Occult Colonic Perforation in a Patient With Coronavirus Disease 2019 After Interleukin-6 Receptor Antagonist Therapy

Kristin Schwab; Sepehr Hamidi; Augustine Chung; Raymond J Lim; Negar Khanlou; Daniel Hoesterey; Camelia Dumitras; Oladunni B Adeyiga; Michelle Phan-Tang; Tisha S Wang; Rajan Saggar; Jeffrey Goldstein; John A Belperio; Steven M Dubinett; Jocelyn T Kim; Ramin Salehi-Rad

doi:10.1093/ofid/ofaa424

Occult Colonic Perforation in a Patient With Coronavirus Disease 2019 After Interleukin-6 Receptor Antagonist Therapy

Open Forum Infect Dis. 2020 Sep 12;7(11):ofaa424. doi: 10.1093/ofid/ofaa424. eCollection 2020 Nov.

Authors

Kristin Schwab¹, Sepehr Hamidi², Augustine Chung¹, Raymond J Lim³, Negar Khanlou², Daniel Hoesterey⁴, Camelia Dumitras¹, Oladunni B Adeyiga⁵, Michelle Phan-Tang², Tisha S Wang¹, Rajan Saggar¹, Jeffrey Goldstein², John A Belperio¹, Steven M Dubinett^{1

2

3

6

7}, Jocelyn T Kim⁵, Ramin Salehi-Rad^{1

6}

Affiliations

¹ Division of Pulmonary and Critical Care, Department of Medicine at University of California, Los Angeles, California, USA.
² Department of Pathology and Laboratory Medicine at University of California, Los Angeles, California, USA.
³ Department of Molecular and Medical Pharmacology at University of California, Los Angeles, California, USA.
⁴ Department of Medicine at University of California, Los Angeles, California, USA.
⁵ Division of Infectious Diseases, Department of Medicine at University of California, Los Angeles, California, USA.
⁶ Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.
⁷ Jonsson Comprehensive Cancer Center at University of California, Los Angeles, California, USA.

Abstract

Background: Interleukin-6 blockade (IL-6) has become a focus of therapeutic investigation for the coronavirus disease 2019 (COVID-19).

Methods: We report a case of a 34-year-old with COVID-19 pneumonia receiving an IL-6 receptor antagonist (IL-6Ra) who developed spontaneous colonic perforation. This perforation occurred despite a benign abdominal exam and in the absence of other known risk factors associated with colonic perforation.

Results: Examination of the colon by electron microscopy revealed numerous intact severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virions abutting the microvilli of the colonic mucosa. Multiplex immunofluorescent staining revealed the presence of the SARS-CoV-2 spike protein on the brush borders of colonic enterocytes that expressed angiotensin-converting enzyme 2. However, no viral particles were observed within the enterocytes to suggest direct viral injury as the cause of colonic perforation.

Conclusions: These data and absence of known risk factors for spontaneous colonic perforation implicate IL-6Ra therapy as the potential mediator of colonic injury in this case. Furthermore, this report provides the first in situ visual evidence of the virus in the colon of a patient presenting with colonic perforation adding to growing evidence that intact infectious virus can be present in the stool.

Keywords: coronavirus; electron microscopy; interleukin-6 receptors; intestinal perforation.

Abstract

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