SARS CoV 2 Gastrointestinal Infection Causing Hemorrhagic Colitis: Implications for Detection and Transmission of COVID 19 Disease
Venue: The American journal of gastroenterology
Year: 2020

The betacoronavirus, SARS CoV 2, that is responsible for COVID 19 disease and that was first described in Wuhan, China, in late 2019, has swiftly made its way around our world, resulting in excess of 30,000 deaths to date (1) Efforts to recognize SARS CoV 2 infection have focused on respiratory symptoms such as cough and shortness of breath (2,3) Currently, theCenters forDiseaseControl and Prevention (CDC) criteria for identifying persons under investigation for SARSCoV 2 infection in the United States comprise respiratory symptoms and/or fever only (4) Recent reports from China have described concomitant digestive symptoms, such as nausea, vomiting, diarrhea, and abdominal pain, in patientswith confirmed SARS CoV 2 pulmonary infection (5 8) and the presence of SARS CoV 2 RNA in fecal samples (8,9) However, it remains unclear whether these digestive symptoms were causally related to SARS CoV 2 gastrointestinal infection. Because the main goals of the care in these cases were to treat the pulmonary disease and limit healthcare worker exposure, a comprehensive evaluation of the gastrointestinal system to implicate the virus and rule out alternative etiologies was not undertaken. We present a case of SARS CoV 2 gastrointestinal infection causing acute hemorrhagic colitis and signaling COVID 19 disease which endoscopy confirmed colonic injury and helped exclude other etiologies of disease. We believe that this observation has important implications for the detection and transmission of COVID 19 disease. A 71 year old woman with a history of hypertension, depression, and chronic back pain had returned to the United States in early March 2020 after a 10 day trip to Egypt which included a 4 day cruise on the Nile River. On her last day in Egypt, she developed diffuse abdominal pain and nonbloody diarrhea. The next day, while traveling back to the United States, her diarrhea became bloody. Over the next 4 days, she experienced nausea, vomiting, anorexia, diffuse abdominal pain and distention, and 10 20 bloody bowel movements daily. She presented to our emergency department 5 days after the onset of her symptoms. Physical examination revealed a temperature of 36.4 degC (97.6 degF) blood pressure of 140/81 mm Hg, pulse of 98 beats per minute, respiratory rate of 18 breaths per minute, and oxygen saturation of 99% on ambient air. Lung auscultation was normal. Abdominal examination demonstrated normal bowel sounds and diffuse tenderness to palpation, but no signs of peritonitis. Red blood, mixed with loose stool, was present in her bedside commode. On further questioning, she denied fever, cough, shortness of breath, sore throat, or any other symptoms. She also denied a personal and family history of gastrointestinal disease and had undergone a normal screening colonoscopy 1 month earlier. She denied antibiotic, antidiarrheal, and nonsteroidal anti inflammatory use, food allergies, lactose intolerance, alcohol abuse, smoking, and drug use. Her medications did include lisinopril and desvenlafaxine, amlodipine, and morphine as needed for chronic back pain. She reported having been vaccinated against Hepatitis A and B. Laboratory evaluation was notable for an elevated white blood cell count of 24.4 K/mL, with 20.8 K/mL neutrophils and normal lymphocyte and eosinophil distributions, a normal hemoglobin, and slightly elevated creatinine at 1.31 mg/dL (baseline 0.90 mg/dL) CT scan of her abdomen and pelvis with intravenous contrast showed severe colonic inflammation that was most pronounced in the ascending, transverse, and descending colon but was also apparent in the sigmoid colon  There was also a small, right pleural effusion. Given the presumptive diagnosis of traveler's diarrhea with dysentery, empiric ceftriaxone, azithromycin, and metronidazolewere initiated intravenously. Before administration of antimicrobials, a fecal sample was obtained and was negative for fecal leukocytes, stool culture (Campylobacter, Salmonella, Shigella, Shiga toxinproducing Escherichia coli, and Yersinia) ova and parasites, andClostridium difficile toxin (Glutamate dehydrogenase antigen toxin screen) The next day, another fecal sample was negative for Entamoeba histolytica antigen and Giardia antigen. Of note, later in the hospitalization (hospital day 7) fecal molecular testing (FilmArray; BioFire Diagnostics, Salt Lake City, UT) was also negative for bacterial, viral, and parasitic pathogens. Human immunodeficiency virus 1, 2 antibodies and Legionella urine antigen were also negative. Over the next 3 days, the patient's abdominal pain and bloody diarrhea persisted despite antimicrobial support. Given a concern for inflammatory bowel disease, C reactive protein on hospital day 3 was 11.6 mg/dL. In addition, on hospital day 3, the patient learned that someone in her travel group had been diagnosed with SARS CoV 2 pulmonary infection. The patient was then immediately moved to a negative pressure room, and SARSCoV 2 precautions were instituted. On hospital day 4, 9 days after the onset of her