S2316 Evaluating Bloody Diarrhea During the COVID-19 Pandemic in a 20-Year-Old Patient

Abstract

INTRODUCTION: During the COVID-19 pandemic, differentiating between acute infectious diarrhea versus a chronic inflammatory bowel disease (IBD) presents a new challenge altering the way we approach the diagnosis and treatment of IBD. CASE DESCRIPTION/METHODS: A 20-year-old gentleman with no known past medical history presented to his PCP with 14 bloody bowel movements daily. He was started on a 5-day course of Azithromycin. Stool studies were sent and his C. Difficile stool antigen turned positive. He was switched to oral Vancomycin. He presented to the hospital 3 days later after no improvement. On presentation, patient was febrile with diffuse abdominal and rectal pain. Initial lab results revealed leukocytosis (29.5K) with elevated bands (35), CRP 127.3, Albumin 3.0, Ferritin 236, Procalcitonin 1.13, Fibrinogen 698, and D-Dimer 1.57. Repeat stool studies were negative. His SARS CoV-2 PCR was positive. Chest X-ray was unremarkable. CT abdomen revealed diffuse colonic wall thickening and peri-colonic inflammation consistent with pancolitis without intra-abdominal or pelvic abscess. Symptoms improved with antibiotics. Flexible sigmoidoscopy revealed diffuse, severely edematous and erythematous mucosa with granularity and discontinuous areas of ulcers of varying size and depth seen in descending colon. Ulcerations were superficial and circumferential. Due to severity of disease and contact bleeding, scope was not advanced beyond this point. The lumen became narrowed due to inflammation without overt stricture or obstructing lesions. The sigmoid colon and rectum, ulcerations became mixed with exudates and the area was generally less effected. Numerous biopsies were taken. Pathology showed severe chronic active colitis with ulceration. Histology showed frequent crypt abscesses, cystic crypt changes and basal lympho-plasmacytosis. There is no definite Paneth cell metaplasia, pseudomembranous or viral cytopathic changes. After multidisciplinary discussion, he was started on IV Solumedrol. 72 hours later patient reported near resolution in symptoms and was transitioned to oral Prednisone taper. He was started on Infliximab 10 mg/kg prior to discharge after a repeat COVID test was negative. Outpatient follow up was arranged for repeat testing and interval colonoscopy. DISCUSSION: The documentation of collective experiences with newly diagnosed IBD patients during the COVID pandemic presents a diagnostic and therapeutic dilemma possibly altering our decisions moving into a new era.Figure 1.: Descending colon images.Figure 2.: Sigmoid colon images.Figure 3.: Rectal images.