Occult Colonic Perforation in a Patient With Coronavirus Disease 2019 After Interleukin-6 Receptor Antagonist Therapy

Abstract

Interleukin-6 blockade (IL-6) has become a focus of therapeutic investigation for the coronavirus-2019 (COVID-19). We report a case of a 34 year-old with COVID-19 pneumonia receiving an IL-6 receptor antagonist (IL-6Ra) who developed spontaneous colonic perforation. This perforation occurred despite a benign abdominal exam and in the absence of other known risk factors associated with colonic perforation. Examination of the colon by electron microscopy revealed numerous intact SARS-CoV-2 virions abutting the microvilli of the colonic mucosa. Multiplex immunofluorescent staining revealed the presence of the SARS-CoV-2 spike protein on the brush borders of colonic enterocytes which expressed angiotensin-converting enzyme 2. However, no viral particles were observed within the enterocytes to suggest direct viral injury as the cause of colonic perforation. These data and absence of known risk factors for spontaneous colonic perforation implicate IL-6Ra therapy as the potential mediator of colonic injury in this case. Furthermore, this report provides the first in situ visual evidence of the virus in the colon of a patient presenting with colonic perforation adding to growing evidence that intact infectious virus can be present in the stool.

Colonic perforation in 91- year- old man with severe Covid-19 infection

“…He got occult colonic perforation following interleukin -6 receptor antagonist therapy. They identifi ed SARS-CoV-2 virions in the colon by electron microscopy [8]. In their description, abdominal examination did not reveal features of peritonitis i.e., similar to initial fi ndings of our case.…”

Large intestinal perforation secondary to COVID-19: A case report

“…Both patients underwent right hemicolectomy, and one of them required ileostomy. However, both patients survived [16] , [17] . Corrêa et al describe an 80-year-old patient with COVID-19 who presented with acute respiratory and gastrointestinal manifestations.…”

“…Treatment in these cases must be surgical. Most of the reported cases of colonic perforation in critically ill patients with COVID-19 have been managed with colectomy [14] , [15] , [16] , [17] , [18] . De Nardi et al reported a 53-year-old patient with COVID-19 infection who had a perforation in the ascending colon during his hospitalization.…”

Colon perforation as a complication of COVID-19: a case report

“…The cause of colonic perforation varies, including colonic pseudo-obstruction, diverticulitis, stercoral perforation and medication-induced perforation. In COVID-19 cases, colonic perforation caused by interleukin-6 receptor antagonist therapy was also reported [ 14 ]. However, in the present case, these causes were unlikely based on the radiological and surgical findings.…”