David Hudesman, MD, on COVID-19 in a Patient With Severe UC
Dr Hudesman discusses the case of a pregnant patient who presented with severe acute ulcerative colitis and also tested positive for COVID-19.
David Hudesman, MD, is codirector of the Inflammatory Bowel Disease Center at NYU Langone Health in New York City.
I'm Dr. David Hudesman, codirector of the Inflammatory Bowel Disease Center at NYU Langone Health in New York City.
I'm going to be speaking about a patient of mine, a case report we published in the IBD Journal. This patient came to see us and unfortunately admitted to the hospital very early on in the COVID pandemic in the spring when things started to get a little hectic in New York City.
This was a young female patient who was admitted with severe ulcerative colitis. She was also pregnant. This was a 26‑year‑old female diagnosed with ulcerative colitis over 10 years prior. Initially, we started on some steroids tapered off in mesalamine, went into remission, and was off therapy for a long period of time and was not following up.
She went to an outside hospital, admitted for severe ulcerative colitis, multiple bloody bowel movements a day, upwards of 8 to 10, very elevated CRP, close to 100. She was started on some IV steroids. Due to COVID, she was sent home on a pretty rapid prednisone taper due to concerns of COVID and prednisone. Plan was to start a biologic.
Then she was readmitted to NYU as she went to oral steroids with her symptoms flared up again. And it's interesting—as I go through the case, I'll talk about how we managed it and what may be different now as we've learned more about COVID. This was before we had any data about anything.
She got readmitted, severe ulcerative colitis. Again, an elevated CRP over 100, over 10 bloody bowel a day, weight loss, significant abdominal pain. She was started on IV steroids, and she did not respond. When she got readmitted to our hospital, we tested her for COVID. She was found out to be COVID‑positive.
So I'm going to break down the case in two ways. First, talk about how we usually manage severe ulcerative colitis, and then talk about how COVID was being managed then. I'll let you know what happened with our patient.
Usually, with acute severe ulcerative colitis, somebody presents a very important full set of labs, check for C. diff. It's very important to do a sigmoidoscopy very early on, ideally within the first 24 hours, to get a better sense of the severity of the disease. Then we start these patients on IV steroids.
At our institution, we use IV Solu‑Medrol, 20 milligrams every 8 hours. Also, very important for these patients that they're put on anticoagulation, whether it's low molecular weight heparin or a different form. Some type of sub-q heparin or Lovenox needs to be given. These patients are much higher risk for clotting. The relative risk is over 15 times higher than in the general population, at somebody relatively similar age. Again, even if these patients are bleeding, even if your UC patients are anemic, it's extremely important that they are put on anticoagulation.
After three days, usually, that's the cut‑off I use—by 3 days on IV steroids, at that point, you're going to make that decision on, are they responding? In my mind, the blood has to be gone, or nearly gone. That CRP has to significantly drop. If those things are not happening, then we're talking about salvage therapy with infliximab, cyclosporin, or surgery is always an option, as well.
Moving to the COVID part, at this time, early in the pandemic, everybody that came into our institution was getting azithromycin as well as hydroxychloroquine or Plaquenil, which we now know is not effective for COVID, but a lot of people were getting that.
Initially, when this patient came in, depending on the severity, people were deciding whether to use azithromycin and hydroxychloroquine. Now, as patients come into our institution, they're now getting steroids. They're now getting remdesivir. Very different things are happening now versus about a year ago, or a little less than a year ago.
Back to this case presentation. She came in, she received IV steroids for 3 days. Known diagnosis of COVID, but add‑on presentation asymptomatic. She did not respond to the IV steroids. As we were going into day 4, we were having the discussion between infliximab and cyclosporin.
We had our high‑risk OB team, because she was found out to be newly pregnant as well. There was a fetal heartbeat. In our ultrasound, they saw a yolk sac. We were discussing with them, have them on board discussing next steps.
Right around this time, as she was not responding to steroids, she started to have pleuritic chest pain. The concern of pericarditis from COVID possibly, or just worsening COVID symptoms. Now, we were in a situation with her ulcerative colitis is not doing well. Her COVID symptoms seems to be worsening. She's very early on in her pregnancy.
At this point, we decided to treat her with cyclosporin. We were discussing between infliximab and cyclosporin. At that time, the thought was cyclosporin is something where for COVID does progress, or if she has superimposed pneumonia, or other complicating infections with COVID, that cyclosporin is something we can turn off quickly, whereas infliximab might not be something we can turn off as quickly as possible. Also, there was some interesting data in the 2003 SARS outbreak. Some of the vitro studies showing the use of cyclosporin to decrease SARS replication.
Because of those two things, we put her on IV cyclosporin, continuous 7‑day infusion. It's something there are multiple risks besides infections. However, it's something that could be done at an institution where you're able to check daily cyclosporin levels. The key is to be able to check that daily level. Keep it in that therapeutic range. That's how you can minimize side effects such as seizures, renal insufficiency, high blood pressure, neuropathy, and so forth.
She did very well on cyclosporin from the ulcerative colitis perspective. She was able to be discharged home. We transitioned her to vedolizumab as an outpatient. She's continuing to do well from an ulcerative colitis perspective.
Unfortunately, at about day 13, 14 of the hospitalization, she did have a miscarriage, spontaneous abortion. So she did lose the baby, which was unfortunate. It is unclear whether that was from her severe ulcerative colitis. We know patients with severe disease, acute inflammation are at an increased risk for this to happen.
There was a systematic review looking at MERS, SARS, COVID. There were increased rates of miscarriage and spontaneous abortion in that study as well. It's unclear whether that was due to the virus, whether that was due to the ulcerative colitis, was there some pre‑existing genetic component, or a combination of those factors?
During her admission, as well for her COVID, we were treating her aggressively. We started her on azithromycin and the hydroxychloroquine, as I mentioned earlier, because we knew her COVID symptoms were progressing, her UC symptoms were progressing, and we wanted to treat aggressively for both.
A very complicated case, a tough case. Unfortunately, she did lose the baby. It was early on. She did not need a d&c. From the ulcerative colitis perspective, she continues to do well on vedolizumab. If a similar patient were to present to the hospital now, how would we manage? What things would change?
Obviously, we wouldn't be using the azithromycin and the hydroxychloroquine. She'd be getting steroids either way as well as remdesivir.
It'll be interesting whether we would still use cyclosporin, which is still a very good option, or infliximab, as there's more and more data suggesting that anti‑TNFs possibly could help COVID‑19, although we need more data.
Hopefully, you'll take some important pointers from this case, on both managing acute severe UC as well as dealing with a COVID patient. Thank you very much.