwaskeptnilperoral,andtotalparenteralnutritionwasinitiated.Hereceivedproki-neticagentsandintravenouspotassiumreplacementtomaintaintargetserumpotassiumof4mmol/L.Thepatientconditionimprovedoverthenextweek,andhewasabletotolerateanoraldiet.ArepeatCTscanperformedforfurtherevaluationofrenalmassshowedimprovementinthesig-cantboweldilatationandresolutionofsmallboweldi-latation.Thepatientiscurrentlyonrenalreplacementtherapythreetimesaweekthroughapermanentsubclaviantunneledcatheter.Gastrointestinalinvolvementhasbeenincreasinglyreport-edinassociationwiththeSARS-CoV-2infection.Amulti-centercohortstudyofhospitalizedU.S.adultsfoundthattwo-thirdsofpatientswithCOVID-19hadatleastonegas-trointestinalsymptom.Areviewof29studiesnotedt

hat12%ofpatientswithSARS-CoV-2infectionhadgastrointestinalsymptoms,includingdiarrhea,nausea,andvomiting.clinicalsignicanceofthispresentationwasdemonstratedinareviewbyMaoetal.,whoreportedthatpatientswhopre-sentedwithgastrointestinalsysteminvolvementhaddelayeddiagnosisandalsotendedtohaveapoorerdiseasecourse.Ithasbeenproposedthattheangiotensin-convertingen-zyme2(ACE2)receptorplaysacentralroleinthemechanismofgastrointestinaltractinvolvementinCOVID-19.TheACE-2receptoristhefunctionalhostreceptorfortheSARS-CoV-2AlthoughACE2ishighlyexpressedinalveolarcellsinthelungs,ACE2receptorsarealsoabundantinthegastrointestinaltract,especiallyinthesmallandlarge12,13ThegastrointestinalsymptomsthatappearearlyduringCOVID-19suggestthatthesmallbowelmaybeanimportantentrysiteforthevirus.Zhangetal.thatACE2expressiononsmallintestinalenterocytesmaymediatetheinvasionofthevirusandactivationofgastroin-testinalinammation.Therefore,thiscouldbeapotentialmechanismofparalyticileusinsevereCOVID-19cases.ThereisagrowingbodyofevidencedescribinglargebowelinvolvementinCOVID-19infection.Carvalhoetal.describedacaseofSARS-CoV-2gastrointestinalinfectioncausingacutehemorrhagiccolitiswithendoscopicndingsofcoloproctopathybutnormalhistologicndings.Sattaretal.reportedthreecasesofCOVID-19withcolonicndings,in-cludingcolitisandairinthebowelwall.However,therearefewreportsofparalyticileusinpatientswithCOVID-19.Kaafaranietal.describedaseriesof141criticallyillpatientswithCOVID-19,wherehalfofthepatientsdevelopedhypomotility-relatedcomplicationsofvariablese-verity.Onlytwopatientswerediagnosedwithacolonicpar-alyticileus(Ogilviessyndrome).Similarly,thepatientincase1hadextensivelargeboweldilatationandmid-transversecolonperforation.Histopathologyoftheresectedbowelspecimenshowedfatnecrosis,acuteinammation,reactiveproliferation,andhemorrhage.However,themesentericvesselswerepatentonimaging,suggestingthattheetiologycouldbeSARS-CoV-2inducedmicro-thrombosis.IthasbeenhypothesizedthatSARS-CoV-2causesvascularendo-thelialcellinammation,leadingtoimpairedmicrocirculatoryfunctionindifferentvascularbeds.Moreover,Bhayanaetal.reportedbowelwallabnormal-itiesin31%ofabdominalCTscanimagesinCOVID-19pa-tients,includingpneumatosisandportalvenousgas.Thepatientswerefoundtohavebowelinfarctionduetoischemicenteritiswithpatchynecrosisandbrinthrombiinthearteri-oles.Oursecondcasehaddiffusedistensionofbothsmallbowelandlargebowelbutrespondedwelltoconservativemanagement.Thedevelopmentofileus,inthiscase,mayalsobeexplainedbyelectrolytederangement,asthepatienthadhypokalemiaandhypocalcemia.However,SARS-CoV-2maycauseileusinanindependentmechanism,asalludedOurcaseswerebothobservedtohaveelevatedlivertransaminases.Inasystematicreview,abnormalliverenzymelevelswerenotedin1520%ofpatients.StudiesbyMaoetal.andGuanetal.foundthatpatientswithsevereCOVID-19hadhigherratesofabnormalliverfunction.Case2developedsevereacutepancreatitisofuncleareti-ology,withelevatedlipaseandperipancreaticfatstrandingonimaging.Afewsimilarcaseshavebeenreported,butthereisuncertaintyaboutitspathogen

esis.TheoriesincludeacuteinammationassociatedwiththeexpressionofACE2inthepancreasandheightenedsystemicinammatoryre-sponsefromcytokinestormsyndromeleadingtomulti-organAreviewbyBourgonjeetal.alsopointsoutthatitistherelativeproportionofACEtoACE2receptorsthatisre-sponsiblefortheresultantpro-inammatoryandpro-symptomatology,andithasbeenreportedthatthesemaybeaffectedbygender,withmaleshavingarelativelyhigherproportionofACEtoACE2,thusfavoringinammationandcolitis.Bothourpatientsweremale,supportingthistheory.Furtherstudiesareneededtoelaborateonthecausativere-lationshipbetweenSARS-CoV-2andthegastrointestinalmanifestationsofCOVID-19. 2.Computedtomography(CT)scanoftheabdomeninpatientsdiagnosedwithCOVID-19pneumonia.()Contrast-en-hancedCTscan,anaxialplaneoftheabdomenoftherstcaseshowinglargeboweldilatationwithnostrictureorobstruction,andpatentmesentericvessels.()Contrast-enhancedCTscan,anaxialplaneoftheabdomenofthesecondcaseshowingdiffuselydistendedsmallandlargebowelwithairuidlevels.IBRAHIMANDOTHERS Inconclusion,wereportparalyticsmallandlargebowelileusasacomplicationofCOVID-19.Furthermore,weexploreapotentialmechanismofileusandexplorethemanagementstrategies.Theaddedvalueofthepresentcasereportisthedetailedhistopathologicalevidencesupportingaroleforinducedmicro-thrombosis,therebycompromis-ingmicrocirculatoryfunctionandresultantcolonicboweldi-latationandperforationintherstpatient.Recognizingparalyticileusasapossiblecomplicationnecessitatestimelydiagnosisandmanagement.ReceivedJuly22,2020.AcceptedforpublicationAugust23,2020.PublishedonlineAugust31,2020.Acknowledgments:Wethankthecriticalcare,medical,radiology,infectiousdisease,andsurgicalpersonnelinvolvedinthesepatientscare.Publicationchargesforthisarticlewerewaivedduetotheon-goingpandemicofCOVID-19.Disclosure:Allpatientsconsentedtosharetheircases.Wesoughtapprovalfromalocalcommitteeforreportingthiscaseseries.Authorsaddresses:YassminS.Ibrahim,GowriKaruppasamy,JessiyaV.Parambil,andShaikhaD.Al-Shokri,InternalMedicineDepartment,HamadMedicalCorporation,Doha,Qatar,E-mails:yibrahim4@hamad.qa,gkaruppasamy@hamad.qa,jparambil2@hamad.qa,andsalshokri@hamad.qa.HussamAlsoub,InfectiousDiseaseDepartment,HamadMedicalCorporation,Doha,Qatar,E-mail:halsoub@hamad.qa.Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttribution(CC-BY)License,whichpermitsun-restricteduse,distribution,andreproductioninanymedium,providedtheoriginalauthorandsourcearecredited.1.BikdeliBetal.,2020.COVID-19andthromboticorthromboem-bolicdisease:implicationsforprevention,antithrombotictherapy,andfollow-up:JACCstate-of-the-artreview.JAmCollCardiol75:2.OranDP,TopolEJ,2020þ.PrevalenceofasymptomaticSARS-CoV-2infection:anarrativereview.AnnInternMedM20-3012(Epubaheadofprint,2020June3].Availableat:https://www.acpjournals.org/doi/abs/10.7326/M20-3012.3.ZouLetal.,2020.SARS-CoV-2viralloadinupperrespiratoryspecimensofinfectedpatients.NEnglJMed382:4.CheungKSetal.,2020.GastrointestinalmanifestationsofSARS-CoV-2infectionandvirusloadinfecalsamplesfromaHongKongcohort:system

