A. Sorce

F. Caprioli

F. Peyvandi

M. Vecchi

S. Mazza

English

AIR Universita degli studi di Milano

1148  Gut June 2020 Vol 69 No 6
Letter
A fatal case of COVID-19 
pneumonia occurring in a 
patient with severe acute 
ulcerative colitis
Since December 2019, a novel corona-
virus referred to as SARS- CoV-2 (severe 
acute respiratory syndrome coronavirus 
2)1 was identified as the causative agent of 
a respiratory syndrome named COVID-
19.2 Since February 2020, an outbreak of 
COVID-19 has developed in Lombardy, 
in northern Italy, posing serious chal-
lenges to healthcare system. As reported, 
COVID-19 severity directly correlates 
with patient’s age and several comorbid-
ities,3 but no data are currently available 
regarding clinical outcome in inflamma-
tory bowel diseases (IBD). Recently, the 
International Organization for the Study 
of Inflammatory Bowel Disease (IOIBD) 
recommended a reduction of corticoste-
roid therapy in IBD patients, while main-
taining thiopurines and biologics,4 even 
if Authors recognised that specific IBD 
research on COVID-19 is lacking.
On 12 February 2020, days before this 
outbreak was recognised, an 80- year- old 
female with a 3- year history of left- sided 
ulcerative colitis (UC), in maintenance 
with mesalamine, presented to our clinic 
with a 7- day history of fever and bloody 
diarrhoea. On admission, the patient 
reported four bowel movements per day 
with blood and fever up to 38.5°C. Labo-
ratory tests documented severe anaemia 
(haemoglobin 7 g/dL) and increased 
C- reactive protein (CRP) (6 mg/dL). A 
sigmoidoscopy showed large and deep 
ulcers in sigmoid colon and rectum 
(figure 1). Stool cultures were negative, 
including tests for Clostridium difficile. 
The patient was therefore diagnosed 
with a severe UC relapse and intrave-
nous corticosteroid therapy (methyl-
prednisolone 40 mg/day) was started. 
During the next 3 days, the frequency 
of bowel movements decreased, fever 
resolved and CRP returned into normal 
range. On the fourth day, fever up to 
39°C developed, followed by dry cough. 
On the basis of the evolving knowl-
edge regarding SARS- CoV-2 outbreak, 
including data relative to hospital- 
acquired infections, a case of COVID-19 
was suspected. Chest radiography 
showed bilateral pneumonia, confirmed 
by chest CT scan (figure 2). The naso-
pharyngeal swab sample confirmed the 
presence of SARS- CoV-2 and a diag-
nosis of COVID-19 pneumonia was 
made. The patient was treated with non- 
invasive ventilation, and a combination 
of lopinavir/ritonavir and hydroxychlo-
roquine. Intravenous corticosteroid was 
rapidly switched to oral prednisone, 
and an accelerated tapering was initi-
ated. Despite an initial improvement, the 
patient’s condition subsequently wors-
ened and the patient died after 14 days 
of hospitalisation. Prednisone dosage at 
the time of patient’s death was 25 mg 
daily.
Corticosteroids administration showed 
no effect on mortality but delayed lower 
respiratory tract clearance of the coro-
navirus in both SARS and Middle East 
respiratory syndrome.5 In a recent retro-
spective study, corticosteroids were more 
frequently administered in patients with 
poor outcome,6 although another study 
showed potential benefit for patients 
who develop acuterespiratory distress 
syndrome.7 Current WHO recommen-
dations suggest that routine corticoste-
roids should be avoided in COVID-19, 
unless they are indicated for another 
reason.5 According to recent reports, 
>75% of patients with COVID-19 
received antiviral drugs, including 
lopinavir/ritonavir. Lopinavir/ritonavir 
has shown anti- coronavirus activity in 
vitro and was associated with a reduced 
mortality in SARS,8 however a recent 
clinical trial demonstrated no benefit 
in hospitalised patients with severe 
COVID-19.9 Chloroquine is a cheap and 
a safe drug widely used for malaria and 
autoimmune diseases, and has recently 
been reported as a potential broad- 
spectrum antiviral drug. A recent study 
revealed that chloroquine was highly 
effective in the control of SARS- CoV-2 
in vitro.10 Finally, we hereby report the 
first case of a COVID-19 pneumonia in 
an elderly patient with severe acute UC 
treated with corticosteroids. Considering 
a COVID-19 incubation time of up to 14 
days, it is possible that the patient was 
already harbouring SARS- CoV-2 when 
corticosteroids were initiated; as a conse-
quence, it would be advisable to test for 
the virus before systemic steroid initia-
tion in highly epidemic areas. Neverthe-
less, further evidences are required to 
define the best treatment strategy in IBD 
patients.
Stefano Mazza   ,1 Andrea Sorce,1 
Flora Peyvandi,2,3 Maurizio Vecchi,1,3 
Flavio Caprioli1,3
1Gastroenterology and endoscopy Unit, Fondazione 
IrCCS Ca’ Granda Ospedale Maggiore Policlinico, 
Milan, Italy
2Angelo Bianchi Bonomi Hemophilia and thrombosis 
Center, Fondazione IrCCS Ca’ Granda Ospedale 
Maggiore Policlinico, Milan, Italy
3Department of Pathophysiology and transplantation, 
Università degli Studi di Milano, Milan, Italy
Correspondence to Prof Flavio Caprioli, 
Gastroenterology and endoscopy Unit, Fondazione 
IrCCS Ca’ Granda Ospedale Maggiore Policlinico, 
Milan, Italy;  flavio. caprioli@ gmail. com
Contributors SM and FC wrote the letter; AS, FP and 
MV critically reviewed the letter and made adjustments 
to the text.
Funding the authors have not declared a specific 
grant for this research from any funding agency in the 
public, commercial or not- for- profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; 
internally peer reviewed.
this article is made freely available for use in 
accordance with BMJ’s website terms and conditions 
for the duration of the covid-19 pandemic or until 
otherwise determined by BMJ. You may use, download 
and print the article for any lawful, non- commercial 
purpose (including text and data mining) provided 
that all copyright notices and trade marks are 
retained.
© Author(s) (or their employer(s)) 2020. No commercial 
re- use. See rights and permissions. Published by BMJ.
To cite Mazza S, Sorce A, Peyvandi F, et al. Gut 
2020;69:1148–1149.
Received 22 March 2020
revised 31 March 2020
Accepted 31 March 2020
Published Online First 3 April 2020
PostScript
Figure 1 Endoscopic image of the sigmoid 
colon showing severe inflammation with large 
and deep ulcers.
Figure 2 On the left, a plain chest X- ray 
showing bilateral pulmonary infiltrates; on 
the right, a chest CT scan showing multiple 
bilateral pulmonary ground- glass opacities.
 o
n
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ay 25, 2020 at Universita degli Studi di M
ilano. Protected by copyright.
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G
ut: first published as 10.1136/gutjnl-2020-321183 on 3 April 2020. Downloaded from 
1149Gut June 2020 Vol 69 No 6
PostScript
Gut 2020;69:1148–1149. doi:10.1136/
gutjnl-2020-321183
ORCID iD
Stefano Mazza http:// orcid. org/ 0000- 0002- 9068- 3209
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A fatal case of COVID-19 pneumonia occurring in a patient with severe acute ulcerative colitis

https://air.unimi.it/bitstream/2434/730568/2/1148.full.pdf

A fatal case of COVID-19 pneumonia occurring in a patient with severe acute ulcerative colitis

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