Sclerosing Encapsulating Peritonitis Following Recovery From COVID-19 Pneumonia.

Coronavirus disease 2019 (COVID-19) is primarily a respiratory illness and pulmonary manifestations are the typical presentations of the disease. However, it became evident that the COVID-19 is not limited to the respiratory system. Specifically, gastrointestinal involvement in patients with COVID-19 is very common, particularly in patients with a critical illness. We present a case of a 52-year-old man who was diagnosed as having severe COVID-19 pneumonia and underwent endotracheal intubation and mechanical ventilation. The patient remained in the intensive care unit for seven days. Following his recovery, he started to experience generalized abdominal pain. The pain did not resolve with conservative measures. A computed tomography scan of the abdomen demonstrated small bowel loops clustered with a surrounding thin membrane. Such findings conferred the diagnosis of sclerosing encapsulating peritonitis. The patient was prepared for laparoscopic surgery. Resection of the membrane was performed without any injury to the encapsulated bowel. Analysis of peritoneal fluid by reverse transcription-polymerase chain reaction (RT-PCR) was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient had an uneventful recovery. Sclerosing encapsulating peritonitis is a very rare condition associated with COVID-19 pneumonia. The present case is the first reported case to document the presence of the SARS-CoV-2 virus in the peritoneal fluid in a patient with sclerosing encapsulating peritonitis.

Introduction

Coronavirus disease 2019 (COVID-19) is primarily a respiratory illness and pulmonary manifestations are the typical presentations of the disease. However, it became evident that the COVID-19 is not limited to the respiratory system. The manifestations and complications of COVID-19 include a wide spectrum of conditions, including gastrointestinal manifestations, cardiac complications, coagulopathies, and neurological manifestations [1]. It is estimated that over 70% of critically ill patients with COVID-19 experienced gastrointestinal involvement [2]. It is worth noting that the high incidence of such complications is not merely related to the critical illness itself but is attributed to COVID-19. For example, El Moheb et al. [3] conducted a cohort study with matched comparison of over 184 patients with acute respiratory distress syndrome and found that patients with COVID-19 pneumonia had twice the rate of gastrointestinal complications compared to those without COVID-19. Further, there is a growing body of evidence suggesting that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be detected in multiple sites in the gastrointestinal tracts [4]. Here, we present a case of a middle-aged man who developed sclerosing encapsulating peritonitis following the recovery from COVID-19 pneumonia. The SARS-CoV-2 virus was detected in the peritoneal fluid. To the best of our knowledge, this is the second reported case of sclerosing encapsulating peritonitis in association with COVID-19.

Case presentation

We present a case of a 52-year-old man who presented to the emergency department with a one-week history of cough and fever. His cough was productive of yellowish sputum with no blood. His fever was continuous and measured 38.7℃ in the maximum reading. The patient tried over-the-counter medications, including cough syrups and antipyretics, with no clinical improvement. He reported a recent worsening of his condition and he started to experience shortness of breath. He reported no history of chest pain, wheezing, night sweats, or weight loss. Notably, his spouse had recently recovered from mild COVID-19 pneumonia with home isolation. The past medical history of the patient was remarkable for hypertension, diabetes mellitus, and dyslipidemia. The patient had good compliance with his medications and his regular follow-up visits showed optimal control of his comorbid conditions. The patient did not have any history of abdominal surgeries. He had a smoking history of 20 packs a year and he never consumed alcohol.

Upon examination, the patient appeared drowsy and was in respiratory distress. He was not pale, jaundiced, or cyanosed. He was not able to speak in full sentences. His vital signs were temperature of 38.2℃, pulse rate of 110 bpm, respiratory rate of 23 bpm, and blood pressure of 128/86 mmHg. His oxygen saturation was 82% on room air. Respiratory examination revealed decreased air entry with diffuse crepitations throughout both lung fields. Cardiovascular examination revealed loud S2 with no added sounds or murmurs. Abdominal examinations findings were unremarkable. Initial laboratory findings showed elevated leukocyte count (15,000 cells/μL), erythrocyte sedimentation rate (39 mm/hr), and C-reactive protein (16 mg/dL). Other laboratory markers are summarized in Table 1.

Table 1

Summary of the results of laboratory findings.

