Introduction: In December 2019, a novel coronavirus was identified known as acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resulting disease called coronavirus disease 2019 (COVID-19). The majority of patients with COVID-19 primarily present to the hospital with respiratory symptoms, it is particularly important that physicians are familiar with rare extrapulmonary manifestations in the effort to reduce the delay of diagnosis, treatment and exposure to healthcare workers.

Case Description

Methods: An 80-year-old Caucasian woman with a history of hypertension, hyperlipidemia and hypothyroidism presented to the ER with 5-days of fever, abdominal discomfort, nausea, diarrhea and hematochezia. The patient denied symptoms of chills, shortness of breath, cough, recent travel or ill-contacts, including exposure to COVID-19. Physical examination revealed a temperature of 100.6 F, a blood pressure of 130/65 mmHg, pulse of 83 bpm, respiratory rate of 15 bpm, and oxygen saturation of 96%. Lung auscultation was clear bilaterally. Abdominal examination revealed a soft abdomen, with positive bowel sounds and tenderness in the lower abdominal quadrants. Rectal exam was positive for bright red blood. A computed tomography (CT) scan of the abdomen revealed thickening of the descending colon with fat stranding- suggestive of an acute colitis (Figure 1).

Outpatient colonoscopy completed 3 years prior, was normal. A white-blood count (WBC) of 6.4 K/uL. Liver function tests, lactic acid, lactic acid dehydrogenase (LDH) and coagulation profile were normal. C. difficile and influenza A and B testing were negative. COVID-19 RT-PCR testing returned positive.
Rectal bleeding and diarrhea resolved and hemoglobin remained stable. Empiric antibiotic therapy and supportive measures were continued. In the setting of an active colitis, colonoscopy was deferred to the outpatient setting. The patient was discharged home with 10 days of metronidazole therapy and instructed to continue 14 days of home self-isolation.

Discussion: This case report highlights the significance of limiting fecal-oral transmission along with adding to the body of evidence that SARS-CoV-2 has the potential to directly infect the gastrointestinal tract in the absence of pulmonary involvement. With mounting evidence, we underline the importance of instituting appropriate precautions in patients who present with respiratory, digestive or other rare clinical presentations.