key: cord-0945080-yy651wfg authors: Lee, Jin Wook; Song, Eun Mi; Jung, Sung-Ae; Jung, Sung Hoon; Kim, Kwang Woo; Koh, Seong-Joon; Lee, Hyun Jung; Hong, Seung Wook; Park, Jin Hwa; Hwang, Sung Wook; Yang, Dong-Hoon; Ye, Byong Duk; Byeon, Jeong-Sik; Myung, Seung-Jae; Yang, Suk-Kyun; Park, Sang Hyoung title: Clinical Course of COVID-19 in Patients with Inflammatory Bowel Disease in Korea: a KASID Multicenter Study date: 2021-11-24 journal: J Korean Med Sci DOI: 10.3346/jkms.2021.36.e336 sha: a560709e003ea7f18f7451fe39f85536642116f9 doc_id: 945080 cord_uid: yy651wfg In 2020, the novel coronavirus disease 2019 (COVID-19) began to spread worldwide and remains an ongoing medical challenge. This case series reports on the clinical features and characteristics of patients with inflammatory bowel disease (IBD) and confirmed COVID-19 infection. From February 2020 to March 2021, nine patients with IBD had confirmed COVID-19 across four hospitals in Korea. The median age at COVID-19 diagnosis was 42 years. Six patients were male, and seven patients had ulcerative colitis (UC). No patients required oxygen therapy, intensive care unit hospitalizations, or died. The most common symptom was fever, and gastrointestinal (GI) symptoms developed as diarrhea in five patients with UC. Oral steroids were used to combat UC aggravation in two patients. In this case series of nine IBD patients diagnosed with COVID-19 in Korea, the clinical presentation was predominately a mild respiratory tract infection. Most patients with UC developed new GI symptoms including diarrhea. The authors have no potential conflicts of interest to disclose. This case series began with a survey of COVID-19 confirmed cases in patients with IBD at the IBD Study Group of the Korean Association for the Study of Intestinal Diseases. A surveillance questionnaire confirmed that nine patients with IBD in Korea had confirmed COVID-19 across four hospitals between February 2020 and March 2021. Based on this questionnaire, patients' symptoms and clinical courses were investigated at each institution. Patients who had confirmed COVID-19 and either Crohn's disease (CD) or ulcerative colitis (UC) were included in the study. A confirmed diagnosis of COVID-19 was defined as a positive result of reverse transcriptase-polymerase chain reaction (PCR) in a nasopharyngeal swab sample. 9 We reviewed the medical records of eligible patients to investigate their baseline characteristics, IBD status, and IBD treatment. Patients' age, sex, IBD type, IBD disease activity before a diagnosis of COVID-19, IBD medication, and comorbid diseases were evaluated. Symptoms and clinical course of COVID-19 were investigated by reviewing the patients' medical records at the time of diagnosis or after full recovery. Respiratory symptoms, new gastrointestinal (GI) symptoms, laboratory and radiological findings, discontinuation of IBD medication, oxygen requirement, use of COVID-19 therapies, COVID-19 complications, and COVID-19 outcomes were also investigated. IBD disease activity was evaluated using the partial Mayo score (pMS) for patients with UC and the CD activity index for patients with CD. In the surveillance questionnaire, nine patients with IBD (seven UC and two CD) and confirmed COVID-19 were identified. Their baseline characteristics, IBD type, and IBD treatment are shown in Table 1 . Of them, 5 patients (55.6%) received 5-aminosalicylic acid (5-ASA) alone as a maintenance therapy. Two patients (22.2%) received biologics (infliximab for one patient with CD and vedolizumab for one patient with UC). The 5-ASA with an immunomodulator or corticosteroid was used to treat two patients. The patient on steroid treatment was diagnosed with COVID-19 while using prednisolone 10 mg during steroid tapering after steroid rescue therapy. While infected COVID-19, 55.6% of patients experienced fever and 44.4% experienced myalgia. New GI symptoms emerged in 55.6% of patients, including diarrhea, abdominal pain, or bloody stools at the time of COVID-19 diagnosis. Diarrhea was identified as a new GI symptom in 5/7 patients with UC. Patients experienced COVID-19 symptoms for a mean during of 9.8 days. Six patients underwent testing for COVID-19 using PCR in the screening center and two in the hospital. Four patients were admitted to the hospital, and three were admitted to the residential treatment center. The remaining two patients were quarantined at home. Two patients had documented infection routes: one patient contracted the virus from a friend and the other from a family member. One patient had focal patchy infiltration on chest radiography, and no patients required oxygen therapy, mechanical ventilation, or ICU admission. One patient was treated for COVID-19 with regdanvimab therapy. All patients could leave quarantine after the conditions for release had been met. All nine reported no complications related to COVID-19; however, one patient temporarily discontinued IBD medication after diagnosis of COVID-19. Azathioprine was temporarily halted in one patient using infliximab and azathioprine together because of decreased leukocyte count. Biologic therapy was used without discontinuation or postponement in two patients because the dosing interval did not overlap with the two-week COVID-19 treatment period. Two patients experienced IBD aggravation while infected with COVID-19. In one patient with UC under 5-ASA monotherapy with a pMS of 0, fecal