A Rare and Late Complication of COVID-19 Infection: Pneumatosis Intestinalis

Introduction: Pneumatosis intestinalis (PI) is a rare incidental radiologic or endoscopic finding characterized by the presence of gas in the bowel wall. Primarily it happens due to ischemia of bowel. Intestinal ischemia has been reported in association with COVD-19 infection. From literature review, it is commonly seen in patient with severe illness and happens in the first 1- 3 weeks of the illness. Late presentation of COVID-19 associated PI is even very rare. We present a patient with no significant medical history presented with abdominal discomfort 6 months post COVID-19 illness, and he was found to have PI. Case description/methods: A46-year old male patient with no significant medical history presented with on and off left sided abdominal discomfort/pain 4 months after COVID-19 illness. The pain became more frequent over the next 2-3 months, and patient came to GI clinic for evaluation. During his COVID illness, patient had low grade fever, fatigue, significant visual acuity issues. Patient denies shortness of breath, diarrhea or constipation. He did not require hospital admission, but patient took dexamethasone, Ivermectin for 3-5 days. Patient was evaluated by gastroenterologist, and it was decided to do colonoscopy which showed typical PI (Figure). This patient was found to have PI 6 months after his COVID illness. He is healthy person with no other risk factors for PI. Patient is not diabetic and does not have any pulmonary, cardiac or autoimmune disease. His pain was not associated with eating. No significant laboratory abnormality was found. Patient had CT scan of abdomen/pelvis 1 week after colonoscopy which showed resolution of the PI. On follow up appointment, symptom has improved well. Discussion: Late presentation of pneumatosis intestinalis associated with COVID- 19 is very rare. Parthenogenesis can be due to direct injury of GI mucosa through attachment to angiotensin converting enzyme receptors of enterocytes, disruption of normal colonic flora or due to COVID-19 induced thromboembolic complications. It is important that clinicians are aware of this late complication. In general, most cases of PI are asymptomatic and may be incidental finding on imaging or endoscopy. Treatment varies but most cases does not need surgical treatment. Steroid treatment, bowel rest and hyperbaric oxygen therapy can resolve the problem. In our patient, he had good bowel rest, bowel preparation for colonoscopy which might contributed for the resolution on his CT scan.Figure 1.: Colonoscopy showing Pneumatosis intestinalis in descending colon.