key: cord-0980691-3ysvjto9
authors: Calabrese, Emma; Zorzi, Francesca; Monteleone, Giovanni; Blanco, Giovanna Del Vecchio
title: Ref. No. DLD-20-852: Onset of ulcerative colitis during SARS-Cov-2 infection
date: 2020-06-11
journal: Dig Liver Dis
DOI: 10.1016/j.dld.2020.06.003
sha: 88404b08a45e224f448003e035d52710ba75672e
doc_id: 980691
cord_uid: 3ysvjto9

nan

A 19-year-old, non-smoker woman with a recent history of fever, nausea, vomiting, bloody diarrhea and loss of taste and smell was admitted to the Tor Vergata Hospital. A nasofaringeal swab resulted positive for SARS-CoV-2. At entry, she had a body temperature of 38°C, pulse of 110 beats/min, and 99% oxygen saturation. She had severe anemia but no shortness of breath or chest pain. C-reactive protein, platelets, fibrinogen and D-dimer were elevated. A chest and abdominal CT scan showed no pneumonia but increased contrast enhancement in the ileum and colon. No further pathogen was evidenced. After 1 week treatment with hydroxychloroquine, all the symptoms/signs disappeared except the severe anemia, which required a blood transfusion, and the enhanced inflammatory markers. The subsequent nasofaringeal swabs were negative for SARS-CoV-2. At day 16, a small bowel ultrasonography revealed an increased bowel wall thickening of the whole colon associated with an increased blood flow vascularization (Limberg score 4) ( Figure  1 , panels A-B) and ileocolonscopy showed an extensive colitis with mucosal friability, spontaneous bleeding and tiny and large ulcerations ( Figure 1 , panels C-D). Hematoxylin and eosin staining of the colonic biopsy samples showed ulcerations, crypt architectural distortion, a diffuse and active inflammatory infiltrate with crypt abscesses (Figure 1 , panels E-F). SARS-CoV2 RNA in colon/ileal and fecal samples was negative (1) (2) . A diagnosis of ulcerative colitis was made and treatment with oral beclomethasone dipropionate and MMX-mesalamine was started.

The clinical spectrum of SARS-CoV-2 ranges from asymptomatic or mild respiratory disease to pneumonia with respiratory distress syndrome and/or sepsis (Covid-19) , which can result in a fatal outcome. Common symptoms are fever, cough, and shortness of breath, but gastrointestinal symptoms can occur in infected patients in line with the demonstration that SARS-CoV-2 RNA can be detected in faeces and some of the infected patients remain positive in stools after becoming negative in respiratory samples (3) . Notably, the human intestine expresses constitutively high levels of angiotensin-converting enzyme 2 (ACE2) and the transmembrane serine protease, which are needed for SARS-CoV-2 to gain entry into the cells. Consistently, elevated levels of fecal calprotectin have been documented in Covid19-infected patients with ongoing diarrhea even in the absence of faecal SARS-CoV-2 RNA (4). Overall these findings suggest that SARS-CoV-2 infection can instigate an acute intestinal inflammation, which under specific circumstances (e.g. genetic susceptibility, exposure to environmental factors), can eventually evolve towards a chronic inflammatory disorder or potentially deteriorates the course of IBD (5) . The persistence of severe anemia and increased levels of inflammatory markers together with the marked mucosal inflammation, after clearance of the SARS-CoV-2, strongly support such a hypothesis. 

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The Presence of SARS-CoV-2 RNA in Feces

Enteric involvement of coronaviruses: is faecal-oral transmission of SARS-CoV-2 possible?

Faecal calprotectin indicates intestinal inflammation in COVID-19. Gut

Are Patients with inflammatory bowel disease at increased risk for Covid-19 infection?