A case report published in the Journal of the Royal College of Physicians of Edinburgh details a middle-aged woman with underlying ulcerative colitis and paroxysmal nocturnal hemoglobinuria (PNH) who was diagnosed with mesenteric ischemia secondary to COVID-19 infection.
The 47-year-old woman, who had underlying ulcerative colitis and PNH since 2017, presented with a 1-day history of fever, followed by severe abdominal pain 3 days later.
Her initial diagnosis of PNH was made after clinical investigations were initiated due to anemia and extrahepatic portal venous obstruction; upon diagnosis, she received danazol 200 mg/day and subcutaneous low molecular weight heparin 60 mg/day. As for her ulcerative colitis, she was prescribed oral mesalamine 4.8 g/day. Both of these conditions were well-controlled.
Read more about PNH etiology
Her presentation of fever during the COVID-19 pandemic prompted her physicians to carry out a COVID-19 reverse transcriptase polymerase chain reaction (RT-PCR) test, which returned positive. The patient was not in respiratory distress and did not require breathing support. Further history-taking revealed that her abdominal pain was associated with bilious vomiting, abdominal distention, and obstipation.
Laboratory investigations revealed that her leucocyte count was 4500/mm3 and her C-reactive protein was 86 mg/dL. Fecal calprotectin was 72 mcg/g.
An abdominal computed tomography (CT) carried out on the 4th day of illness revealed segmental bowel wall thickening in the proximal and distal ileum; in addition, dilated small bowel loops with mesenteric stranding and ascites were observed.
This prompted her surgeons to carry out an explorative laparotomy. The surgeons found 2 gangrenous bowel segments—in the proximal and the distal ileum. They performed a resection of the proximal gangrenous bowel segment, as well as a resection and anastomosis of the distal gangrenous bowel segments. An end ileostomy with distal mucosal fistula was performed.
The extracted specimen was sent for histopathological testing; this revealed transmural acute hemorrhagic necrosis with a number of venous thrombi. The mesentery had thrombosed vessels with hemorrhage.
The patient was discharged 12 days after the surgery. Three months later, her bowel continuity was restored and she remained well on follow-up.
“The case is reported for the fact that the occurrence of COVID-19 tilted the balance (even with prophylactic anticoagulation) towards a prothrombotic state,” the authors of the study wrote.
Choudhury A, Sundaram M, Luwang TT, Singh H, Sharma V. COVID induced mesenteric ischemia in a patient having ulcerative colitis and paroxysmal nocturnal haemoglobinuria in spite of thromboprophylaxis. J R Coll Physicians Edinb. Published online January 26, 2023. doi:10.1177/14782715221148642