Abstract:A 73-year-old man with significant medical history including renal transplantation and chronic immunosuppression presented to the hospital with acute respiratory failure. His initial treatment included steroids for concern for Pneumocystis jiroveci pneumonia, although this was later excluded as the diagnosis. The patient’s illness was consistent with COVID-19; however, he was not diagnosed with the virus until late in his course. The patient was found to have pneumatosis intestinalis that was successfully mana… Show more
“…Pneumoperitoneum, pneumoretroperitoneum, or gas inclusions can be present in the portal vein [5] , [6] , [7] , [8] . The pathophysiology of PI is still unknown, but a variety of theories have been proposed: the mechanical theory (increase of intraluminal pressure causing mechanical damage), pulmonary theory (alveolar rupture due to chronic lung disease causing release of gas along the aorta and mesenteric arteries and into the intestinal wall), and bacterial theory (aerogenic bacteria penetrating the mucosal barrier and producing gas) [ 1 , 3 , 4 , 6 ]. We have listed the diseases and conditions that most strongly predispose patients to PI using the acronym “TRAPInG” ( Fig 6 ): T ransplantation (eg, bone marrow, solid organs, graft vs host) R elated to medications (eg, corticosteroids, chemotherapeutic agents) A utoimmune (eg, lupus) P ulmonary (eg, asthma, chronic obstructive pulmonary disease) I nfectious (eg, human immunodeficiency virus, cytomegalovirus, COVID-19) I atrogenic (eg, endoscopy, barotrauma) I diopathic G astrointestinal (inflammatory bowel disease, colitis, diverticulitis) Fig 6 TRAPInG acronym, based on Khalid et al [1] …”
Section: Discussionmentioning
confidence: 99%
“…PI is usually asymptomatic, with a clinical spectrum raging from benign to life-threatening. The most common symptoms include mild abdominal pain, nausea, vomiting, and diarrhea [ [1] , [2] , [3] , [4] , 7 , 9 , 10 , 11 , 13 , 14 ]. The life-threatening forms are related to mesenteric ischemia, bowel obstruction, and necrosis [ 4 , 6 , 10 ].…”
Section: Discussionmentioning
confidence: 99%
“…Among adults it is only occasionally seen and, when present, is associated with conditions including infectious diseases (cytomegalovirus, human immunodeficiency virus, Mycobacterium tuberculosis), pulmonary diseases (chronic obstructive pulmonary disease, pulmonary fibrosis), and gastrointestinal diseases (inflammatory bowel disease, toxic megacolon) [ 1 , 2 ]. Patients who have undergone immunosuppression after solid organ transplantation, especially with glucocorticoids, are predisposed to PI [3] . Despite having been described for the first time in 1730 by DuVernoi in an autopsy report, there are no conclusive guidelines for diagnosing and treating PI [ 1 , 4 ].…”
Section: Introductionmentioning
confidence: 99%
“…In most cases it is asymptomatic and diagnosed accidentally during imaging studies such as a computed tomography scan [5] , [6] , [7] , [8] . The symptoms can vary from mild abdominal pain, nausea, and vomiting to features of peritonitis due to bowel perforation [ [1] , [2] , [3] , [4] , 7 , 9 , 10 , 11 , 13 , 14 ]. The most common treatment is conservative: nihil per os, total parenteral nutrition, empirical antibiotics, and hyperbaric oxygen.…”
Section: Introductionmentioning
confidence: 99%
“…The most common treatment is conservative: nihil per os, total parenteral nutrition, empirical antibiotics, and hyperbaric oxygen. In a few reported cases the treatment of choice was surgical because of peritonitis symptoms [ 3 , 7 , 10 , 12 , 15 ].…”
Background
Pneumatosis intestinalis (PI) is a rare condition usually occurring among adults who have undergone solid organ transplant and are taking steroid therapy. The coronavirus disease 2019 (COVID-19) virus uses angiotensin-converting enzyme 2 in gastrointestinal epithelium as a receptor for entry process. Due to the steroid intake, the COVID-19 virus is present in the patient's gastrointestinal tract for extended period of time. It may therefore increase the possibility of PI in such patients. It is usually asymptomatic, with a clinical spectrum ranging from indolent to life-threatening. Unfortunately, there are no algorithms concerning diagnosis and treatment of PI.
