https://orcid.org/0000-0002-8077-8175
To the Editors,
We have read with interest the article by Occhipinti and Pastorelli, with particular reference to the management of inflammatory bowel diseases (IBD) relapse during the COVID-19 outbreak.1 Diagnostic challenges may arise in the presence of symptoms that overlap between active IBD and COVID-19, and concerns about the use of immunosuppressive drugs, mainly corticosteroids, which potentially lead to an increased risk for infections.2 Lombardy, in northern Italy where our clinic is located, has been severely hit by COVID-19 since February 2020. We hereby report on a representative case of how COVID-19 has redefined priorities and changed our clinical approach to active IBD patients.
In April 2020, a 29-year-old man with a 1-year history of ulcerative colitis (UC) on maintenance with mesalamine was admitted to our clinic with a 2-week history of fever up to 38.5°C, bloody diarrhea, dry cough, and ageusia. Physical examination revealed tachycardia. Blood tests showed neutrophilia and increased C-reactive protein. Two consecutive nasopharyngeal plus one rectal swabs for SARS-CoV-2 tested negative. A contrast-enhanced chest-abdomen-pelvis CT scan revealed no signs of pneumonia but a widely thickened and hyper-enhancing colonic wall (Fig. 1A). Abdominal imaging and gastrointestinal symptoms were consistent with IBD relapse. However, the persistence of fever, cough, and ageusia made it necessary to definitely rule COVID-19 out. After a multidisciplinary discussion, a bronchoalveolar lavage was performed, which eventually tested negative for SARS-CoV-2. Ileocolonoscopy, performed 2 days later, showed segmental cobblestone appearance and scattered aphthous erosions in the right and left colon (Fig. 1B), as opposed to a relative sparing of the rectum (Fig. 1C). Histological examination was consistent with IBD colitis. A diagnosis of severe flare of IBD-unclassified was made, and corticosteroid therapy was initiated, with the subsequent rapid improvement of both gastrointestinal and respiratory symptoms.
A, CT scan image showing a cross-sectioned descending colon (white arrow) with wall thickening and mucosal hyperenhancement. B, Left-colon image showing mucosal oedema, cobblestone appearance, and aphthous erosions. C, Rectum image showing an endoscopically normal appearance of the mucosa.
Gastrointestinal manifestations have occurred in about half of COVID-19 patients and may precede respiratory symptoms.3 Therefore, the differential diagnosis between IBD relapse and SARS-CoV-2 infection has possibly proved challenging at the peak of the COVID-19 outbreak. Currently, ruling out COVD-19 has become a priority for both clinical and public health reasons, and the timing of endoscopic examination, as well as treatment decisions, closely depend on the COVID-19 diagnostic results.4 Ageusia and anosmia have been reported in about one third of COVID-19 patients,5 whereas they have rarely been observed in IBD patients. Ageusia, as reported by our patient, contributed to increase the suspicion of SARS-CoV-2 infection and made the differential diagnosis trickier.
ACKNOWLEDGMENTS
Marcello Hinxman-Allegri performed the linguistic revision. The patient gave informed consent.
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