S2438 COVID-19: A Potential Trigger for Inflammatory Bowel Disease?

Introduction: Coronavirus Disease 2019 (COVID-19) has been shown to infect gastrointestinal tissues, and a wide variety of gastrointestinal manifestations have been described including alterations in the composition of the intestinal microbiome. Microbiome changes have been implicated in the pathogenesis of inflammatory bowel disease (IBD), but a clear relationship between viral infection and IBD has not been established. Case description/methods: Case 1 A 45-year-old woman presented to clinic with painless hematochezia and fecal urgency 2 weeks after developing anosmia and being diagnosed with COVID-19. She had a history of constipation but no other gastrointestinal problems. Her vital signs were normal and her exam was unremarkable. Her labs showed iron deficiency anemia with hemoglobin 10.2 and ferritin <2. Colonoscopy showed 10cm of moderately friable rectal mucosa with erosions and loss of vascular pattern. Rectal pathology showed chronic active proctitis. She was diagnosed with ulcerative proctitis and treated with mesalamine suppositories with resolution of her symptoms. Case 2 A 48- year-old woman was admitted for five months of watery, bloody bowel movements that developed after an initial hospitalization for COVID-19 pneumonia. She reported 10-15 bowel movements daily, diffuse abdominal pain, nausea, and 10kg weight loss. She was initially diagnosed with C. difficile at another hospital but her symptoms did not improve with oral vancomycin. She was mildly tachycardic, but her exam was otherwise unremarkable. Labs showed hemoglobin 6.7, CRP 6.9, ESR 50, and fecal calprotectin 1880. C. difficile testing was negative. Colonoscopy showed pancolitis with moderate inflammation, edema, erosions, erythema, and friability most severe in the distal colon with ileal sparing. Pathology showed crypt architectural distortion and branching with cryptitis and crypt abscesses consistent with ulcerative colitis. After not responding to prednisone, she achieved clinical remission with infliximab. Discussion: Prior research has described the role of abnormal immune response to intestinal microbiota in the pathogenesis of IBD. Some studies have found an increased risk of IBD after infectious gastroenteritis, but no specific causal link has been demonstrated and the role of specific infections in the development of the dysregulated immune response is incompletely understood. These cases of new ulcerative colitis diagnosed after COVID-19 infection have implications for understanding potential viral triggers of IBD.