COVID-19 Pneumonia Presenting as Abdominal Pain
Updated: Apr 15, 2021
Abdominal pain with incidental lung abnormality on CT • Xray of the Week
No SOB, cough or fever.
Figure 1. CT abdomen and pelvis showing peripherally distributed bibasilar ground-glass opacities (red and blue arrows)
Discussion:
On January 7, 2020, a novel coronavirus was isolated and named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses (ICTV) in the wake of an outbreak of pneumonia of unknown cause in Wuhan city, China[1, 2]. This pneumonia was called Coronavirus Disease 2019 (COVID-19) by the World Health Organization on February 11, 2020. Globally, more than 20 million confirmed cases of COVID-19 have been reported. An outbreak at Wuhan, identified an initial association of human with a seafood market that sold live animals. However, as the outbreak progressed, person-to-person spread through the airborne route became the main mode of transmission. SARS-CoV-2 has been detected in non-respiratory specimens, including stool, blood, ocular secretions, and semen, but the role of these sites in transmission is uncertain [3-6]. Most commonly seen in adults than in children. The incubation period for COVID-19 is up to 14 days, with most cases occurring four to five days after exposure. [7, 8]. Infectivity is high during earlier stages of illness, when viral RNA levels from upper respiratory specimens are the highest [9-12]. The duration of viral RNA shedding is variable and may increase with the severity of illness and does not indicate prolonged infectiousness [11, 13-15].Transmission of SARS-CoV-2 from individuals with infection but no symptoms (including those who later developed symptoms and thus were considered presymptomatic) has been documented [16-18]. As per CDC in United States, pneumonia is the most frequent serious manifestation of infection, characterized primarily by fever ( in 43%), cough (in 50%), dyspnea (in 29%), and bilateral infiltrates on chest imaging. Other features includes sore throat (in 20%), myalgias (in 36%), diarrhea (in 19%), headache (in 34%), nausea/vomiting (in 12 %) and smell or taste disorders, abdominal pain, and rhinorrhea (in <10 % each) [8, 19, 20].
SARS-Cov-2 has high affinity to angiotensin converting enzyme 2 (ACE2) receptors, leading to cytokine-mediated immune response and inflammation, thereby affecting organs posing ACE2 receptors i.e. brain, heart, arterial and venous endothelial cells, kidneys, liver (hepatocytes and cholangiocytes), gastrointestinal tract, and gallbladder giving atypical symptoms of COVID-19 pneumonia [3-5]. The optimal time to test for COVID-19 following exposure is uncertain as the time to detectable RNA following exposure is unknown, hence five to seven days post exposure is recommended and a negative viral test following exposure, still necessitates quarantine. Nucleic acid amplification testing (NAAT), most commonly with a reverse-transcription polymerase chain reaction (RT-PCR) assay, to detect SARS-CoV-2 RNA from the upper respiratory tract is the preferred initial diagnostic test for COVID-19 [21].
Table 1: Diagnostic tests for COVID-19 [36]. COVID-19: coronavirus disease 2019; RT-PCR: real-time polymerase chain reaction; IgG: immunoglobulin G; CDC: United States Centers for Disease Control and Prevention.* single positive test generally confirms the diagnosis. If initial testing is negative and clinical suspicion remains, performing a second test can enhance diagnostic yield.
In the United States, the CDC recommends collection of one of the upper respiratory specimens: nasopharyngeal/ nasal swab specimen from both anterior nares, nasal or nasopharyngeal wash/aspirate, oropharyngeal swab (has lower sensitivity) (Table 1) Multisystem involvement leads to the following laboratory findings; lymphopenia, elevated aminotransaminase levels, elevated lactate dehydrogenase levels, elevated inflammatory markers (eg, ferritin, C-reactive protein, and erythrocyte sedimentation rate), and abnormalities in coagulation tests [8, 20, 22].
Table 2: Proposed reporting language for CT findings related to COVID-19 [23]. COVID-19: coronavirus disease 2019; CT: computed tomography; GGO: ground-glass opacity; PUI: person under investigation; RT-PCR: reverse transcription polymerase chain reaction.
CXR findings in COVID-19 pneumonia include consolidation and ground glass opacities, with bilateral, peripheral, and lower lung zone distributions. According to the American College of Radiology (ACR), Chest CT is more sensitive than CXR and is reserved for hospitalized patients under treatment. We present a case of 47-year-old female with atypical presentation with abdominal pain and fever but no respiratory symptoms. CT abdomen/pelvis demonstrated bibasilar, peripherally distributed crazy paving pattern (ground-glass opacifications with superimposed septal thickening), which was later diagnosed as COVID-19 pneumonia on further laboratory evaluation (Fig. 1). The Radiological Society of North America has categorized chest CT features as typical, indeterminate, or atypical for COVID-19 (Table 2) [23]. Other chest CT findings includes bronchiectasis, pleural effusion, pericardial effusion, and lymphadenopathy.
Acute respiratory distress syndrome (ARDS) is a serious complication that can manifest shortly after the onset of dyspnea. [20, 24]. Other complications include thromboembolic events [25-27], acute cardiac injury [20, 28], kidney injury, and inflammatory complications [19, 29] The risk of transmission after contact with an individual with COVID-19 increases with the closeness and duration of contact and appears highest with prolonged contact in indoor settings i.e. household contacts, cruise ships [30], homeless shelters [31, 32], and detention facilities [33], in health care settings like hospitals [20] when personal protective equipment are not used, and after social or work gatherings. Hence transmission can be reduced by wearing masks (with NO exhalation valves) in public, washing hands, social or physical distancing.
For patients with non-severe disease, primarily supportive care, with close monitoring for disease progression is recommended. For patients with severe disease requiring supplemental oxygen, mechanical ventilation/ECMO, low dose Dexamethasone and/or Remdesivir has had some success in early clinical trials. [34, 35]
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Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening.
Follow Shama Jaswal on Twitter @Jaswal_Shama
Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.
Follow Dr. Rice on Twitter @KevinRiceMD
