CHEARS

As the second wave of COVID-19 recedes, the fatalities are also increasing. An erratic transmission dynamics are observed from first wave to second wave. There has been diverse clinical manifestation for COVID-19 around the world. Blood clotting was observed as both pulmonary and extrapulmonary symptom in affected patients. COVID-19 not only affects lung tissues but also in intestines by intestinal blood vessel blockage leading to ischemia and further leading to gangrene. The new, serious complication associated with COVID-19 is intestinal gangrene and isolated cases are being reported in various places on gangrene without any respiratory illness. This condition was mostly prevalent earlier in elderly with diabetes, hypertension or dyslipidemia.

Most common clinical manifestations with COVID-19 are shortness of breath, anosmia, fever, myalgia, cough, fatigue, headache whereas extrapulmonary symptoms are overlooked. About 15% of symptoms were gastrointestinal symptoms like nausea, abdominal pain, vomiting, anorexia and diarrhea and are self limiting. However, 10 % of the COVID-19 infection is diagnosed by GI symptoms without respiratory illness. More often the GI symptoms are observed in severely ill patients with complications such as ileus, extensive hepatic necrosis, acute acalculous cholecystitis, and bowel ischemia. Hence gastrointestinal symptoms should not be ignored completely. Coagulopathy, vasculitis and mesenteric involved is suspected to be a cause for gangrene. Intestinal clots may further leads to acute mesenteric ischemia, a rare abdominal emergency associated with high rates of morbidity and mortality.

The patient may show up symptoms like severe abdominal pain, gradual increase in heart rate, increased abdominal distension and hypotension. Gastrointestinal tract can be a possible portal of entry and multiplication site for SARS-COV-2. ACE2 receptor and transmembrane serine protease 2 (TMPRSS2) are important proteins aiding viral entry into host. These are found in esophagus, ileum and colon. Hence the probability of viral entry, replication and multiplication process within the GIT cannot be ruled out completely. SARS-COV-2 infection triggers immune response in vascular endothelium, associated with cell breakdown. Gangrene is suspected to be with or without the involvement of the major arteries or veins such as superior mesenteric artery or superior mesenteric vein and portal veins.

Presence of virus can be confirmed by performing RT-PCR on intestinal biopsy specimen collected from patient. This can increase the credibility of observed findings. This condition either requires surgical removal of intestine or life-long feeding of TPN. Contrast-enhanced CT of the abdomen can be done to ignore the chance of bowel gangrene. Early treatment is important to reduce mortality particularly in chronic illness. Surgical resection and anticoagulants is the mainstay for treatment. The chance for survival of diseased patients decline by 50% if not treated within 24 hours.