S2292 Gastrointestinal Manifestations in Patients With Inflammatory Bowel Disease and Novel Coronavirus Infection

Abstract

INTRODUCTION: There has been speculation about the level of risk and severity of symptoms in patients with Inflammatory Bowel Disease (IBD). Studies have shown that patients with Crohn’s disease and Ulcerative Colitis (UC) have increased expression of Angiotensin-converting Enzyme 2 (ACE 2) in their inflamed guts.2 SARS-CoV-2 uses ACE2 on the host receptor to enter into cells.1 The utilization of immunosuppressants or immunomodulators is another consideration that needs to be made for patients with IBD. We present a case series of 2 patients with different forms of IBD as well as differing forms of management. CASE DESCRIPTION/METHODS: Case 1: 64-year-old AA female with a PMH of CD, DM2, HTN, and Breast Cancer presented to the ER with fevers, cough, and myalgias for 5 days. SARS-CoV-2 PCR was collected. The patient was admitted five days later due to worsening symptoms of dyspnea, fevers, and diarrhea. Her physical exam was within normal limits. Initial management included initiation of broad spectrum intravenous antibiotics, cessation of immunosuppressant Azathioprine, continuation of Cholestyramine, and Hydroxychloroquine. RNA PCR returned positive for Sars-Cov-2. Stool studies collected during hospitalization were significant for lactoferrin and osmolality (390 mOsm/kg). Stool infectious studies were negative. Case 2:50-year-old AA female with PMH of UC presented with symptoms of fevers and dyspnea. SARS-CoV-2 PCR collected and she was discharged. The patient returned to the ER with 1 week worsening GI symptoms. Symptoms of previous flares were sharp hypogastric pain associated with increased frequency of hematochezia and tenesmus different from the symptoms experienced during this admission. DISCUSSION: This is the first case series of patients with IBD on immunomodulators who developed gastrointestinal manifestations of COVID-19. A dilemma faced in both of the patients presented was whether their symptoms were secondary to COVID-19 or IBD flare. ACE2 is ubiquitously expressed in the gastrointestinal tract with upregulation in IBD. Specific guidance on Covid-19 infected patients has been published for patients with IBD stratified by risk. IBD medication management varied drastically in our two cases. Studies have shown an increased risk of viral infection in clinically active IBD with exposure to thiopurines and so Azathioprine was held in Patient 1. In contrast it was felt appropriate to continue 5-Aminosalicylic acid in patient 2. Both IBD patients had extended clinical courses but positive outcomes.Table 1Table 2