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Citation: Castellanos Aguilar L, Jaimes Duran EM, Heras Lorenzana R. Caecum perforation and SARS COV-2 infection: More than association?
Jr.med.res.2021;4(1): 13-15. Aguilar et al © All rights are reserved. https://doi.org/10.32512/jmr.4.1.2021/13.15
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Case report
Castellanos Aguilar Leonel
1*
, Jaimes Duran Edwing Michel
1
, Heras Lorenzana Roberto
1
.
Caecum perforation and SARS COV-2 infection: More than association?
1: Department of general Surgery,
Central Norte Pemex Hospital, Mexico
* Corresponding author
Correspondence to:
Leocastellanos92@gmail.com
Publication Data:
Submitted: March14,2021
Accepted: May 11,2021
Online: May 30,2021
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Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection is a worldwide
pandemic involving more than 150 million people. The coronavirus disease 2019 (COVID-
19) predominantly presents as a respiratory tract infection that may lead to acute
respiratory distress. Gastrointestinal (GI) manifestations have been reported in several
Chinese studies about SARS COV-2 infection. The most frequently reported GI symptoms
are nausea, vomiting, diarrhea, and abdominal pain [1]. Bowel perforation was rarely
reported in less than 20 cases [2]. We herein report the case of caecum perforation in
severely infected female patient.
Keywords:
SARS COV-2; Colon perforation; Intensive care.
Introduction
The GI perforation in critically ill patients was described and classified before the outbreak of
the COVID-19 pandemic as one of the complications of long intensive care unit management
[2]. However, a possible direct action of the virus on the digestive tract has been proved. The
presence of viral materials in the feces and receptors similarities that allow the virus to bind the
enterocyte surface could be arguments of some direct interference of the disease with severe
GI presentations [3].
Observation
A 48-year-old female obese patient presented to the emergency department (ED) for
headache, fever and myalgias of six days evolution. On the examination the patient was
vitally stable with mild tachypnea and desaturation. Nasopharyngeal swab tested positive
for SARS-CoV-2 polymerase chain reaction (PCR).
The patient was hospitalized, and treatment was started according to the local protocol.
During her hospitalization, she presented gradual respiratory deterioration and was shifted
to ICU, intubated, and mechanically ventilated. Diarrheal evacuations were noted, and the
patient was kept on parenteral nutrition. Respiratory improvement allowed gradual
sedation to decrease, and the patient was extubated two days later. Oral diet was started
with acceptable tolerance and patient was candidate for discharge.
However, she presented suddenly with acute abdomen and hemodynamic deterioration.
Computed tomography (CT) of the abdomen and pelvis confirmed acute peritonitis and
bowel perforation. The patient underwent emergency laparotomy. The findings were in
favor of fecal peritonitis due to a large 4cm perforation the caecum wall (figure1).
Peritoneal lavage, hemicolectomy and, ileocolostomy were performed. The postoperative
course was marked by persistent and severe septic shock which led to death on the fourth
postoperative day. The histopathological examination of the colon specimen was in favor
of ischemic enterocolitis and ileum lymphoid sinusoidal hyperplasia (figure2).
Abstract
Caecum perforation and SARS COV-2 infection: More than association?
Citation: Castellanos Aguilar L, Jaimes Duran EM, Heras Lorenzana R. Caecum perforation and SARS COV-2 infection: More than association?
Jr.med.res.2021;4(1): 13-15. Aguilar et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
14
Figure 1: CT abdomen showing right paracolic gutter and pelvic collections with extra-digestive free air.
a b c
Figure 2: histopathological examination findings
a: large perforation in the posterolateral caecum wall
b,c: ischemic mucosal features with vascular congestion and neutrophilic infiltration of the submucosa, and eosinophilia of the muscularis propria (HE, 4x).
Discussion
The GI manifestations are the most frequently reported extra-pulmonary manifestations of COVID-19 disease. It
has been reported that found that 17.6% cases had digestive symptoms. Virus RNA was detected in stool samples
from 48.1% patients, even those tested negatives for respiratory samples [3]. Acute surgical abdomen due to
bowel perforation was usually fatal in the previously reported cases. Considered first as associated, GI symptoms
have been confirmed as the result of direct interaction between the coronavirus and the digestive tract. The
receptor for Angiotensin Converting Enzyme 2 (ECA2) and proteases of endogenous serine may allow virus fixation
to the enterocyte membranes and its infection [4]. However, the severity of GI symptoms was never correlated
the viral load suggesting a multifactorial phenomenon that may lead to severe complications specially bowel
perforation [5]. COVID-19 ischemic colitis is characterized by transmural inflammatory infiltration. It may be the
result of extended colonic pseudo-obstruction (Ogilvie syndrome). Most of the reported cases were associated with
extended pulmonary
Caecum perforation and SARS COV-2 infection: More than association?
Citation: Castellanos Aguilar L, Jaimes Duran EM, Heras Lorenzana R. Caecum perforation and SARS COV-2 infection: More than association?
Jr.med.res.2021;4(1): 13-15. Aguilar et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
pulmonary lesions and hypercoagulability. Intramural thrombi formation affects the parietal blood supply and may
constitute the primum movens of the ischemic process. Mesenteric and portal vein thrombosis might contribute to GI
lesions in some cases. Ischemic bowel wall further induces a massive spread of the viruses [6,7]. Some other authors
suggested an indirect effect of the immunomodulation created by the long steroid and anti-interleukin6 receptor
monoclonal antibodies treatment used worldwide in the treatment of this disease [8,9]. Spontaneous stercoral or
idiopathic perforation colonic injury are also to be discussed. However, the perforation mechanisms might be more
complex and involve underlaying personal factors in some reported cases. The direct mediation of the virus seems to
be plausible but needs more investigation to be confirmed.
15
Conflict of Interest: None
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