Colitis after SARS-CoV-2 infection

Most cases of COVID-19 present with pulmonary involvement, but it is now known that there are patients with gastrointestinal symptoms along with pulmonary involvement and some with gastrointestinal symptoms only [1]† The most common symptoms of COVID-19 are fever and cough [2]† Gastrointestinal symptoms seen with COVID-19 include nausea, vomiting, diarrhea, abdominal pain, and anorexia. A minority of cases have been seen with acute abdomens such as acute appendicitis, intestinal ischemia and acute pancreatitis [1]†

A 65-year-old male with a history of multiple substance use disorder, alcohol withdrawal, pancreatitis, bipolar disorder, and gout initially presented to the emergency department with a suicide attempt with intranasal heroin use two days prior to presentation. On assessment of the systems, he was found to have non-bloody diarrhea accompanied by abdominal pain. He tested positive for the SARS-CoV-2 virus during this presentation, but had no respiratory symptoms. He was given bebtelovimab and was allowed to go home after his symptoms subsided. Ten days later, he presented with new onset diffuse abdominal pain associated with non-bloody diarrhea for two days. He felt nauseous and had two episodes of non-bloody, non-bilious vomiting. He denied coughing, chest pain, shortness of breath, or swelling of the legs.

In the emergency department, a physical examination revealed a temperature of 37.5 degrees Celsius, a blood pressure of 128/92, a heart rate of 98/minute and an oxygen saturation of 99% in room air. Abdominal examination was relevant to a soft, undistended abdomen and sensitive to palpation in the left lower quadrant and right lower quadrant. He still tested positive for the SARS-CoV-2 virus. The initial laboratory workup was unremarkable and shown in Table 1†

Computed tomography (CT) of abdomen and pelvis was notable for left-sided colitis shown in Figure 1this radiographic finding was not previously seen on the CT of abdomen and pelvis obtained on its first exposure 10 days earlier, as shown in Figure 2† We started him on ciprofloxacin and metronidazole as empirical treatment for bacterial infection, this regimen was stopped once the gastrointestinal polymerase chain reaction test (GI-PCR) was negative. Clostridium difficle testing was not done because no recent antibiotics had been used. He had melena on day 2 of hospitalization, but his hemoglobin level remained stable. His pain resolved by day 4 of hospitalization and he was able to tolerate oral intake with an improvement in overall clinical condition and was discharged home.

figure
2: Previous CT scan without any evidence of colitis

We see the different presentations and consequences in patients with COVID-19. A subset of people with COVID-19 infection had long-term symptoms such as persistent deterioration of lung function, reduced diffusion capacity of the lungs, impaired exercise tolerance, neuropsychiatric symptoms, chronic fatigue and tachycardia. Some have postulated that gastrointestinal symptoms are seen in COVID-19 because gastrointestinal cells have a high expression of angiotensin convertase enzyme 2 (ACE2). 15-20% of patients present with gastrointestinal symptoms. Some cases of acute COVID-19 were found to have developed acute type I diabetes mellitus, which is explained by ACE2 expression on islet cells [3]†

Post-acute SARS-CoV-2 syndrome is likely associated with sustained elevation of inflammatory markers such as interferon-alpha, interferon-gamma, soluble T-cell immunoglobulin, and mucin domain-containing protein 3 (TIM3) [4]† According to the current literature, cases of inflammatory bowel disease (IBD) after acute COVID-19 have been seen with persistent diarrhea [5]† According to one study, 29% of patients after acute SARS-CoV-2 infection had persistent gastrointestinal symptoms, including nausea, vomiting, abdominal pain and diarrhea [6]† Studies have shown a high amount of SARS-CoV-2 in gastrointestinal cells by detecting it in stool through nucleic acid amplification tests [7]†

There has been a case of severe ulcerative colitis after COVID-19 that was fatal, in this case SARS-CoV-2 infection was thought to trigger changes in immunomodulatory pathways [8]† Further studies on the gastrointestinal consequences of COVID-19 are important to develop strategies that can manage, treat or prevent complications.

Our patient initially presented for suicide attempt with intranasal heroin use two days prior to presentation, then reported mild gastrointestinal symptoms with unremarkable vital signs, physical examination and imaging including CT of his abdomen and pelvis was not revealing of any etiology; hence the possibility that his initial presentation was consistent with early colitis associated with COVID-19 or that it could be nonspecific gastrointestinal symptoms seen with opiate withdrawal.

In addition, this patient had received bebtelovimab with gastrointestinal symptoms prior to presentation. Bebtelovimab is a monoclonal antibody that binds to the receptor binding domain of spike protein present in SARS-CoV-2 virus [9]† This raises the question of whether his later presentation could be related to the administration of bebtelovimab. We are not aware of any current observation demonstrating the association between bebtelovimab and colitis.

Patients with COVID-19 who develop colitis may initially have mild symptoms that may worsen and have delayed the onset of the first positive test for SARS-CoV-2. We need further studies to learn more about the gastrointestinal consequences of SARS-CoV-2 infection and further monitor possible adverse effects of monoclonal antibody therapy for COVID-19.