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Occult colonic perforation in a patient with COVID-19 following interleukin-6 receptor antagonist therapy

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

Online: https://academic.oup.com/ofid/advance-article/doi/10.1093/ofid/ofaa424/5904997

Issue: Open Forum Infect Dis . 2020 Sep 12;7(11):ofaa424.


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.