key: cord-0956814-pq5526m9
authors: Eghbali, Foolad; Bhahdoust, Mansour; Khanafshar, Elham; Pazouki, Abdolreza; Shahabi, Shahab; Kermansaravi, Mohammad
title: Retroperitoneal duodenal perforation due to COVID-19: An extremely rare case report
date: 2022-05-11
journal: Int J Surg Case Rep
DOI: 10.1016/j.ijscr.2022.107191
sha: af13c04166dc77f80966e5354967443ec0e793b5
doc_id: 956814
cord_uid: pq5526m9

INTRODUCTION AND IMPORTANCE: Gastrointestinal (GI) symptoms are the most common extrapulmonary presentation of coronavirus disease 2019 (COVID-19) infection. GI perforation may be an unusual manifestation of COVID-19 infection. CASE PRESENTATION: We report a 45-year-old man who presented with acute abdominal pain without any respiratory symptoms to our emergency department. Investigations revealed retroperitoneal duodenal perforation and fibrotic changes in lung bases. Laboratory findings demonstrated a positive polymerase chain reaction (PCR) test for COVID-19 and mild leukocytosis. CLINICAL DISCUSSION: COVID-19 related perforation of the retroperitoneal part of the duodenum is extremely rare, and to the best of our knowledge, this is the first reported case. With increasing COVID-19 infection, we might see more cases of GI perforation. In the era of COVID-19 pandemic, any abdominal signs and symptoms should alert the clinicians to consider COVID-19 diagnosis in the differential. CONCLUSION: Conservative management with close monitoring, antibiotic therapy and serial examinations were completely successful. The patient's general condition improved, and he was discharged on day 7 of hospitalization.

COVID-19 pandemic is the major disaster that human beings is confronted with in the last decade, with about 231 million affected patients and 4.76 million deaths until 27 September 2021 [1] .

Gastrointestinal (GI) symptoms are the most prevalent extraperitoneal COVID-19 infection, with about 26.8% as a pooled analysis, including anorexia, nausea, vomiting, abdominal pain, diarrhea, altered taste, and GI bleeding [2, 3] .

There are a few reported cases of GI perforations due to . To the best of our knowledge, there have been no reports of retroperitoneal duodenal perforation due to inion.

A 45-year-old man was admitted to our emergency ward with a chief complaint of sudden abdominal pain with maximum intensity in the epigastrium and right side of the abdomen. He was a smoker without any significant surgical and medical history except close contact with the COVID-19 patient at home. A physical exam revealed normal vital signs but a generalized abdominal tenderness and voluntary guarding. He was neither febrile nor dehydrated. Upright chest and abdominal X-rays were normal. Bilateral pulmonary fibrosis, predominantly at the bases, was found in High-resolution computed tomography (HRCT) ( Figure   1 ).

Lab tests showed a positive COVID-19 PCR test in 14 cycles for RdRp genes and 15 processes for N genes (Table 1) , mild leukocytosis, and negative urine toxicology (Table 2- Figure 2 ).

Abdominal and pelvic Ultrasound was normal without any evidence of free fluid. Abdominal computed tomography (CT) scan with intravenous (IV) contrast demonstrated a contained J o u r n a l P r e -p r o o f duodenal perforation with a current of fluid to retroperitoneal space till the right gutter ( Figure   3 ).

Transit of the small intestine demonstrated a retroperitoneal leak from the second part of the duodenum toward the right paracolic gutter. Small intestine transit of contrast revealed leakage ( Figure 4 ).

Closed monitoring with serial physical exams, repeat lab tests, and antibiotic therapy (according to our GI perforation protocols) was successful. He was free of pain after 48 hours. However, Covid-19 pulmonary signs and symptoms such as cough and mild dyspnea started on the second day of admission, which persuaded us to start antiviral therapy with Remdesivir (200 mg/IV loading dose and 100mg/IV daily for five days). After five days, the patient was recovered and tolerated oral (PO) intake and discharged after seven days of hospitalization without any consequences. The work has been reported in line with the SCARE 2020 criteria[5]. 

Although we can't suggest the Covid-19 infection as the risk factor for PPUD, our successful conservative approach may encourage colleagues to avoid early surgical approach in Covid-19 patients with contained GI perforation. In conclusion, we recommend evaluating each case individually to decide the best plan of treatment.

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The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish Dr.Foolad Eghbali Highlights 1. Retroperitoneal perforation of duodenum in COVID patients may occur rarely 2. Conservative management with close observation in these patients is feasible 3. CT scan and contrast study to roll out the generalized peritonitis are helpful J o u r n a l P r e -p r o o f