S2216 Mesenteric Ischemia: An Unusual Presentation of COVID-19

Abstract

INTRODUCTION: We report an unusual case of a patient with COVID-19 who presented with acute mesenteric ischemia without pulmonary symptoms. We believe that this observation has important implications for early identification and management of patients with COVID-19. CASE DESCRIPTION/METHODS: An 87 year-old female with atrial fibrillation, not on anticoagulation due to falls, presented to the ED with acute abdominal pain and bloody diarrhea. She denied recent travel but had exposure to a relative who had COVID-19. Initial vitals, including O2 saturation were normal. On exam she exhibited diffuse abdominal tenderness out of proportion to palpation and bloody stool in the rectum. Laboratory studies:WBC 8.4,RBC 12.7,platelets 277,INR 1.0, PTT 36,CRP 25,D-dimer 2262,LDH 126, and lactate 4.0. CT abdomen and pelvis showed focal occlusion of the SMA with ischemic enteritis and colitis involving the terminal ileum and ascending colon. Moreover, a pneumonia was noted with typical findings of COVID-19. The patient was started on a heparin drip and underwent thrombectomy with catheter-directed thrombolysis. A repeat angiogram demonstrated satisfactory SMA perfusion. The patient’s abdominal pain and bloody diarrhea resolved. A nasopharyngeal swab was taken (SARS-CoV-2 RT-PCR) which resulted positive on day 2 of admission. Though she remained asymptomatic, she was treated with Plaquenil and discharged on day 7 with Xarelto, Plavix, and Atorvastatin.The patient returned 13 days later with dyspnea requiring O2 via NC and no GI symptoms. CXR showed worsening pneumonia. She was treated with antibiotics and steroids and was discharged on day 2 with 2L of O2. DISCUSSION: The mechanism of COVID-19 induced GI injury or thrombosis is unknown. The virus may have certain tropism to the GI tract as evidenced by the presence of virus in the stool. This may be due to the expression of ACE2 receptors in enterocytes to which the virus binds to and enters the cells, thus increasing GI permeability. The small bowel, a lymphoid organ, may serve as an entry for the virus and potentiate the immune response. Endothelial cells also express the ACE2 receptor. Thus, the virus may predispose patients to thrombosis via endothelial dysfunction and activation of the coagulation cascade related to the interaction of the virus with the receptor.No cases of mesenteric ischemia related to COVID-19 were found. Unusual GI presentations of COVID-19 without pulmonary symptoms should alert gastroenterologists to identify those with the illness promptly.Figure 1.: CT abdomen and pelvis with IV contrast with focal occlusion of the SMA with corresponding ischemic enteritis and colitis involving the terminal ileum and ascending colon due to thrombosis.Figure 2.: Angiogram Pre-Catheter Directed Thrombolysis.Figure 3.: Angiogram Post-Catheter Directed Thrombolysis.