Case Report: Paralytic Ileus: A Potential Extrapulmonary Manifestation of Severe COVID-19

Abstract

The COVID-19 pandemic has recently spread worldwide, presenting primarily in the form of pneumonia or other respiratory disease. In addition, gastrointestinal manifestations have increasingly been reported as one of the extrapulmonary features of the virus. We report two cases of SARS-CoV-2 infection complicated by paralytic ileus. The first patient was a 33-year-old man who was hospitalized with severe COVID-19 pneumonia requiring ventilator support and intensive care. He developed large bowel dilatation and perforation of the mid-transverse colon, and underwent laparotomy and colonic resection. Histopathology of the resected bowel specimen showed acute inflammation, necrosis, and hemorrhage, supporting a role for COVID-19-induced micro-thrombosis leading to perforation. The second patient was a 33-year-old man who had severe COVID-19 pneumonia, renal failure, and acute pancreatitis. His hospital course was complicated with paralytic ileus, and he improved with conservative management. Both cases were observed to have elevated liver transaminases, which is consistent with other studies. Several authors have postulated that the angiotensin-converting enzyme 2 receptors, the host receptors for COVID-19, that are present on enterocytes in both the small and large bowel might mediate viral entry and resultant inflammation. This is a potential mechanism of paralytic ileus in cases of severe COVID-19 infection. Recognizing paralytic ileus as a possible complication necessitates timely diagnosis and management.

Figure 1.

Radiographs for patients diagnosed with COVID-19 pneumonia. (A) Chest radiograph for case 1 showing bilateral free air under the diaphragm and (B) abdominal radiograph showing distended bowel loops. (C) Chest radiograph for case 2 showing bilateral patchy infiltrates and (D) abdominal radiograph showing diffuse dilatation of the small and large bowel loops.

Figure 2.

Computed tomography (CT) scan of the abdomen in patients diagnosed with COVID-19 pneumonia. (A) Contrast-enhanced CT scan, an axial plane of the abdomen of the first case showing large bowel dilatation with no stricture or obstruction, and patent mesenteric vessels. (B) Contrast-enhanced CT scan, an axial plane of the abdomen of the second case showing diffusely distended small and large bowel with air–fluid levels.