Carolinas Research Day 2021

PNEUMATOSIS INTESTINALIS AS THE ONLY PRESENTING SYMPTOM IN A COVID-19 PATIENT SUBSEQUENTLY REQUIRING SURGICAL INTERVENTION Ashlyn McConnell, OMSIII; Matthew P. Forte, MD; Thomas Chow, MD The Regional Medical Center, Department of Radiology. Orangeburg, South Carolina. Diagnostic Imaging (cont.) Patient Presentation Discussion

CBR-1

Pneumatosis intestinalis (PI) is defined as the presence of gas within the wall of the small or large intestine. PI is a radiologic sign, rather than a specific disease. Alarming signs that may warrant surgical intervention include progressive symptoms, peritonitis, signs of bowel necrosis, portal venous gas, or associated neoplasia. 1,2 Previous literature has cited between 25% - 50% of all patients hospitalized with COVID-19 present with digestive problems. One study found 4% of all patients to describe enteric symptoms alone. 2,3 Enteric manifestations are likely multifactorial and may involve direct viral infection, neuroinvasive injury, microbiome impairment, or small vessel thrombosis. 2,4,5 The cellular angiotensin-converting enzyme 2 (ACE2) receptor, which plays a prominent role for SARS-CoV-2 entry, has been found in enterocytes and the vascular endothelium. 4 This finding provides one explanation to enteric susceptibility. Recent literature also indicates an increased risk of coagulopathy in COVID- 19 patients. 5,6 The interplay between enteric inflammation and increased risk of coagulopathy could contribute to intestinal disease severity. The presence of PI could therefore be a subsequent manifestation of an initial enteric infectious and/or ischemic event. 5,6 Further research is needed to identify long term sequalae. With the rapidly evolving understanding of COVID-19 and its clinical manifestations, this report of pneumatosis intestinalis in a COVID-19 patient points toward tendency of the virus to cause atypical enteric disease manifestations. It is imperative to maintain a high index of suspicion for SARS-CoV-2 infection and the need for prompt intervention and precautionary measures.

A 59 year old female presented to the Emergency Department with complaints of acute abdominal pain for twelve hours. On admission she endorsed periumbilical sharp intermittent pain that radiated to the left flank, flatulence, and nausea. She denied fever, chills, shortness of breath, or cough. Patient reported a past medical history of HTN, HLD, DM, and renal stones. Surgical history included cholecystectomy and inguinal hernia repair. Patient denied smoking, ETOH or illicit drug use. During ED physical exam, the patient exhibited diffuse abdominal tenderness, worse in the left lower quadrant. Guarding and rebound tenderness were present. Bowel sounds were active. She was found to be hypertensive (BP 178/79) and tachycardic (HR 105). Her vital signs were otherwise within normal limits. Initial labs obtained in ED demonstrated anemia (Hgb 7.9), a normal leukocyte count and preserved renal function. IV fluids and oral pain medications were administered.

Image 2 . Several tiny clustered gravity-independent air bubbles present eccentrically along the small bowel loops in the left midabdomen (red circle) concerning for pneumatosis intestinalis with mesenteric infiltration (orange circle). There is no portal venous air or pneumoperitoneum present to indicate perforation.

Diagnostic Imaging

Surgical Findings

The patient was initially thought to have possible renal stones however a non-contrast CT ( Images 1, 2 ) identified the presence of pneumatosis intestinalis in the left mid-abdomen with suspicion of bowel ischemia.

Prompt surgical intervention was warranted due to the unstable nature of her condition. The patient underwent an exploratory laparotomy. Gross intraoperative findings included an erythematous and edematous jejunum with fibrinous exudate. The corresponding mesentery appeared edematous, indurated, and chronically scarred. Small bowel resection with primary anastomosis was performed. Pathological examination of resected small bowel revealed microabscesses and focal submucosal cysts consistent with pneumatosis intestinalis. The resected corresponding mesenteric fat showed abscesses and acute peritonitis. At time of operation, the patient was noted to be febrile, however, the degree of which did not correlate with visible intraabdominal disease. Clinical suspicion for COVID-19 prompted post-operative nasopharyngeal testing which subsequently revealed positivity for SARS-CoV-2. The patient later admitted to known viral exposure. Strict isolation measures were initiated and Infectious Disease was consulted to assist with management. Her post- operative course was unremarkable. She was discharged on post-operative day four with instructions to quarantine.

References

1. Knechtle SJ, Davidoff AM, Rice RP. Pneumatosis intestinalis. Surgical management and clinical outcome. Ann Surg. 1990;212(2):160-165. 2. Wong K, Kim DH, Khanijo S, Melamud A, Zaidi G. Pneumatosis Intestinalis in COVID-19: Case Series. Cureus. 2020 Oct 16;12(10):e10991. doi: 10.7759/cureus.10991. PMID: 33209547; PMCID: PMC7667714. 3. Docherty AB, Harrison EM, Green CA, et al. Features of 20 133 UK patients in hospital with covid -19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ. 2020; 369:m1985 4. Li Y.C., Bai W.Z., Hashikawa T, The neuroinvasive potential of SARS-CoV2 may be at least partially responsible for the respiratory failure of COVID-19 patients, J. Med. Virol. 2020; 2: 0-2 5. Bhayana, R, Som, A, Li, MD, et al. Abdominal Imaging Findings in COVID-19: Preliminary Observations. Radiology. 2020; 297:E207 – E215. 6. Connors, JM, Levy, JH. Thromboinflammation and the hypercoagulability of COVID ‐ 19. J Thromb Haemost. 2020;18:1559-1561.

Image 1. Cluster of abnormal small bowel loops in the left midabdomen with associated pneumatosis (red circle) and mesenteric infiltration suspicious for bowel ischemia.

Special thanks to Dr. Matthew Forte, Dr. Thomas Chow, and Dr. Terry Mac Math for their time, input, and clinical guidance.

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