key: cord-0756954-fp938ll1 authors: Ahmed, Ashraf Omer Elamin; Mohamed, Sara F.; Saleh, Ahmed O.; Al-Shokri, Shaikha D.; Ahmed, Khalid; Mohamed, Mouhand F.H. title: Acute abdomen -like-presentation associated with SARS-CoV-2 infection date: 2020-07-03 journal: IDCases DOI: 10.1016/j.idcr.2020.e00895 sha: ff5b132448aaae0bb82ef3140505637ead7c57e7 doc_id: 756954 cord_uid: fp938ll1 As the cases of COVID-19 are flooding around the world, atypical presentations are being recognized, making the diagnosis challenging. Gastrointestinal symptoms and mild abdominal pain are common. However, severe abdominal pain associated with COVID-19 warranting surgical evaluation has been rarely described; recognizing such presentations and differentiating them from a surgical abdomen is critical to effectively and safely manage COVID-19 patients. Here we present a case of a middle-aged gentleman who developed features resembling secondary peritonitis. Eventually, he was found to have COVID-19 and was managed conservatively. In this report, we discuss his management course, and we explore pertinent relevant literature. Since the start of the COVID-19 pandemic, COVID-19 had displayed its gastrointestinal manifestation, which included diarrhea, nausea, vomiting, and mild abdominal pain. However, few reports of COVID-19 resulting in an acute abdomen-like picture have been published (1, 2) . This may result in a diagnostic and a therapeutic dilemma as extensive workup is required to rule out surgical emergencies, leading to a prolonged hospital stay, management impasse, and overburden of the resources. We here report a case of SARS-CoV-2 infection mimicking bacterial sepsis due to perforated viscus. The patient was a 47-year-old man with no prior comorbidities. He presented to the emergency department with a three-day history of fever, sore throat, and left-sided neck swelling that associated with generalized fatigue and myalgia. No other symptoms were present. His initial vitals were recorded as the following: blood pressure measured (BP) 100/65 mm hg, heart rate (HR) 115 beat/min, temperature (T) 38.9 degree Celsius, respiratory rate (RR) 20 breath/min, and oxygen saturation (SpO2) 100% on ambient room air. On examination, his throat was congested, and leftsided mild posterior lymphadenopathy was noted. The remainder of the systemic examination was insignificant. The initial laboratory investigations were significant for high C-reactive protein, a slight rise in serum creatinine, and high international normalized ratio (INR) ( Table 1 ). The initial chest x-ray was unremarkable. A real-time polymerase chain reaction (RT-PCR) confirmed the SARS-CoV-2 infection. The patient received COVID-19 treatment following a local protocol including hydroxychloroquine, azithromycin, and cefuroxime, and the patient was transferred to a quarantine facility for care continuity. Two days later, the patient developed diarrhea and vomiting with mild, diffuse abdominal pain that became severe and more localized to the right lower quadrant for which he was transferred back to the hospital. He looked sick, alert, but not oriented. Vitals were BP 84/52 mm hg, HR 102 beats/min, T 38.1 degree Celsius, SpO2 96% on 2 liters oxygen via nasal cannula. Abdominal examination showed diffuse abdominal tenderness more in the right iliac fossa with guarding. Repeated laboratory investigation showed acute kidney injury, transaminitis, worsening CRP, and procalcitonin ( Table 1 ). The repeat chest x-ray revealed bilateral reticular infiltrates with no gross J o u r n a l P r e -p r o o f consolidation ( Figure 1 ). Based on these parameters, the patient was shifted to the intensive care unit (ICU) with suspicion of sepsis versus severe SARS-CoV-2 infection. He was started on meropenem and resuscitated with crystalloid fluids. Urgent computed tomography (CT) scan of the abdomen was done to rule out acute appendicitis and perforation as a source of infection and to explore the reason for the severe abdominal pain. The CT scan revealed no evidence of bowel perforation or appendiceal inflammation. However, it depicted diffuse paracolic gutters fat stranding, mild free fluid, bilateral mild pleural effusion with consolidations, and filling defect at superior mesentery vein that is attributed to streaming artifact or thrombosis ( Figure 2 ). CT angiogram of the abdomen was subsequently done due to pain persistence, high D-dimers, and previous CT findings to rule out mesenteric vein thrombosis and bowel ischemia. Although the CT angiogram scan showed suboptimal venous system opacifications, no acute thrombosis detected, and the major abdominal arterial system was patent. Serum lipase and amylase were sent following that and found to be high, >600 U/L (normal range 13-60 U/L), and 451 U/L (normal range 13-53 U/L), respectively. Sepsis workup, including blood, urine, sputum cultures, was unremarkable. After an extensive workup, surgical causes were ruled out; hence, the patient was treated conservatively with close monitoring. His pain settled within few days. The kidney and liver injury improved with trending down inflammatory markers. A follow-up phone call one week after discharge confirmed that the patient was doing well and remained asymptomatic. Coronavirus Disease 2019 (COVID 19) is known to cause respiratory symptoms like cough, sore throat, shortness of breath, chest pain, and respiratory distress. As the cases expanded, In conclusion, we presented an acute abdomen like-presentation in the course of COVID-19. It is essential to identify and treat concomitant infections as a possibility. Nonetheless, acknowledge SARS-CoV-2 infection as a possible cause when all other etiologies are ruled out. This will prevent the resources drain and will help in avoiding additional extra investigations. We think with the accumulating data, we will see more reports that are similar to our report. Learning from such reports will enable us to manage these patients efficiently and cost-effectively. The patient provided verbal consent for the publication of this case. Local IRB approval was sought for the publication of the case. All authors do not have any conflict of interest from this case report. Open access publication fees were covered by the Qatar National Library (QNL) Written consent has been obtained from the patient himself Suspected acute abdomen as an extrapulmonary manifestation of Covid-19 infection Severe SARS-CoV-2 Infection in Children With Suspected Acute Abdomen: A Case Series From a Tertiary Hospital in Spain Case report: COVID-19 Masquerading as an Acute Surgical Abdomen Pancreatic injury patterns in patients with COVID-19 pneumonia Clinical Presentation of COVID-19: A Systematic Review Focusing on Upper Airway Symptoms. Ear, Nose and Throat Journal Beware of Too Aggressive Approach in Children With Acute Abdomen During COVID-19 Outbreak! Prevention, diagnosis and treatment of venous thromboembolism in patients with COVID-19: CHEST Guideline and Expert Panel Report We want to acknowledge the efforts of all teams who took part in the care of this patient. Additionally, we thank the QNL for sponsoring the open-access publication fees of this paper.