S2841 SARS-CoV-2 Associated Gastroenteritis Under Microscope

Abstract

INTRODUCTION: SARS-CoV-2 most commonly presents with respiratory symptoms and fever. A significant proportion of patients are also experiencing gastrointestinal (GI) symptoms with loss of appetite, nausea, vomiting and diarrhea (variable, up to 10%); however, there is limited data about the associated histologic findings in the GI tract. CASE DESCRIPTION/METHODS: A 71 year old male presented with fever for past five days after going on a cruise two days prior. Antibiotics were initiated along with self-quarantine. Over the next few days, he developed cough, shortness of breath, fever and myalgia. SARS-CoV-2 infection was confirmed on nasopharyngeal swab. He was intubated for ARDS and started on Remdesivir, which was stopped due to acute kidney injury. Over the next month he developed septic shock, arrythmias, spontaneous venous bleeds, acalculous cholecystitis, ventilator associated pneumonia and profuse diarrhea. GI pathogen panel and Clostridium difficile testing were negative. CT of the abdomen showed colonic and distal small bowel wall thickening with adjacent inflammatory changes. EGD and colonoscopy demonstrated ulceration of the duodenum, splenic flexure, sigmoid colon and rectum (Figure 1). Biopsies from the terminal ileum showed increased apoptotic bodies (>10 apoptosis per 10 crypts), mild villous blunting, patchy crypt dropout and crypt abscess (Figure 2). Colon biopsies had similar features along with mucosal erosion and focal crypt abscess formation. No significant increase in intra-epithelial lymphocytes was identified. Viral stains for CMV and Adenovirus were negative. DISCUSSION: Limited data on GI specimens from SARS-CoV-2 positive patients have showed no significant damage with few infiltrating plasma cells and lymphocytes in lamina propria along with interstitial edema. In our case, we observed extensive apoptotic injury with acute inflammation. Although confirmatory stool testing was not performed, SARS CoV-2 was favored as the etiology due a long gap between the administration of Remdesivir and lack of any other identifiable causes. Further studies are needed to characterize SARS-CoV-2 associated gastrointestinal disease.Figure 1.: Sigmoid colon with focal ulceration.Figure 2.: Terminal ileum with increased apoptotic bodies, patchy crypt dropout and crypt abscess (H&E, 200X).