Laboratory investigation	Unit	Result	Reference range
Hemoglobin	g/dL	14.5	13.0–18.0
White blood cells	1000/mL	15.0	4.0–11.0
Platelet	1000/mL	480	140–450
Erythrocyte sedimentation rate	mm/hr	39	0–20
C-reactive protein	mg/dL	16.0	0.3–10.0
Total bilirubin	mg/dL	0.9	0.2–1.2
Albumin	g/dL	4.4	3.4–5.0
Alkaline phosphatase	U/L	120	46–116
Gamma-glutamyltransferase	U/L	91	15–85
Alanine transferase	U/L	64	14–63
Aspartate transferase	U/L	40	15–37
Blood urea nitrogen	mg/dL	17	7–18
Creatinine	mg/dL	1.2	0.7–1.3
Sodium	mEq/L	138	136–145
Potassium	mEq/L	4.7	3.5–5.1
Chloride	mEq/L	104	98–107

Considering the decreased level of consciousness of the patient and the deranged arterial blood gas analysis findings, the decision of elective endotracheal intubation and mechanical ventilation was taken. The patient was shifted to the intensive care unit. During his stay, he received intravenous dexamethasone, ceftriaxone, and azithromycin. His blood pressure was maintained and did not require the use of inotropic agents. He was extubated and shifted from the intensive care unit after seven days.

The patient had remarkable clinical improvement in his respiratory status. He was gradually weaned from supplementary oxygen and he was planned for discharge. However, the patient experienced abdominal discomfort. It was associated with nausea and decreased bowel motions. Abdominal examination revealed a distended abdomen with generalized tenderness. However, no clinical signs of peritonitis were evident. Despite the use of symptomatic treatment, her complaints persisted and worsened in severity. Hence, a computed tomography scan of the abdomen was performed. It demonstrated small bowel loops clustered with an appearance similar to that of an internal hernia. The small bowel loops were surrounded by a thin membrane (Figures 1, 2). No significant dilatation of the bowel loops was observed. Such findings conferred the diagnosis of sclerosing encapsulating peritonitis.

Figure 1

Axial CT image.

Selected axial computed tomography scan of the abdomen demonstrating clustered small bowel loops (arrows) in the center of the abdomen.

Figure 2

Coronal CT image.

Selected coronal computed tomography scan of the abdomen demonstrating a thin membrane (arrow) encasing small bowel loops.

The patient was prepared for laparoscopic surgery. The operation was performed under general anesthesia and the patient was in the supine position. The small bowel was found to be covered by a fibrinous membrane. Resection of the membrane was performed without any injury to the encapsulated bowel. The total operative time was 90 minutes and the estimated blood loss was 5 mL. Analysis of peritoneal fluid by reverse transcription-polymerase chain reaction (RT-PCR) was positive for SARS-CoV-2. The patient had an uneventful recovery. He was able to tolerate oral feeding after the operation. He was discharged on the third postoperative day. For two months of follow-up, the patient remained asymptomatic with no active complaints.

Discussion

We presented a case of sclerosing encapsulating peritonitis that developed in a middle-aged man following his recovery from severe COVID-19 pneumonia. To the best of our knowledge, this is the second reported case of sclerosing encapsulating peritonitis associated with COVID-19. Yusuf [5] reported a case of acute intestinal obstruction due to sclerosing encapsulating peritonitis in a patient with COVID-19. However, the findings of that study were limited by the lack of RT-PCR testing for the peritoneal fluid. Hence, the author suggested that the association of sclerosing encapsulating peritonitis and COVID-19 could be merely incidental.

Sclerosing encapsulating peritonitis is a rare inflammatory condition that results in the formation of a thick fibrotic membrane encasing the abdominal content. The first case of sclerosing encapsulating peritonitis was reported more than one century ago [6]. Sclerosing encapsulating peritonitis can be classified into idiopathic and secondary forms. The secondary form may be related to a wide variety of conditions, including abdominal tuberculosis, peritoneal dialysis, intraperitoneal chemotherapy, sarcoidosis, liver cirrhosis, endometriosis, and certain medications [7].

A computed tomography scan of the abdomen is the imaging modality of choice in making the diagnosis of sclerosing encapsulating peritonitis. Since the clinical manifestation of sclerosing encapsulating peritonitis is non-specific, the diagnosis is made by imaging or incidentally during the operations. As in the present case, the computed tomography scan demonstrates a central accumulation of the small bowel surrounded by a thin membrane. Additional findings such as ascites, intestinal obstruction, peritoneal calcifications, and lymphadenopathy may be present [8].

Surgical management is the optimal treatment of choice. The key part of the surgery is to perform complete excision of the encasing membrane to avoid any recurrence. In certain cases, the excision of the membrane could be difficult due to the presence of dense adhesions. Conservative management with bowel rest and nasogastric tube decompression may be attempted in patients with mild symptoms and those who are not fit for surgery. In the present case, laparoscopic excision of the membrane was successfully conducted with no post-operative complications.

Conclusions

Sclerosing encapsulating peritonitis is a very rare condition associated with COVID-19 pneumonia. The present case is the first reported case to document the presence of SARS-CoV-2 in the peritoneal fluid in a patient with sclerosing encapsulating peritonitis. This finding illustrates the possible pathogenic role of SARS-CoV-2 in sclerosing encapsulating peritonitis in the present case. Laparoscopic management of sclerosing encapsulating peritonitis is a feasible approach for the treatment of sclerosing encapsulating peritonitis.