Aim of study
The aim of this study is to highlight the problem of PI induced by COVID-19, especially in high-risk groups such as solid organs recipients.
Conclusion
On the basis of the presented case of a severe course of COVID-19–induced PI, we conclude that laparotomy with bowel resection can be a feasible and a safe option for treatment.
“…Pneumoperitoneum, pneumoretroperitoneum, or gas inclusions can be present in the portal vein [5] , [6] , [7] , [8] . The pathophysiology of PI is still unknown, but a variety of theories have been proposed: the mechanical theory (increase of intraluminal pressure causing mechanical damage), pulmonary theory (alveolar rupture due to chronic lung disease causing release of gas along the aorta and mesenteric arteries and into the intestinal wall), and bacterial theory (aerogenic bacteria penetrating the mucosal barrier and producing gas) [ 1 , 3 , 4 , 6 ]. We have listed the diseases and conditions that most strongly predispose patients to PI using the acronym “TRAPInG” ( Fig 6 ): T ransplantation (eg, bone marrow, solid organs, graft vs host) R elated to medications (eg, corticosteroids, chemotherapeutic agents) A utoimmune (eg, lupus) P ulmonary (eg, asthma, chronic obstructive pulmonary disease) I nfectious (eg, human immunodeficiency virus, cytomegalovirus, COVID-19) I atrogenic (eg, endoscopy, barotrauma) I diopathic G astrointestinal (inflammatory bowel disease, colitis, diverticulitis) Fig 6 TRAPInG acronym, based on Khalid et al [1] …”
Section: Discussionmentioning
confidence: 99%
“…PI is usually asymptomatic, with a clinical spectrum raging from benign to life-threatening. The most common symptoms include mild abdominal pain, nausea, vomiting, and diarrhea [ [1] , [2] , [3] , [4] , 7 , 9 , 10 , 11 , 13 , 14 ]. The life-threatening forms are related to mesenteric ischemia, bowel obstruction, and necrosis [ 4 , 6 , 10 ].…”
Section: Discussionmentioning
confidence: 99%
“…Among adults it is only occasionally seen and, when present, is associated with conditions including infectious diseases (cytomegalovirus, human immunodeficiency virus, Mycobacterium tuberculosis), pulmonary diseases (chronic obstructive pulmonary disease, pulmonary fibrosis), and gastrointestinal diseases (inflammatory bowel disease, toxic megacolon) [ 1 , 2 ]. Patients who have undergone immunosuppression after solid organ transplantation, especially with glucocorticoids, are predisposed to PI [3] . Despite having been described for the first time in 1730 by DuVernoi in an autopsy report, there are no conclusive guidelines for diagnosing and treating PI [ 1 , 4 ].…”
Section: Introductionmentioning
confidence: 99%
“…In most cases it is asymptomatic and diagnosed accidentally during imaging studies such as a computed tomography scan [5] , [6] , [7] , [8] . The symptoms can vary from mild abdominal pain, nausea, and vomiting to features of peritonitis due to bowel perforation [ [1] , [2] , [3] , [4] , 7 , 9 , 10 , 11 , 13 , 14 ]. The most common treatment is conservative: nihil per os, total parenteral nutrition, empirical antibiotics, and hyperbaric oxygen.…”
Section: Introductionmentioning
confidence: 99%
“…The most common treatment is conservative: nihil per os, total parenteral nutrition, empirical antibiotics, and hyperbaric oxygen. In a few reported cases the treatment of choice was surgical because of peritonitis symptoms [ 3 , 7 , 10 , 12 , 15 ].…”
Background
Pneumatosis intestinalis (PI) is a rare condition usually occurring among adults who have undergone solid organ transplant and are taking steroid therapy. The coronavirus disease 2019 (COVID-19) virus uses angiotensin-converting enzyme 2 in gastrointestinal epithelium as a receptor for entry process. Due to the steroid intake, the COVID-19 virus is present in the patient's gastrointestinal tract for extended period of time. It may therefore increase the possibility of PI in such patients. It is usually asymptomatic, with a clinical spectrum ranging from indolent to life-threatening. Unfortunately, there are no algorithms concerning diagnosis and treatment of PI.
Aim of study
The aim of this study is to highlight the problem of PI induced by COVID-19, especially in high-risk groups such as solid organs recipients.
