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.