Graft-versus-host disease-like reactions in the gastrointestinal tract in a patient with SARS-CoV-2 infection.

A middle‐aged man with respiratory failure associated with a severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection was referred. He had a history of hypertension, hyperthyroidism, and bronchial asthma. After being successfully weaned from venovenous extracorporeal membrane oxygenation support, he gradually developed watery diarrhea (approximately 4 L/day). Stool cultures excluded common gastrointestinal bacterial and protozoal pathogens. There was no history of drug use that could lead to intestinal damage (e.g., non‐steroidal anti‐inflammatory drugs). He underwent endoscopy (Fig. 1a–d), which revealed remarkable villous atrophy, mucosal sloughing in the duodenum and terminal ileum, edematous mucosa in the stomach, mucosal sloughing, and edematous mucosa with tortoise shell‐like appearance throughout the colon.

Figure 1

Endoscopic images. Remarkable villous atrophy and mucosal sloughing in the duodenum (a) and terminal ileum (b). Mucosal sloughing in the transverse colon (c) and edematous mucosa with tortoise shell‐like appearance in the sigmoid colon (d).

Biopsy specimens obtained from the terminal ileum revealed extensive crypt loss and crypt abscess with lymphoplasmacytic infiltration, and those from the transverse colon revealed mucosal sloughing and multiple apoptotic bodies per crypt with lymphoplasmacytic and eosinophilic infiltration (Fig. 2a–c). His endoscopic and histological findings were similar to those of patients with graft‐versus‐host disease (GVHD). , , Consequently, we diagnosed the gastrointestinal impairment cause as an acute GVHD‐like reaction, which may have occurred from cytokine‐storm‐related events caused by coronavirus disease 2019 (COVID‐19). Intravenous corticosteroid administration (1 mg/kg/day) was initiated, leading to partial improvement of diarrhea. Infliximab (5 mg/kg), which is used for the steroid‐refractory GVHD treatment, was added, leading to remarkable diarrhea improvement. Endoscopy revealed evident improvement of the gastrointestinal damage.

Figure 2

Histological images. (a) Extensive crypt loss and crypt abscess with lymphoplasmacytic infiltration in the terminal ileum (arrow: crypt abscess; HE ×200). (b, c) Mucosal sloughing and multiple apoptotic bodies per crypt with lymphoplasmacytic and eosinophilic infiltration in the transverse colon (b, HE ×200; c, arrows: apoptotic bodies; HE ×400). HE, hematoxylin‐eosin.

From a pathogenetic perspective, COVID‐19 mimics acute GVHD, characterized by the cytokine storm and hyperactivation of the immune response. To date, there have been no reports focusing on COVID‐19‐related gastrointestinal impairments that present as a GVHD‐like reaction. This case demonstrated novel endoscopic and histological findings in the gastrointestinal tract, similar to those of patients with GVHD, which improved remarkably after therapy with infliximab and corticosteroid. We should analyze more cases to clarify the pathophysiology.

Authors declare no conflict of interest for this article.

Patient Consent: The authors have obtained consent from the family of the patient.