COVID-19 pneumonia is a widespread viral disease, which affects all the world and has been accepted as pandemic by the World Health Organization (WHO). It is possible to understand that first studies reported from China have focused only on respiratory symptoms associated with COVID-19 as the disease has caused respiratory failure and mortality in the first series. However, these publications have not highlighted diarrhea and the other gastrointestinal system complaints, which might led to underrecognition of these symptoms. The disease more commonly manifest with the upper respiratory tract (URT) and lower respiratory tract (LRT) complaints, there are studies reporting the involvement of other organs and diarrhea (9, 10). It has been shown that, COVID-19 RNA can be detected in the stool after respiratory samples become negative in some infected patients, and PCR test performed on the stool can give a positive result in these patients (11). However, today there are no data showing how long COVIS-19 viruse can remain viable in the stool.
In a case report of a 19-year-old non-smoker female patient reported from Italy, the patient presented to the hospital with fever, vomiting, bloody diarrhea and loss of taste and smell. PCR test was positive. CT did not show pneumonia, but contrast enhancement was detected in the ileum and colon of the patient. All symptoms disappeared following hydroxychloroquine therapy ad PCR test resulted negative. In the small bowel ultrasonography performed on the 16th day, thickness of the bowel walls and blood flow revascularization were increased in entire the colon. In the biopsy, ulcerations, crypt distortion and an active crypt abscess were observed. The patient in whom COVID-19 was negative in the stool samples was diagnosed with ulcerativ colitis (12).
Similarly, in our patient gastrointestinal system complaints were developed after the completion of COVID-19 treatment. To our knowledge, our case is the second case of COVID-19/ulcerative colitis in the literature following the patient reported from Italy. Despite PCR test of our patient was negative, clinical complaints of the patient and PCR (+) tests in all family member suggested COVID-19. Chest CT revealed ground glass opacities. In COVID-19, ground glass opacities with or without consolidation are reported as the most common tomographic findings (13). Complaints of the patient disappeared following treatment with hydroxychloroquine and azithromycin and a significant improvement was observed on repeat tomography.
Ulcerative colitis is an inflammatory bowel disease with unknown cause. Triggering of inflammation due to any reason may lead to the occurrence of the disease. In our patients, there was no GIS complaints previously, and development of bloody diarrhea and abdominal pain short time after the beginning of COVID-19, and colonoscopy and pathologic examinations compatible with ulcerative colitis suggest that the disease migh be triggered by COVID-19. Human intestines express high levels of angiotensin-converting enzyme-2 (ACE-2) and transmembrane serine protease that are needed for COVID-19 virus to gain antry into the cell. Emerging data suggest that GIS and liver may also be influenced by COVID-19 based on the hepatic cells expressing ACE-2, which is the major receptor of gastrointestinal epithelial cells and COVID-19 (14).
Although research on COVID-19 and IBD is known to be lacking, recently the International Organization for the Study of Inflammatory Bowel Disease (IOIBD) recommended reducing corticosteroids therapy and maintaining thiopurines and biologics (15).
So far most triage was made based on the presence of respiratory symptoms in COVID-19 cases. However, since the disease has a dynamic process and number of the publication reporting gasrtointestinal symptoms in addition to other symptoms is increasing, there is an urgent need to appropriately determine clinical features in COVID-19.
Our limitation in this case was lack of PCR investigations in the stool or tissue sample, but PCR test performed twice was already negative in our patient and positivity of IgG in the viral screening carried out following the treatment, clinical and CT findings of the patient were compatible with COVID-19, all family member had PCR (+) and full recovery was obtained following the treatment, suggesting that the patient experienced COVID-19.