Pathohistological features of Clostridium difficile-associated pseudomembranous colitis in post-COVID-19 patients

AIM: to assess features of pathomorphological changes in the intestinal wall in patients who had new coronavirus infection SARS-CoV-2.
PATIENTS AND METHODS: the study included 8 patients who underwent surgery for complications of pseudomembranous colitis and had previously COVID-19. Six patients underwent colectomy, and two underwent subtotal colectomy with end ileostomy. Histology of the removed specimens was standard.
RESULTS: in all specimens, in addition to the changes peculiar for pseudomembranous colitis, vascular lesions of the bowel wall were detected as vasculitis of small arteries and vessels of the microcirculatory network, phlebitis and thrombosis of venous vessels like in COVID-19. These pathological changes in blood vessels may reveal the intramural perfusion disorders of blood circulation, leading subsequently to ischemic changes.
CONCLUSION: when treating patients with pseudomembranous colitis and postcovid syndrome, it is necessary to take into account the mutually aggravating effect of both diseases, when assessing risks, determining indications for surgery and conservative measures.

1. Pan L, Mu M, Yang l. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, crosssectional, multicenter study. Am J Gastroenterol. 2020;115:766–773.

2. Xiao F, Sun J, Xu Y. Infectious SARS-CoV-2 in feces of patient with severe COVID-19. Emerg Infect Dis. 2020;26:1920–1922.

3. Han C, Duan C, Zhang S. Digestive symptoms in COVID-19 patients with mild disease severity: clinical presentation, stool viral RNA testing, and outcomes. Am J Gastroenterol. 2020;115:916–923.

4. Hoffmann M, Kleine-Weber H, Schroeder S. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell. 2020;181:271–280.

5. Babaev F.A., Babazade D.F. Gastrointestinal complications in patients with COVID-19. Modern problems of science and education.2021;4. (In Russ.). https://science-education.ru/ru/article/view?id=30969

6. Korneeva O.N., Ivashkin V.T. Antibioticassociatedcolitis: pathomorphology, clinic, treatment. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2007;17(3):65–70. (In Russ.).

7. Goudarzi M, Seyedjavadi SS, Goudarzi H, et al. Clostridium difficile infection: Epidemiology, pathogenesis, riskfactors, andtherapeutic options. Scientifica. 2014;2014:916826.

8. Culligan EP, Sleator RD. Advances in the microbiome: Applications to Clostridium difficile infection. J Clin Med. 2016; 5(9). Article ID 916826.

9. Ivashkin V.T., Shifrin O.S., Tertychny A.S., et al. Clostridium difficileassociated disease. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2015;25(6):5–17. (In Russ.).

10. Sheptulin A.A. Refractory and recurrent forms of colitis associated with Clostridium difficile. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2011;21(2):50–3. (In Russ.).

11. Pimanov S.I., Dikareva E.A. Gastroenterological manifestations of COVID-19: the first generalizations. Clinical analysis in general medicine.2020;1:6–13. (In Russ.). doi: 10.47407/kr2020.1.1.00001

12. Bartlett JG. Clostridium difficile: clinical consideration. Rev Infect Dis. 1990;12(2):243–251.

13. Lobzin Yu.V., Zakharenko S.M., Ivanov G.A. Modern ideas about Clostridium difficile infection. Clinical microbiology and antimicrobial chemotherapy. 2002;4(3):200–232. (In Russ.).

14. Finney JM. Gastroenterostomy for cicatriziny ulcer of the pylorus. Johns Hopkins Hosp Bull. 1893;11:53–55.

15. Pyakurel D. Pseudomembrenous colitis. Journal of Pathology of Nepal. 2019;9:1497–1501. doi: 10.3126/jpn.v9i1.23378

16. Furuya-Kanamori L, Marquess J, Yakob L, et al. Asymptomatic Clostridium difficile colonization: epidemiology and clinical implications.BMC Infect Dis. 2015;15:516.

17. SurawiczСM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478–98.

18. Sartelli M, Malangoni MA, Abu-Zidan FM, et al. WSES guidelines for management of Clostridium difficile infection in surgical patients. World J Emerg Surg. 2015;10:38.

19. Peterson LR, Gerding DN. Antimicrobial agents in Clostridium difficile-associated intestinal disease. In. Raumbaud J.-C., Ducluzeau R., editors. Clostridium difficile-associated Intestinal Diseases. Paris: springer Verlag. 1990:115–127.

20. Cohen H, Brocavich JM. Managing Clostridium difficile colitis in patients who lock oral acces. Infect Med. 1996;13:101–109.

21. Lipsett PA, Samantaray UK, Tam ML, et al. Pseudomembranous colitis: a Surgical disease? Surgery. 1994;116:491–496.

22. Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(23):2950–2973.

23. Tan BK, Mainbourg S, Friggeri A, et al. Arterial and venous thromboembolism in COVID-19: a study-level meta-analysis. Thorax. 2021;76:970–979.

24. Nopp S, Moik F, Jilma B, et al. Risk of venous thromboembolism in patients with COVID-19: a systematic review and meta-analysis. Res Pract Thromb Haemost.2020;4:1178–91.

25. Lowe GDO. Common risk factors for both arterial and venous thrombosis. Br J Haematol. 2008;140:488–95.

26. Previtali E, Bucciarelli P, Passamonti SM, et al. Risk factors for venous and arterial thrombosis. Blood Transfus.2011;9:120–38.

27. Burn E, Duarte-Salles T, Fernandez-Bertolin S, et al. Venous or arterial thrombosis and deaths among COVID-19 cases: a European network cohort study. Lancet Infect Dis. 2022. May 13. doi: 10.1013/S1473-3099(22)00223-7

28. Gulshani H. Pseudomembranous colitis. PathologyOutlines.com website. Accessed June 30th, 2022.https://www.pathologyoutlines.com/topic/colonAAcolitis.html.

29. Poutanen SM, Simor AE. Clostridium difficile-associated diarrhea in adults. Can Med Assoc J. 2004;171:51–58.

30. Dignan CR, Greenson JK. Can Ischemic Colitis in Biopsy Specimens? Am J Surg Pathol. 1997;21:706–710.

31. Zou X, Cao J, Yao Y, et al. Endoscopic findings and clinicopathologic characteristics of ischemic colitis: a report of 85 cases. Dig Dis Sci. 2009;54:2009–2015.

32. Yuan S, Reyes V, Bronner MP. Pseudomembranous Collagenous Colitis. Am J Surg Pathol. 2003;27:1375–1379.

33. Olofinlade O, Chiang C. Cytomegalovirus Infection as a Cause of Pseudomembranous Colitis. A Report of Four Cases. J Clin Gastroenterol. 2001;32:84–84.

34. Froberg MK, Palavecino E, Dykoski R, et al. Staphylococcus aureus and Clostridium difficile Cause Distinct Pseudomembranous Intestinal Diseases. Clin Infect Dis. 2004;39:747–750.