Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis

Abstract

Background: Since its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery. Case presentation: A 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination. Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder. The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4)

Necrotising Vasculitis in Covid-19: watch out for bowel perforation

“…We, here, describe a possible critical complication of the still largely unknown disease related to SARS-CoV-2 infection. Many Covid 19 patients presents GI symptoms together with respiratory ones (2,5).…”

“…The most common SARS-CoV-2 infection symptoms are fever followed by dry cough, shortness of breathing, dyspnoea, chest pain, fatigue, intense myalgia and, sometimes, severe acute respiratory failure often complicated by shock [1]. Less commonly, patients present abdominal pain, diarrhoea, nausea and vomiting, cholestatic jaundice [2]. We here report the rst case, to our knowledge, of a Covid-19 patient affected by right colon perforation, needing urgent surgery, due to a necrotizing vasculitis leading to pseudomembranous colitis in absence of Clostridium Di cile toxins nding, but with SARS-Cov-2 identi cation in gastric uid.…”

Histopathological findings in COVID-19 cases: A Systematic Review

“…The copyright holder for this preprint this version posted October 14, 2020. ; https://doi.org/10.1101/2020.10.11.20210849 doi: medRxiv preprint 44-46, 48-52, 54, 63, 65, 66) , Liver in 21 articles (19, 20, 23, 24, 26, 28, 29, 31, 41, 44, 45, 48-52, 54, 61-63, 65) , Kidney in 16 articles, (20, 23, 27-29, 31, 46, 48-52, 54, 56, 65, 67) spleen and lymph nodes in 12 articles, (20,28,29,31,33,38,49,50,52,54,56) CNS in 7 articles, (19,29,45,47,51,54,64) Skin in 2 articles (43,53) gall bladder (1 article), (42) Pharynx (1 article). (50)…”

“…In the one article that described gall bladder postmortem pathology, inflammatory infiltration and endoluminal obliteration of vessels with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy were reported in one case report. (42) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.…”

COVID-19 can mimic acute cholecystitis and is associated with the presence of viral RNA in the gallbladder wall

“…5 COVID-19related acalculous cholecystitis has been described in 2 case reports and was managed with surgery or gallbladder percutaneous drainage. 6,7 Ying et al performed RT-PCR of the bile after percutaneous drainage of the gallbladder in a patient with sludge and acute cholecystitis but did not detect SARS-CoV-2. 8 Gallbladder epithelial cells are very similar to bile duct cells, express ACE2 and could be a target for SARS-CoV-2.…”