calprotectin level was 66.8 µg/g at remission state. However, diarrhea and rectal bleeding started at COVID-19 diagnosis, and a pMS rose to 3. Symptoms persisted for 8 weeks after discharge with COVID-19 negative conversion and involved hospitalization; a pMS of 5 was confirmed. Symptoms improved after 8 weeks of oral beclomethasone administration and a pMS returned to 0. After 2 months, mild disease activity was observed with a pMS of 3, but the fecal calprotectin test was confirmed a level of 27,880 µg/g. Another patient with ulcerative proctitis who used mesalamine suppository treatment was in remission before symptoms occurred. He had a pMS of 0; however, fecal calprotectin was high at 2,441 µg/g. Diarrhea and rectal bleeding occurred, and he was admitted to the hospital with a pMS of 6. Additionally, 10 days after several negative COVID-19 test, the patient tested positive. Despite focal patchy infiltration on chest radiography, oxygen therapy was not required, and the patient was initiated on regdanvimab therapy. After 24 days of management at a dedicated hospital, fever and respiratory symptoms improved, COVID-19 was negative converted, and patient was discharged. Despite continuous administration of oral 5-ASA during hospitalization, diarrhea and rectal bleeding did not subside for 36 days. The patient had a pMS of 8 and 4,758 µg/g fecal calprotectin level at the IBD clinic. After taking oral prednisolone 40 mg for 1-week, rectal bleeding improved, and the pMS improved to 2. To the best of our knowledge, this study is the first case series in Asia to report on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients with IBD. Most of these patients diagnosed with COVID-19 in Korea were young and without comorbidities. There were no cases of severe COVID-19 that required intensive care or mechanical ventilation. Mild respiratory symptoms and diarrhea were characteristics of the infection with COVID-19 in the present study. 27 Furthermore, a nonendoscopy examination is preferred over an endoscopy for IBD patients with GI symptoms throughout the pandemic. 28 Patients in our study did not undergo endoscopy and were followed up with symptom assessment, blood tests, and stool tests. In summary, patients with IBD may develop new GI symptoms as the disease progresses. However, there are some limitations in treating and examining IBD patients during the COVID-19 pandemic, considering the frequent use of immunosuppressive agents in IBD. 29, 30 Moreover, distinguishing between IBD aggravation and COVID-19 GI manifestation is challenging when new GI symptoms occur. During the COVID-19 pandemic, IBD patients with new GI symptoms such as diarrhea and abdominal pain should be screened with the SARS-CoV-2 test to discriminate against COVID-19-associated GI manifestations. The Institutional Review Board (IRB) of Asan Medical Center (IRB No. 2021-0272) approved this study and waived the requirement for informed consent given its observational nature. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Di Napoli R. Features, evaluation, and treatment of coronavirus (COVID-19) Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study Comparison of the second and third waves of the COVID-19 pandemic in South Korea: importance of early public health intervention Risk factors for SARS-CoV-2 infection and course of COVID-19 disease in patients with IBD in the Veterans Affair Healthcare System SARS-CoV-2 testing, prevalence, and predictors of COVID-19 in patients with inflammatory bowel disease in Northern California Baseline disease activity and steroid therapy stratify risk of covid-19 in patients with inflammatory bowel disease 2019 novel coronavirus disease (COVID-19) in patients with inflammatory bowel diseases Risk and outcomes of coronavirus disease in patients with inflammatory bowel disease: a systematic review and meta-analysis. United Comorbidity and its impact on patients with COVID-19 Gastroenterology manifestations and COVID-19 outcomes: a meta-analysis of 25,252 cohorts among the first and second waves Clinical presentation of COVID-19 in patients with inflammatory bowel disease: a systematic review and meta-analysis Gastrointestinal tract diseases as a risk factor for SARSCoV2 rectal shedding? An Italian report on 10 COVID-19 patients An overview of the gut side of the SARS-CoV-2 infection No durable impact of COVID-19 on intestinal disease activity in subjects with IBD but not TNF antagonists, are associated with adverse COVID-19 outcomes in patients with inflammatory bowel diseases: results from an international registry Patients with inflammatory bowel disease are not at increased risk of COVID-19: a large multinational cohort study Association between 5-aminosalicylates in patients with IBD and risk of severe COVID-19: an artefactual result of research methodology? Care of the patient with IBD requiring hospitalisation during the COVID-19 pandemic Inflammatory bowel disease management during the COVID-19 outbreak: the ten do's and don'ts from the ECCO-COVID taskforce Inflammatory bowel disease amid the COVID-19 pandemic: impact, management strategies, and lessons learned Patterns of endoscopy during COVID-19 pandemic: a global survey of interventional inflammatory bowel disease practice Current new challenges in the management of ulcerative colitis Best practices on immunomodulators and biologic agents for ulcerative colitis and Crohn's disease in Asia