Case Report
A 42-year-old gentleman with no past medical history admitted to our intensive care unit (ICU) with a laboratory-confirmed case of COVID-19, requiring non-invasive ventilation (NIV). He developed spontaneous pneumothorax, for which chest drain placed. One day after his admission he was intubated and pronned for deterioration of his oxygen levels and PaO2/FiO2 ratios (Figure 1 ). For possible cytokine storm in view of high ferritin levels and persistent fever patient received IL-6 inhibitor (Tocilizumab 400 mg Once) 3 days after admission to ICU.
His course was complicated by upper gastrointestinal bleeding (melena) with a drop in hemoglobin by one gram on day nine, Gastroenterology team managed him conservatively, as the melena subsided. Almost 22 days after admission, he re-developed bleeding per rectum again (hematochezia), with a drop in hemoglobin from 9 gm/dl to 6 gm/dl, this time he was hemodynamically unstable, requiring nor adrenaline vasopressor support and multiple blood product transfusions. Esophagogastroduodenoscopy did not show active bleeding or altered blood from upper esophageal sphincter to level-D3 part of the duodenum, and only clear biliary secretions were found.
Colonoscopy performed with a difficulty till the splenic flexure, the colon was filled with blood clots and fresh bleed was noted around the colon circumferentially and the scope could not be passed further due to poor visibility due to blood clots, the procedure was abandoned, hemostasis not achieved due to not identifiable active bleeder.
A computed tomography (CT) angiogram was done for identifying the cause of bleeding and for possible angioembolization. No bleeder could be identified, and the only positive finding was mural thickening with intramural axial hemorrhage involving the splenic flexure and proximal part of the descending colon (Figure 2 ). In view of hemodynamical instability, a team of multi-disciplinary surgeons decided to take him for lifesaving emergency laparotomy.
A small bowel enterotomy was done at the suspicious site of bleeding; GI team passed the colonoscope to locate bleeding; no evidence of bleed found up to three meters of small bowel and enterotomy closed. Left hemicolectomy was done in view of the high suspicious site of bleeding at the splenic flexure, both the loops of large bowel brought out as functional transverse colon and descending mucous fistula as double-barrel stoma performed. Histopathology report confirmed CMV colitis with colonic perforation, for which he was started on Ganciclovir therapy 220 mg once daily for 4 days. Intime recognition and timely performance of life-saving surgery helped our patient survival; we continued for ganciclovir 440 mg every 12 hours for a total of 3 weeks, the patient has been tracheostomized and stepped down to the inpatient ward with a functional colostomy.