key: cord-269390-4yn8c34i authors: Rimondi, Alessandro; Tontini, Gian Eugenio; Mazza, Stefano; Caprioli, Flavio; Sangiovanni, Angelo; Lampertico, Pietro; Vecchi, Maurizio title: Fogging IBD Management: An Unusual Case of IBD Flare-up During the COVID-19 Outbreak date: 2020-07-28 journal: Inflamm Bowel Dis DOI: 10.1093/ibd/izaa184 sha: doc_id: 269390 cord_uid: 4yn8c34i nan We have read with interest the article by Occhipinti and Pastorelli, with particular reference to the management of inflammatory bowel diseases (IBD) relapse during the COVID-19 outbreak. 1 Diagnostic challenges may arise in the presence of symptoms that overlap between active IBD and COVID-19, and concerns about the use of immunosuppressive drugs, mainly corticosteroids, which potentially lead to an increased risk for infections. 2 Lombardy, in northern Italy where our clinic is located, has been severely hit by COVID-19 since February 2020. We hereby report on a representative case of how COVID-19 has redefined priorities and changed our clinical approach to active IBD patients. In April 2020, a 29-year-old man with a 1-year history of ulcerative colitis (UC) on maintenance with mesalamine was admitted to our clinic with a 2-week history of fever up to 38.5°C, bloody diarrhea, dry cough, and ageusia. Physical examination revealed tachycardia. Blood tests showed neutrophilia and increased C-reactive protein. Two consecutive nasopharyngeal plus one rectal swabs for SARS-CoV-2 tested negative. A contrast-enhanced chest-abdomen-pelvis CT scan revealed no signs of pneumonia but a widely thickened and hyper-enhancing colonic wall (Fig. 1A) . Abdominal imaging and gastrointestinal symptoms were consistent with IBD relapse. However, the persistence of fever, cough, and ageusia made it necessary to definitely rule COVID-19 out. After a multidisciplinary discussion, a bronchoalveolar lavage was performed, which eventually tested negative for SARS-CoV-2. Ileocolonoscopy, performed 2 days later, showed segmental cobblestone appearance and scattered aphthous erosions in the right and left colon (Fig. 1B) , as opposed to a relative sparing of the rectum (Fig. 1C) . Histological examination was consistent with IBD colitis. A diagnosis of severe flare of IBD-unclassified was made, and corticosteroid therapy was initiated, with the subsequent rapid improvement of both gastrointestinal and respiratory symptoms. Gastrointestinal manifestations have occurred in about half of COVID-19 patients and may precede respiratory symptoms. 3 Therefore, the differential diagnosis between IBD relapse and SARS-CoV-2 infection has possibly proved challenging at the peak of the COVID-19 outbreak. Currently, ruling out COVD-19 has become a priority for both clinical and public health reasons, and the timing of endoscopic examination, as well as treatment decisions, closely depend on the COVID-19 diagnostic results. 4 Ageusia and anosmia have been reported in about one third of COVID-19 patients, 5 whereas they have rarely been observed in IBD patients. Ageusia, as reported by our patient, contributed to increase the suspicion of SARS-CoV-2 infection and made the differential diagnosis trickier. Challenges in the care of IBD patients during the CoViD-19 pandemic: report from a "Red Zone" area in Northern Italy AGA clinical practice update on management of inflammatory bowel disease during the COVID-19 pandemic: expert commentary Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from the Hong Kong cohort and systematic review and meta-analysis Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and postpandemic period Selfreported olfactory and taste disorders in SARS-CoV-2 patients: a cross-sectional study CT scan image showing a cross-sectioned descending colon (white arrow) with wall thickening and mucosal hyperenhancement. B, Left-colon image showing mucosal oedema, cobblestone appearance, and aphthous erosions. C, Rectum image showing an endoscopically normal appearance of the mucosa Marcello Hinxman-Allegri performed the linguistic revision. The patient gave informed consent.