aticreviewandmeta-analysis.terology159:5.ZhangC,ShiL,WangFS,2020.LiverinjuryinCOVID-19:man-agementandchallenges.LancetGastroenterolHepatol5:6.XiaoF,TangM,ZhengX,LiuY,LiX,ShanH,2020.EvidenceforgastrointestinalinfectionofSARS-CoV-2þ.Gastroenterology7.ReddWD,ZhouJC,HathornKE,McCartyTR,BazarbashiAN,ThompsonCC,ShenL,ChanWW,2020.PrevalenceandcharacteristicsofgastrointestinalsymptomsinpatientswithSARS-CoV-2infectionintheUnitedStates:amulticenterco-hortstudy.Gastroenterology159:8.ParasaSetal.,2020.Prevalenceofgastrointestinalsymptomsandfecalviralsheddinginpatientswithcoronavirusdisease2019:asystematicreviewandmeta-analysis.JAMANetwOpen3:e2011335.9.MaoRetal.,2020.Manifestationsandprognosisofgastrointes-tinalandliverinvolvementinpatientswithCOVID-19:asys-tematicreviewandmeta-analysis.LancetGastroenterolHepatol5:10.BourgonjeARetal.,2020.Angiotensin-convertingenzyme2(ACE2),SARS-CoV-2andthepathophysiologyofcoronavirusdisease2019(COVID-19).JPathol251:11.LiG,HeX,ZhangL,RanQ,WangJ,XiongA,WuD,ChenF,SunJ,ChangC,2020.AssessingACE2expressionpatternsinlungtissuesinthepathogenesisofCOVID-19.JAutoimmun112:12.HarmerD,GilbertM,BormanR,ClarkKL,2002.QuantitativemRNAexpressionprolingofACE2,anovelhomologueofangiotensinconvertingenzyme.FEBSLett532:13.LiMY,LiL,ZhangY,WangXS,2002.ExpressionoftheSARS-CoV-2cellreceptorgeneACE2inawidevarietyofhumantis-InfectDisPoverty9:14.M¨onkem¨ullerK,FryL,RickesL2020.COVID-19,coronavirus,SARS-CoV-2andthesmallbowel.RevEspEnfermDig112:15.ZhangH,LiHB,LyuJR,LeiXM,LiW,WuG,LyuJ,DaiZM,2020.cACE2expressioninsmallintestinalenterocytesmaycausegastrointestinalsymptomsandinjuryafter2019-nCoVIntJInfectDis96:16.CarvalhoA,AlqusairiR,AdamsA,PaulM,KothariN,PetersS,DeBenedetAT,2020.SARS-CoV-2gastrointestinalinfectioncausinghemorrhagiccolitis:implicationsfordetectionandtrans-missionofCOVID-19disease.AmJGastroenterol115:946.17.SattarY,ConnerneyM,RaufH,SainiM,UllahW,MamtaniS,SyedU,LuddingtonS,WalshA,2020.ThreecasesofCOVID-19diseasewithcolonicmanifestations.AmJGastroenterol115:18.KaafaraniHetal.,2020.Gastrointestinalcomplicationsincriti-callyillpatientswithCOVID-19.AnnSurg272:19.VargaZetal.,2020.EndothelialcellinfectionandendotheliitisinCOVID-19.Lancet395:20.BhayanaRetal.,2020.AbdominalimagingndingsinCOVID-19:preliminaryobservations.Radiology(Epubaheadofprint,2020May11).Availableat:https://doi.org/10.1148/radiol.2020201908.21.GuanWetal.,2020.Clinicalcharacteristicsofcoronavirusdis-ease2019inChina.NEnglJMed382:22.AloysiusMM,ThattiA,GuptaA,SharmaN,BansalP,GoyalH,2020.COVID-19presentingasacutepancreatitis.ogy20:23.HadiA,WergeM,KristiansenKT,PedersenUG,KarstensenJG,NovovicS,GluudLL,2020.Coronavirusdisease-19(COVID-19)associatedwithsevereacutepancreatitis:casereportonthreefamilymembers.Pancreatology20:24.BonneyG,YujiaG,ChewC,PancreatologyJW,2020.SARS-COV-2associatedacutepancreatitis:cause,consequenceorepiphenomenon?Pancreatology20:25.BourgonjeARetal.,2020.Angiotensin-convertingenzyme2(ACE2),SARS-CoV-2andthepathophysiologyofcoronavirusdisease2019(COVID-19).JPathol251:ILEUSINCOVID-19