Conclusion
On the basis of the presented case of a severe course of COVID-19–induced PI, we conclude that laparotomy with bowel resection can be a feasible and a safe option for treatment.
Multiple drugs Pneumatosis intestinalis: case report A 73-year-old man developed pneumatosis intestinalis (PI) during immunosuppressive treatment with prednisone and mycophenolate mofetil and antibacterial treatment with vancomycin, azithromycin and piperacillin/tazobactam for bacterial pneumonia [routes not stated, not all dosages stated]. The man with end-stage renal disease underwent deceased donor renal transplant in 2013. Thereafter, he started receiving immunosuppressive maintenance therapy with tacrolimus, prednisone and mycophenolate mofetil. Mycophenolate mofetil was later discontinued and dose of prednisone was increased. On 15 February 2020, he presented with shortness of breath to an outside hospital. On presentation, he was afebrile, hypertensive and tachypnoeic. He was clinically fluid overloaded and in atrial fibrillation with rapid ventricular response. He also had an acute kidney injury. On admission, a chest X-ray revealed bilateral interstitial opacities, suggesting multifocal pneumonia. Laboratory test showed white cell count (WCC) 16.7 k/mm 3 , LDH 525 U/L and ALT 34 U/L. He was admitted to the ICU and was intubated on day 2 of admission for acute respiratory failure. As per the outside hospital records, he was treated for a provisional diagnosis of Pneumocystis jiroveci pneumonia (PJP). Though, he was on chronic immunosuppression and his findings of bilateral interstitial opacities were consistent with multifocal pneumonia. Initially, he was started on cotrimoxazole [trimethoprim/sulfamethoxazole], which was quickly switched to clindamycin and primaquine due to hyperkalaemia. Additionally, he was started on high dose prednisone with taper as part of PJP treatment protocol. PJP polymerase chain reaction (PCR) tested negative. Subsequently, the presumptive diagnosis of PJP was changed to bacterial pneumonia. He was started on broad spectrum antibiotics, which included vancomycin, azithromycin and piperacillin/tazobactam for bacterial pneumonia. On 18 February 2020, a transoesophageal echocardiogram was negative for endocarditis and valvular dysfunction. Ventilator requirements increased. Serial chest X-ray findings were concerning for multifocal pneumonia and suggestive of acute respiratory distress syndrome (ARDS). On 26 February 2020, a CT scan of the chest, abdomen and pelvis confirmed diffuse lung opacities and small pleural effusions with no intra-abdominal findings. The presumptive diagnosis of bacterial pneumonia remained and he completed an extended course of antibiotics. On 02 March 2020, he was finally extubated. His remainder course was uncomplicated. He was discharged to inpatient rehabilitation facility (IRF). On 04 March 2020, the level ferritin was 966 ng/mL. No other inflammatory markers were obtained throughout the duration of the his stay. On arrival at the IRF, he was afebrile and hypertensive. He had a regular HR and RR with appropriate oxygen saturation on room air. Laboratory test showed WCC was 12.6 k/mm 3 , normal ALT and elevated ferritin. On day 9, LDH and CRP were sl...
Severe acute respiratory virus syndrome 2 (SARS-CoV-2) has led to a worldwide pandemic. Early studies in solid organ transplant (SOT) recipients suggested a wide variety of presentations, however, there remains a paucity of robust data in this population. We conducted a systematic review and meta-analysis of SOT recipients with SARS-CoV-2 infection from January 1
st
t October 9
th
, 2020. Pooled incidence of symptoms, treatments and outcomes were assessed. Two hundred and fifteen studies were included for systematic review and 60 for meta-analysis. We identified 2,772 unique SOT recipients including 1,500 kidney, 505 liver, 141 heart and 97 lung. Most common presenting symptoms were fever and cough in 70.2% and 63.8% respectively. Majority (81%) required hospital admission. Immunosuppressive medications, especially antimetabolites, were decreased in 76.2%. Hydroxychloroquine and interleukin six antagonists were administered in59.5% and 14.9% respectively, while only few patients received remdesivir and convalescent plasma. Intensive care unit admission was 29% from amongst hospitalized patients. Only few studies reported secondary infections. Overall mortality was 18.6%. Our analysis shows a high incidence of hospital admission in SOT recipients with SARS-CoV-2 infection. As management of SARS-CoV-2 continues to evolve, long-term outcomes among SOT recipients should be assessed in future studies.
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