Bowel ischemia as onset of COVID‐19 in otherwise asymptomatic patients with persistently negative swab

Abstract

Background. Asymptomatic patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can develop hypercoagulable conditions and acute vascular events. The objective of this study is to determine whether SARS-CoV-2 was present in resected specimens from patients with acute bowel ischemia, but asymptomatic for Coronavirus Disease 2019 (COVID-19) and with persistently real-time polymerase chain reaction negative pharyngeal swab.Methods. Three consecutive patients presented severe abdominal symptoms due to extensive ischemia and necrosis of the bowel, with coexistent thrombosis of abdominal blood vessels. None had the usual manifestations of COVID-19, and repeated pharyngeal swabs tested negative.They underwent emergency surgery with intestinal resection. Immunohistochemical testing for SARS-CoV-2 on resected tissue was performed.Results. All tested samples were strongly positive for SARS-CoV-2.Conclusions. This is the first case report in which patients with severe intestinal symptoms presented a marked SARS-CoV-2 positivity in the resected tissues, without any usual clinical manifestations of COVID-19. These results suggest that the patients might be infected with SARS-CoV-2 presenting acute abdominal distress but without respiratory or constitutional symptoms.

The Spectrum of Digestive Tract Histopathologic Findings in the Setting of Severe Acute Respiratory Syndrome Coronavirus-2 Infection: What Pathologists Need to Know

“…31 Gross findings include dilation of the colon with some thickening of the wall, hemorrhagic-dusky necrotic appearance of the serosal surface, petechiae, fibrinous exudates, occasional perforations, and air bubbles. 31,36,[45][46][47] Mucosal alterations included edema, patchy petechiae and erythema, occasional bleeding, focal loss of mucosal folds, erosions and areas of ulceration, areas of necrosis with dark-brown discoloration, and fibrinous exudates. 14,31,32,48,49 In about 18.5% of studied cases of ischemic colitis, a colonoscopic examination was essentially normal.…”

“…14,27,29,31,32,36,[45][46][47][48][50][51][52] SARS-CoV-2 has been detected in some cases of ischemic colitis as a cytoplasmic dot-like staining pattern in the surface and crypt epithelial cells as well as in the LP cells of both inflamed and noninflamed colonic mucosa. 14,36,46,47,50 Features suggestive of vascular injury of the colon due to SARS-CoV-2 have been described, including prominent multifocal small and medium-sized vasculitis of the submucosal vessels with bizarre-appearing endothelial cells, luminal obliteration, early thrombi formation, and bleeding into vessel walls. These observations have been confirmed through the detection of SARS-CoV-2 in the cytoplasm of the injured endothelial cells.…”

“…Microscopic evaluation of these cholecystectomy specimens revealed extensive mucosal ulceration, mucosal to transmural necrosis, hemorrhage, widespread fibroblastic proliferation, transmural inflammatory cell infiltrate, vasculitis with thrombosis of medium-sized vessels, hemorrhagic infarction of the gallbladder wall, and hypertrophy of nerve fibers. 46,[90][91][92][93][94] Spontaneous perforation of the gallbladder in the setting of COVID-19 has been described in a case of acute cholecystitis; that showed ischemic mucosal necrosis upon microscopic evaluation of the cholecystectomy specimen. 95 SARS-CoV-2 nucleocapsid protein and RNA were demonstrated in the gallbladder wall in 2 studies, one of which was for 2 COVID-19 patients who presented with features of acute acalculous cholecystitis and had a microscopically uninflamed gallbladder.…”

Intestinal Damage in COVID-19: SARS-CoV-2 Infection and Intestinal Thrombosis

“…The median age of these patients was 50 (20–82) years, 26 (65%) were male, 38 (95%) developed bowel ischemia or necrosis, 30 (75%) needed bowel resection, 7 (17.5%) required no surgery, at least 3 (7.5%) developed sepsis, and 13 (32.5%) died. Other abdominal thrombotic events (such as celiac aortic thrombosis) leading to mesenteric ischemia can also result in severe intestinal necrosis and require intestinal resection ( Zamboni et al, 2021 ).…”

“…Meanwhile, two large randomized controlled trials (RCTs) from the same platform showed that therapeutic anticoagulation reduced mortality in moderate cases but not in severe ones, suggesting that delayed anticoagulant therapy may lead to treatment failure ( REMAP-CAP Investigators et al, 2021a , b ). More importantly, a recent study reported three asymptomatic COVID-19 patients who developed abdominal (or intestinal) thrombosis leading to intestinal necrosis ( Zamboni et al, 2021 ). All these data suggest that antithrombotic therapy should be initiated once COVID-19 is diagnosed (excluding patients with contraindications).…”