A 68-year-old male patient was initially admitted to an external hospital because of severe acute activity of ulcerative colitis with high-frequency bloody diarrhea on February 01th 2021. In 1984, a left-sided ulcerative colitis was diagnosed. Subsequently, in the following years a psoriatic arthritis and sacroiliitis were diagnosed. He initially treated with systemic and locally 5-aminosalicylic acids. In the event of intermittent relapses, steroid treatment was established, which resulted in remission. A basic therapy with azathioprine was initiated with a gradual reduction of the steroid dose but had to be terminated due to hepatotoxicity. There were further drug changes to adalimumab, methotrexate and leflunomide. At the time of being hospitalized, he was only under medication with prednisolone 5 mg daily.
A colonoscopy was performed and a continuous pronounced inflammation from rectum up to descending colon was detected (Fig. 1). Histology showed a florid ulcerative inflammation, cytomegalovirus infection could be ruled out. Furthermore, fecal tests excluded clostridioides difficile as well as other enteric bacterial or viral pathogens. Oral prednisolone therapy 60 mg daily was initiated.
16 days after hospitalization, the patient was tested positive for SARS-CoV-2 with the variant Wuhan after initial negative polymerase chain reaction. Except for mild cold symptoms without fever, he did not suffer from any other symptoms typical for Covid-19 at that time. Due to the simultaneous infections and the resulting high risk of poor disease progression, the patient was transferred to our unit at University Medical Center Goettingen on February 22nd. At admission to our hospital the patient was in poor general condition with prerenal acute-on-chronic kidney failure.
Initial laboratory findings showed an anemia (hemoglobin 8,1 g/dl; normal value: 13.5–17.5) and elevation of C-reactive protein (202.4 mg/l; normal value: < 5 mg/l) (Fig. 2). The values of procalcitonin (1.02 µg/l; normal value: < 0.07) were elevated with normal number of leucocytes. Albumin levels were low with 1.7 g/dl (normal value: 3.4–5.0). Due to the elevated levels of D-dimers (1.14 mg/l; normal value: < 0.50), we performed a thoracic computer tomography scan with angiography. Pulmonary embolism could be ruled out, but inflammatory infiltrates in accordance with a Covid-19 pneumonia and mild pleural effusions (Fig. 3A) could be detected. Furthermore, abdominal computer tomography scan showed a wall thickening of the sigma, but ruled out an abscess (Fig. 3B).
Regarding the Covid-19 infection, the patient developed acute hypoxemic respiratory failure during the night after takeover to our hospital. The initial Crossing-threshold-value of SARS-CoV-2 was 29.90. The oxygen saturation was 90% and a supply of 4 Liter oxygen per minute using a nasal cannula was necessary (Fig. 2). Thereafter, the oxygen therapy had to be continued for a total of 8 days. Auscultatory findings were bilateral basal crackles over the lungs. Cough or fever did not occur, the patient's sense of smell and taste were still retained. Due to the National Institutes of Health his Covid-19 pneumonia was classified as severe (https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/).
Initially, the therapy was switched to intravenous prednisolone 60 mg daily over 4 days. There was a drop in CRP and procalcitonin values, but also of hemoglobin. Unfortunately, up to 10 bloody bowel movements per day persisted under therapy, why the patient required four transfusions of red blood cell concentrates.
After detailed multidisciplinary risk–benefit assessment, we changed the immunosuppressive treatment by initiating intravenous therapy of tacrolimus daily in a dose of 0.01 mg/kg bodyweight over the time of 12 h on February 26th. Simultaneously, the dose of prednisolone was tapered gradually. According to symptomatic response, we continued tacrolimus therapy under drug monitoring (trough level: 4.0–15.0 µg/l). As the gastrointestinal symptoms were controlled, therapy was adjusted to infliximab with first administration of 400 mg on March 5th.
Laboratory parameters regarding inflammation declined significantly over the course of the patient’s hospitalization (Fig. 2). Additionally, the Crossing-threshold-value—reflecting the SARS-CoV-2 virus load in nasopharyngeal swabs—remained continuously detectable but stable indicating that Covid-19 infection was kept under control despite immunosuppression. In addition, SARS-CoV-2 antibodies were detected serologically. On March 9th the patient could be released in clinical remission. The 2nd and 3rd infliximab infusions were administered on an outpatient setting and the patient was still in clinical remission.