key: cord-0977565-9136us8q authors: Karki, Saurab; Rawal, Sushil Bahadur; Malla, Srijan; Rayamajhi, Jyoti; Thapa, Bikash Bikram title: A case report on spontaneous hemoperitoneum in COVID-19 patient date: 2020-09-14 journal: Int J Surg Case Rep DOI: 10.1016/j.ijscr.2020.09.078 sha: b40b5e6da9c9e77684091c28be35c4d1b6508a6d doc_id: 977565 cord_uid: 9136us8q INTRODUCTION: Corona virus disease (COVID-19) is a global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients commonly present with respiratory tract symptoms and fever. However two third are asymptomatic and unusual presentation is evolving. This has cause management dilemma among physicians. PRESENTATION OF CASE: A 35 year young otherwise healthy male presented to emergency department of this institute with fever of 103o F, abdominal pain, and pancytopenia with progressive fall in hemoglobin level was tested positive for COVID-19. Contrast enhance computed tomography of the patient revealed hemoperitoneum with splenic infarct. He was admitted in intensive care unit and managed with supportive treatment. DISCUSSION: Respiratory and gastrointestinal symptoms with hematological abnormalities like lymphopenia, thrombocytopenia were common presentation of COVID-19. Although coagulopathy and vasculitis has been a well-documented entity in patients with COIVD-19, visceral infarction leading to spontaneous hemoperitoeum was unusual and rare clinical presentation. CONCLUSION: A high degree of clinical suspicion and thorough evaluation helps in diagnosis of COVID-19 and related complications. The management of cases with unusual presentation requires judicious and careful approach. Spontaneous hemoperitoneum is a life threatening condition that usually occurs in patients with known coagulation disorder or under anticoagulants [5] . Vasculitis, a defined entity in patients has been associated with multiple visceral infarct but concomitant massive hemoperitoneum has been scarcely described. This rare but life threatening form of acute abdomen depicts another spectrum of this global pandemic. We report here a rare case presentation of spontaneous hemoperitoneum and splenic infarct in COVID-19 according to SCARE guideline [6] . 32years old serving soldier with no known co-morbidities presented in emergency department (ED) of our institute with fever for 6 days. The fever was associated with chills and rigors. He did not complained of cough, shortness of breath, myalgia, diarrhea and vomiting. He had no history of travel out of duty station in last two months and no history of contact with COVID-19 confirmed cases. He denied history of trauma and drug intake. He was non-smoker, non-alcoholic, and had no known personal or family history of bleeding and coagulation disorders. He was evaluated in ED by attending consultant physician and surgeon on duty. He was admitted in COVID-19 isolation ward and subjected to thorough clinical, laboratory and imaging studies. The maximum temperature recorded was 103 o F, blood pressure was 110/70mmHg, and oxygen saturation in room air was 92%. His blood parameters showed leucopenia and thrombocytopenia with near normal blood hemoglobin level (table 1). Rest of the blood biochemistry, liver enzymes, coagulation profile (prothrombin time, D-dimer) was within normal limit. Chest X-ray did not show any abnormality. His nasopharyngeal swab specimen was tested positive for SARS-COv-2. He was under symptomatic treatment for fever. The urine and blood sample send for culture showed no growth of organism. On third day of admission his cell counts tend to normalize but there was progressive fall in blood hemoglobin level from 14.1 gm/dl to 7.3 gm/dl. (Figure 1a &1b ). Patient developed generalized maculopapular rash without itching ( Figure 2 ). He was transferred to COVID-19 intensive care unit (ICU) with monitoring of vitals, urine output and serial hemoglobin and was transfused with three unit of packed RBC. Besides, he was given symptomatic and supportive care. Our patient remain clinically stable during ICU admission and the hemoperitoneum resolved spontaneously on 7 th day of admission (Figure 1c ). Fever, cough, myalgia are three most common symptoms of COVID-19 [7] . 30-40% of COVID-19 patient are asymptomatic [8] . Thromboembolic phenomenon is common event in this disease. However, spontaneous hemoperitoneum is a rarely reported. Lymphocytic endothelitis within lungs, kidney, heart, intestine and liver has been reported in COVID-19 cases. In these patients vasculitis could be result of viral infiltration of endothelium or result of immune reaction that leads to leucocytoclastic vasculitis. The pathological appearance shows lymphocytic infiltration within the vessels, hyperplasia of small vessels with thickening and stenosis [9] [10] [11] . COVID-19 is also associated with thrombocytopenia and coagulopathy and in severe form develops disseminated intravascular coagulation (DIC). Studies have shown that severe lymphopenia and elevation of D-dimer is associated with high mortality and represents inappropriate activation of coagulation leading to DIC [12, 13] . COVID-19 has non-specific dermatological manifestation like maculopapular, urticarial, and vesicular eruptions and transient livedo reticularis [14] . Thromboembolic complications including acute stroke and pulmonary embolism has been reported in young patient [15, 16] . Visceral infarction has been previously described in COVID-19 patients with previous cardiac events and involved spleen, kidney and small bowel [17] . COVID-19 patient treated with anticoagulants were at high risk of bleeding complications. Radiological embolization was choice of intervention in such events [18] . Hemoperitoneum with substantial drop in hemoglobin due to spontaneous intraperitoneal hemorrhage could be the newer presentation of same disease spectrum. J o u r n a l P r e -p r o o f Abdominal pain in COVID-19 patient requires further evaluation to rule out visceral infarct. Prothrombotic condition in COVID-19 has important implication in its clinical presentation, and management including judicious use of thrombolytic therapy. Vasculitis and small vessel thrombosis resulting in infarct laceration and hemoperitoneum could be self-limiting events. Not applicable /exempt from ethical review committee of Nepalese Army Institute of Health Sciences for case reports. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. [18] C. B. Conti, S. 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Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young Abdominal Visceral Infarction in 3 Patients with COVID-19