S2439 A Crohn's Disease Flare Masquerading as COVID-19 Infection

Abstract

Introduction: The clinical presentation of an inflammatory bowel disease (IBD) flare can mimic COVID-19 infection. Gastrointestinal manifestations have been reported in over one half of COVID-19 patients, sometimes without associated respiratory symptoms. We report a patient whose Crohn’s Disease (CD) flare was challenging to diagnose due to concomitant COVID-19 infection. Case description/methods: A 26-year-old man with history of ileocolonic CD, on ustekinumab, presented with 1 day of diffuse abdominal pain, nausea, intractable vomiting, and chills. On arrival, he was mildly tachycardic. Physical exam was notable for mild abdominal tenderness. Erythrocyte sedimentation rate (ESR) was 54 mm/hr from a prior of 22 mm/hr and c-reactive protein (CRP) was 1.1 mg/dL from normal limits prior. COVID-19 testing was positive. Computed tomography (CT) abdomen was significant for mild edema of the terminal ileum and entire colon. Gastroenterology was consulted for concern of a CD flare. His clinical presentation was suspected to be from COVID-19 infection as opposed to CD because nausea, vomiting and chills were his predominant symptoms, as opposed to abdominal pain. Additionally, his CT findings were felt to be improved from his prior studies. ESR and CRP were noted to be unreliable markers to diagnose a CD flare in his situation because they could be elevated due to COVID-19 infection. The patient was managed supportively with as needed oxycodone for pain. On hospital day 2, the patient reported worsening abdominal pain and had a bloody bowel movement. A repeat CT abdomen now showed progressive colitis involving the entire colon and terminal ileitis, consistent with a CD flare. The patient was started on 40 mg daily prednisone with improvement in his symptoms. He was discharged on hospital day 4. Discussion: GI symptoms are commonly reported in patients with COVID-19. In a study of 318 adult patients hospitalized with COVID-19, 61% had at least one GI symptom. In particular, anorexia was reported in 35%, diarrhea in 34%, and nausea in 26%. Another study reported diarrhea in about 50% of COVID-19 patients. Given the nonspecific nature of these symptoms, and that they can present in the absence of respiratory complaints, clinicians should be aware that an IBD flare can masquerade as COVID-19 infection.Figure 1.: Initial CT abdomen, showing mild edema and hyperemia of the terminal ileum and ascending/transverse/proximal descending colon with skip lesions at the splenic flexure, consistent with clinical suspicion of a Crohn's flare.