Case Reports Documenting COVID-19 Patients Developing Mesenteric Panniculitis And Acute Abdominal Pain As Infection Progresses
: Despite warnings that the newer Omicron variants and sub-lineages that have emerged and started circulating since weeks 18 to now are displaying more tropism towards the gastrointestinal tissues and causing a variety of gastrointestinal tissues, many scientists not in clinical practice or in the study of the pathogenesis of these new variants are expressing skepticisms.
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has also reported of more such cases emerging since weeks 35 to present and there are at least two more pending studies that are to be published soon by researchers from the United Kingdom, France, Australia and Bangladesh on this in preprint formats.
Meanwhile, medical researchers and physicians from the Department of Pulmonary Medicine and the Department of Radiodiagnosis at STAR Hospitals, Telangana have discovered yet another gastrointestinal issue that SARS-CoV-2 infections can cause. The study team found that COVID-19 can also cause acute abdominal pains in individuals as a result of Mesenteric Panniculitis and presented two documented case reports.
Mesenteric Panniculitis Mesenteric panniculitis is a rare, benign and chronic fibrosing inflammatory disease that affects the adipose tissue of the mesentery of the small intestine and colon.
Clinical symptoms of mesenteric panniculitis are highly variable. Some individuals have few or no noticeable symptoms; others may be greatly affected by a variety of complaints including abdominal pain, nausea/vomiting, bloating, early satiety, loss of appetite and diarrhea or constipation.
The COVID-19 disease caused by the SARS-CoV-2 virus primarily manifests as lung infection, with fever and respiratory tract symptoms. Extrapulmonary complications affecting multiple organs are commonly seen, especially in critically ill patients.
A wide variety of gastrointestinal (GI) complications have also been reported spanning from transaminitis, acute pancreatitis, mesenteric ischemia, GI bleeding, and ileus.
The study team reported two cases of acute abdominal pain in patients with COVID-19 in their second week of illness.
One patient had mild COVID-19 disease and the other had severe disease. Both patients had diffuse abdominal tenderness and raised inflammatory markers. The diagnosis of mesenteric panniculitis (MP) was made radiologically, and demonstrated with the presence of increased density of the mesentery with fat stranding (misty mesentery). Glucocorticoid administration resulted in the complete resolution of pain. They remained pain-free at 3 months of follow-up.
The study findings were published in the peer reviewed Indian Journal of Critical Care Medicine.
It has been already reported in past studies that gastrointestinal (GI) symptoms are reported by up to a third of COVID-19 patients and also covered in various COVID-19 News
GI symptoms range from diarrhea, abdominal pains, vomiting, constipation and also bloody stools.
GI complications range from mild transaminitis to severe bowel ischemia.
In fact, intestinal ischemia is also becoming a very common occurrence with the never variants since weeks 31 onwards, often with fatal outcomes due to sepsis or even the condition causing heart failures, Most of such deaths are often being recorded as non-COVID-19!
The Indian study team described Mesenteric Panniculitis in two patients with COVID-19. The first patient was a female aged 55 who presented with nausea and upper abdominal pain for four days. The subject tested SARS-CoV-2-positive 10 days before and had mild disease. The patient had asthma for three decades and diabetes for the past two years. The case was afebrile for five days before admission.
Upon examination, the temperature was 100°F, the pulse oximetric saturation (SpO2) was 96% (breathing room air), blood pressure was 130/80 mm Hg, respiratory rate was 20 breaths per minute, and pulse rate was 114 beats/minute. Examination of the abdomen showed tender umbilical and epigastric areas.
Detailed laboratory investigation showed elevated D-dimer and C-reactive protein (CRP) levels and neutrophilic leukocytosis. Contrast-enhanced computed tomography (CECT) of the abdomen showed smudging of flat planes around superior mesenteric vessels and branches in the root of small bowel mesentery associated with mesenteric lymph nodes, suggesting Mesenteric Panniculitis.
The female patient was given intravenous (IV) methylprednisolone, fentanyl infusion, fluids, and subcutaneous (SC) enoxaparin. Tenderness and pain subsided after three days. The subject was discharged with oral glucocorticoids tapered over the following four weeks.
In the second documented case, the patient was a male aged 69 who presented with cough, fever, and dyspnea for the past week.
Clinical examination revealed a pulse rate of 130 beats/minute, normal blood pressure, SpO2 of 86% (breathing room air), and a respiratory rate of 30 breaths/minute. Auscultation revealed bilateral crackles. Chest CT scan showed bilateral diffuse ground-glass opacities concordant with COVID-19 pneumonia, also confirmed by a SARS-CoV-2 reverse-transcription polymerase chain reaction (RT-PCR) test.
Treatment protocols involving intravenous remdesivir, methylprednisolone, SC enoxaparin, and supportive care were initiated. The patient initially required oxygen supplementation and showed symptomatic improvement. The subject experienced severe epigastric pain on day 7 of hospitalization, with diffused tenderness throughout the abdomen.
Blood sample investigations revealed normal serum lipase and amylase levels but elevated CRP. Abdominal CT scan showed fat in the central mesentery, indicative of MP.
The attending physicians initiated high-flow oxygen due to worsening hypoxia, and the patient required admission to the intensive care unit. The dose of methylprednisolone was increased; abdominal pain subsided after 48 hours, with a gradual improvement of hypoxia. The patient was discharged with oral glucocorticoids tapered over the following month. After three months, the patient had exertional dyspnea.
This is the first documented clinical case studies to described cases of Mesenteric Panniculitis with abdominal pain during COVID-19 infection. of Mesenteric Panniculitis was diagnosed by radiological and clinical examination. Glucocorticoid treatment led to the complete resolution of abdominal pain without recurrence at three months of follow-up.
It is expected that in the coming COVID-19 surges, besides pulmonary issues, we can expect to see more issues also involving the gastrointestinal tract, the liver, the kidneys, the heart and the brain besides issues involving the endocrine and vascular systems.
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