S1705 A Rare Case of Bowel Perforation in a SARS-CoV-2 Patient

INTRODUCTION: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) patients commonly present with respiratory symptoms;however, the incidence of gastrointestinal symptoms is rising We submit a case of cecal perforation in a SARS-CoV-2 infected patient, highlighting a lifethreatening complication of the virus CASE DESCRIPTION/METHODS: A 65-year-old with past medical history of atrial fibrillation on anticoagulation presents with fever and dyspnea Initial observation showed an obese male on supplemental oxygen, with a benign abdominal exam He tested SARS-CoV-2 positive and began Remdesivir therapy While hospitalized, he had regular bowel movements but worsening abdominal distension and tenderness to palpation CT of the abdomen revealed peritoneal free air signifying bowel perforation (Figure 1), which required emergent exploratory laparotomy and a right hemicolectomy Biopsy of the perforation site showed acute inflammation and vascular congestion (Figure 2B) After an uneventful postoperative period, he was discharged DISCUSSION: SARS-CoV-2 infection often arises with respiratory symptoms However, as the pandemic ensues, gastrointestinal symptoms(GI) such as vomiting, abdominal pain and diarrhea, are emerging Our case examines bowel perforation in a SARS-CoV-2 infected patient The virus downregulates expression of the Angiotensin converting enzyme 2 (ACE2), found most abundantly in lung, intestinal and vascular tissue Suppression in the intestinal tissue may cause an inflammatory response, thereby weakening the intestinal wall leading to bowel perforation Similarly, the virus may induce complement-mediated inflammatory damage to the vascular endothelium and systemic coagulopathy causing vascular and microvascular thrombi formation We postulate that by these mechanisms, SARS-CoV-2 begets intestinal ischemia and eventual bowel perforation Our case also highlights a significant clinical issue regarding Remdesivir In vitro, it inhibits Multi drug resistance associated protein 4 (MRP4), which partakes in cell proliferation This may lead to reduced integrity of the epithelial barrier, causing bowel perforation Further studies to elicit the adverse effects of Remdesivir are warranted With few reports of bowel perforation in SARS-CoV-2 patients, our case magnifies potential GI symptoms and complications of this novel virus Moreover, with growing Remdesivir use as a SARS-CoV-2 therapy, it is Vital to investigate its adverse effects (Figure Presented)