Abstract
It is now known that COVID-19 not only involves the lungs, but other organs as well including the gastrointestinal tract. Although clinic-pathological features are well-described in lungs, the histopathologic features of gastrointestinal involvement in resection specimens are not well characterized. Herein, we describe in detail the clinicopathologic features of intestinal resection specimens in four patients with COVID-19 infection. COVID-19 viral particles by in situ hybridization and immunofluorescence studies are also demonstrated. All four patients were males, aged 28–46 years, with comorbidities. They initially presented with a severe form of pulmonary COVID-19 and showed gastrointestinal symptoms, requiring surgical intervention. Histopathologic examination of resected GI specimens, mostly right colectomies, revealed a spectrum of disease, from superficial mucosal ischemic colitis to frank transmural ischemic colitis and associated changes consistent with pneumatosis cystoides intestinalis. Three patients were African American (75%), and one was Caucasian (25%); three patients died due to complications of their COVID-19 infection (75%), while one ultimately recovered from their GI complications (25%), but experienced prolonged sequela of COVID-19 infection including erectile dysfunction. In conclusion, COVID-19 infection, directly or indirectly, can cause ischemic gastrointestinal complications, with predilection for the right colon.
Highlights
All patients initially presented with respiratory symptoms, including fever, dyspnea, and/or flu-like symptoms which developed into acute respiratory distress syndrome (ARDS) requiring intubation, ventilation, and critical care management
GI symptoms associated with COVID-19 are present in up to 30% of patients, with diarrhea, abdominal pain, and hematochezia occasionally evident as the initial presentation (5)
We demonstrated by immunofluorescence (Figure 6) and in situ hybridization (ISH) studies (Figures 2–5) evidence of the virus in affected area of the intestine
Summary
COVID-19, the infectious disease caused by SARS-CoV-2, is a pandemic affecting countries throughout the world. The receptor of SARSCoV-2, angiotensin converting enzyme 2 (ACE2) is highly expressed both in GI epithelial cells and in liver (2). Almost the entire GI tract, including the stomach, small intestine, and rectal epithelial cells express the SARS-CoV-2 nucleocapsid protein and the ACE2 protein (3). The SARS-CoV-2 nucleocapsid protein, which encapsulates the viral genome, is essential for SARS-CoV-2 replication (4). High levels of these two proteins in cells of the GI tracts of SARS-CoV2 infected patients can explain the concomitant digestive symptoms, including diarrhea, nausea, vomiting, and abdominal pain (3)
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