key: cord-0977345-yis1pf4k authors: Di Ruscio, Mirko; Variola, Angela; Angheben, Andrea; Resimini, Silvia; Geccherle, Andrea; Ruffo, Giacomo; Barugola, Giuliano title: A Challenging Colectomy for Acute Severe Ulcerative Colitis Complicated by COVID-19 date: 2020-07-06 journal: Inflamm Bowel Dis DOI: 10.1093/ibd/izaa186 sha: 6939b569b416dcd9dbed152d781e7d0a402ffce9 doc_id: 977345 cord_uid: yis1pf4k nan Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn disease, are conditions with variable clinical patterns and multiple disease courses. 1 About 20-40% of patients with IBD require immunemodulating biological treatment, which is associated with an increased risk of various infections. When such treatment fails, surgery often represents the next valid option. 2 Recently, management of patients with IBD has been severely disrupted by the SARS-CoV-2 outbreak. 3 Since January 2020, SARS-CoV-2 has rapidly spread to many countries, with Northern Italy being one of the worstaffected areas. 4 The Italian national health care system underwent swift and significant alterations to address the emergency, with hospitals deferring elective services and activities, including surgery. Access to IBD units was limited to patients with disease flares only and for dispensing biological drugs. 5, 6 No data or formal recommendations for the management of patients with IBD with concomitant COVID-19 were available during the first phase of the emergency. 7 We report here the case of a patient with acute severe ulcerative colitis (ASUC) complicated by COVID-19 who required an urgent colectomy after a prolonged hospitalization. On February 28, 2020, a female patient aged 60 years affected by long-standing, left-sided UC was admitted with a severe disease flare to the gastroenterology unit of the Istituto di Ricovero e Cura a Carattere Scientifico Sacro Cuore Don Calabria, Negrar di Valpolicella (Verona), Italy, presenting with bloody diarrhea, up to 10 bowel movements per day, abdominal pain, and fatigue. A week earlier, the patient had received an infusion of the infliximab biosimilar CT-P13, 8 which was interrupted because of a severe reaction. At admission, laboratory tests showed mild anemia (hemoglobin level of 11 g/dL) and a C-reactive protein level of 35 mg/ dL, and her body temperature was 36.8°C. Infection and toxic megacolon were dismissed, and a sigmoidoscopy revealed severe disease with large, deep ulcers and mucosal friability (Fig. 1A) . Therefore, intravenous corticosteroid therapy with anti-thrombotic prophylaxis and total parenteral nutrition were started. During the following 5 days, clinical features did not improve. A second sigmoidoscopy confirmed no improvement (Fig. 1B) , and no feasible "rescue" therapy was obvious because of the previous failure of infliximab and the poor safety record of cyclosporine. Thus, the multidisciplinary team (MDT) agreed upon an elective colectomy and accelerated steroid tapering was initiated. Unfortunately, the patient developed a fever with a dry cough and dyspnea in the subsequent days. A diagnosis of SARS-CoV-2 infection was reached on March 12 after real-time polymerase chain reaction testing of a nasopharyngeal swab. 9 Chest radiography and a chest computed tomography scan showed multiple pulmonary infiltrates and areas of parenchymal thickening, with bilateral "ground-glass" opacities, confirming COVID-19-related pneumonia (Fig. 2) . The patient was transferred to a dedicated COVID-19 unit and treated with oral hydroxychloroquine and darunavir/cobicistat along with supplemental oxygen for 10 days 10 as per local treatment protocol. Her ASUC symptoms worsened to up to 12 bowel movements per day, with continued abdominal pain and persistent hypoalbuminemia requiring albumin supplementation and blood transfusions for worsening anemia. In the absence of any COVID-19 surgery protocol, colectomy was repeatedly delayed because of COVID-19-related risks such as postoperative respiratory failure and because of the patient's nutritional status. Repeat nasopharyngeal swabs tested positive, and septic shock occurred because of a central venous catheter-related infection; the septic shock was promptly resolved with daptomycin and meropenem. Respiratory conditions slowly improved over the following days, and on April 7 a chest CT scan revealed a substantial regression of pneumonia. Thus, the MDT decided upon an urgent colectomy in adherence with a dedicated COVID-19 surgical care pathway because nasopharyngeal swabs continued to test positive. On April 10, the patient underwent a laparoscopic colectomy with terminal ileostomy in a dedicated COVID-19 operating room (Figs. 3 and 4) . There were no acute surgical complications, and the ileostomy remains viable. No signs of respiratory failure were apparent in the postoperative phase. However, because of recurrent discharge from the inflamed rectal stump and a new central venous catheter-related infection, a combination of meropenem, daptomycin, and caspofungin was prescribed. On April 18, 8 days after surgery, the patient's body temperature was stable at 37°C, rectal discharge had decreased, and serum inflammation markers had improved. On April 28, 2020, a negative result was obtained from a nasopharyngeal swab, and the patient was discharged the following day. We have reported the complex multidisciplinary management of a patient with ASUC undergoing a colectomy while suffering COVID-19-related pneumonia. In reviewing the recent literature, we determined that this is one of the first such reports. The European COVID-19 outbreak seems to have started in January 2020. With Italy at its center, an emergency was declared, and management strategies for patients with IBD were dramatically affected. The World Health Organization 11 and the International Organization for the Study of Inflammatory Bowel Disease 12 advised avoiding routine corticosteroids and canceling or postponing elective surgery. Formal recommendations, published only recently, have since confirmed these indications. 13, 14 Furthermore, a preliminary report on the clinical outcomes of COVID-19 in patients with IBD has shown that active disease, older age, and comorbidities are associated with worse outcomes. 15 Our patient with ASUC and concomitant COVID-19 represented a significant management challenge. She developed a severe IBD flare requiring corticosteroid treatment, increasing the risk of a negative COVID-19 outcome. The persistence of COVID-19related pneumonia and the progressive worsening of her IBD led to a prolonged hospital stay and several MDT discussions. The necessary colectomy, initially elective and then urgent, was hindered by infection complications, logistical difficulties, and the lack of real-world COVID-19 case studies to refer to. The worsening of a patient's clinical condition before surgery because of anemia, hypoalbuminemia, and infection is a known risk factor for surgical complications. 16 Ulcerative colitis Surgery in the age of biologics Clinical features of patients infected with 2019 novel coronavirus in Wuhan COVID-19 and Italy: what next? The daily impact of COVID-19 in gastroenterology Management of IBD during the COVID-19 outbreak: resetting clinical priorities AGA clinical practice update on management of inflammatory bowel disease during the COVID-19 pandemic: expert commentary the treatment of inflammatory bowel disease Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR SARS CoV-2: recent reports on antiviral therapies based on lopinavir/ritonavir, darunavir/ umifenovir, hydroxychloroquine, remdesivir, favipiravir and other drugs for the treatment of the new coronavirus Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance International Organization for the Study of Inflammatory Bowel Disease. IOIBD update on COVID19 for patients with Crohn's disease and ulcerative colitis British Society of Gastroenterology guidance for management of inflammatory bowel disease during the COVID-19 pandemic International Organization for the Study of IBD recommendations for surgery in patients with IBD during the coronavirus disease 2019 pandemic Outcomes of COVID-19 in 79 patients with inflammatory bowel disease in Italy Colectomy with ileostomy for severe ulcerative colitis-postoperative complications and risk factors The authors thank Elinor Julie Rae Anderson for language editing. Patient verbal and formal consent for publication was given.