Coronavirus Disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has emerged in Wuhan city, China since December 2019. COVID-19 has rapidly spread worldwide and was declared as a pandemic by World Health Organization on March 11, 2020 . Persons with underlying diabetes mellitus, chronic lung disease, and cardiovascular disease appear to be at higher risk for severe COVID-19-associated disease . Patients with COVID-19 typically present with fever, cough, and myalgia . Digestive symptoms including diarrhea, nausea, and vomiting have been reported as clinical presentations of the patients infected with SARS-CoV-2 but were less common .
A 56-year-old man with a history of hypertension, coronary artery disease required coronary artery bypass grafting, and ascending aortic aneurysm presented to our emergency department in Houston, Texas with a 2-day history of fever, shortness of breath, nausea, vomiting, severe abdominal pain, and bloody bowel movements. Patient had not traveled outside Houston area, neither had he contacted with anyone known to have COVID-19.
Physical examination revealed temperature of 101.1 °F, blood pressure of 184/109 mmHg, pulse of 143 beats per minute, respiratory rate of 16 breaths per minutes, and oxygen saturation of 98% on ambient air. Lung auscultation was clear. Abdominal examination revealed distended abdomen and generalized tenderness to palpation. Bright red blood was present on bed sheet.
Blood tests on presentation (Table 1) revealed leukocytosis, lymphopenia, thrombocytopenia, elevated C-reactive protein, and lactic acid. Chest X-ray (CXR) showed bibasilar sub-segmental atelectasis (Fig. 1). Computerized tomography (CT) scan of the chest, abdomen, and pelvic with contrast revealed no pulmonary airspace disease but demonstrated wall thickening of the ascending, transverse, and descending colon which was compatible with colitis (Fig. 2). Blood cultures, HIV serology, and acute viral hepatitis serology were negative. Stool gastrointestinal pathogen panel polymerase chain reaction (PCR) was negative. Given an ongoing COVID-19 outbreak in the community, nasopharyngeal swab was obtained for COVID-19 qualitative PCR test, which was reported as detected on the day of admission.
Timeline and Therapeutic Intervention
On hospital day 2, patient had persistent abdominal pain and bloody diarrhea with no respiratory symptom. His laboratory findings during hospitalization were showed in Table 1. His hemoglobin level dropped and he developed worsening thrombocytopenia and elevated CRP. Repeat CXR showed no pulmonary infiltrate. Enteral hydroxychloroquine 800 mg once followed by 400 mg daily in combination with ribavirin 400 mg three times a day were initiated.
Follow-Up and Outcomes
His abdominal pain improved and bloody diarrhea stopped within the next 48 h. His hemoglobin and hematocrit had been stable. Therefore, endoscopic examination was not performed during this admission. On hospital day 5, CT angiogram of abdomen and pelvic with intravenous contrast was performed which did not reveal evidence of vascular abnormality but demonstrated improvement of colitis. His two sets of nasopharyngeal swabs collected for COVID-19 PCR were not detected on hospital day 6 and 7 consecutively. The patient was discharged on hospital day 7 after he completed a 5-day course of hydroxychloroquine and ribavirin with a satisfactory response in both clinical and laboratory findings.