S2538 Pneumatosis With Hepatic Portal Venous Gas in COVID-19

INTRODUCTION: Hepatic portal venous gas (HPVG) historically has been known to be an ominous sign in patients with acute abdominal pathology including necrotizing enterocolitis and pneumatosis intestinalis, which prompt urgent surgical intervention as the underlying etiologies carry a mortality of greater than 75% However, with advancements in diagnostic imaging modalities, recent studies suggest a mortality rate of 25-35% due to increased awareness of benign causes Here we report a rare presentation of HPVG in the setting of acute COVID-19 infection CASE DESCRIPTION/METHODS: A 42-year-old male with type 1 diabetes mellitus and end stage renal disease (with pancreatic and renal transplants), presents with a 4-day history of abdominal pain, nausea, nonbloody/nonbilious vomiting, and nonbloody loose stools Patient was afebrile, tachycardic, and hypotensive (73/41 mmHg) on arrival Lab work revealed lymphocytopenia with an absolute lymphocyte count of 610 cells/μL, contraction alkalosis with severe electrolyte derangement (Na 123, K 2 1, Cl 45), serum lactate of 6 9 mmol/L, ferritin 4202 ng/mL, CRP 2 51 mg/dL, and D-dimer 230 ng/mL CT abdomen and pelvis revealed a right middle lobe ground glass opacity suspicious for COVID-19 infection, along with gastric pneumatosis with severe extensive HPVG (image 1 and image 2) COVID-19 PCR nasopharyngeal swab was positive Rapid viral panel via PCR, stool culture, and Clostridium difficile toxin PCR were negative The patient received fluids and antibiotics Laparotomy was deferred to assess for any interval clinical improvement On hospital day 2, repeat CT abdomen and pelvis revealed gastroenterocolitis with complete resolution of pneumatosis and portal venous gas and no evidence of active GI bleeding (image 3) He was discharged on day 5 with resolution of electrolyte derangements and symptom improvement DISCUSSION: Although there have been increasing numerous benign causes of HPVG such as following endoscopic procedures, hepatic transplantation, and viral gastroenteritis, not much is known about HPVG in the setting of COVID-19 This case is one of two known cases of COVID-19 induced pneumatosis, and the only known case complicated by transient HPVG It highlights the importance of gastrointestinal complications of COVID-19, as it is not limited to predominantly respiratory symptoms It is important to note that both cases of COVID-19 induced pneumatosis were successfully treated with bowel rest, adequate hydration, and intravenous antibiotics