COVID-19 can cause acute abdominal pains in individuals as a result of Mesenteric Panniculitis

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medical researchers and physicians from the Department of Pulmonary Medicine and the Department of Radiodiagnosis at STAR Hospitals, Telangana have discovered yet another gastrointestinal issue that SARS-CoV-2 infections can cause. The study team found that COVID-19 can also cause acute abdominal pains in individuals as a result of Mesenteric Panniculitis and presented two documented case reports. 

The study findings were published in the peer reviewed Indian Journal of Critical Care Medicine.
https://www.ijccm.org/doi/pdf/10.5005/jp-journals-10071-24310  or  
https://pubmed.ncbi.nlm.nih.gov/36213717/

This article reports two cases of MP presenting with abdominal pain during the course of COVID-19 illness. The diagnosis of MP was made on the basis of clinical and radiologic findings. The association between the two diseases is less common.

Gastrointestinal symptoms in COVID-19 have been commonly reported in patients diagnosed with COVID-19, the most common being anorexia and diarrhea.6 Also patients with preadmission digestive symptoms in severe COVID-19 are shown to have a high proportional mortality rate.7

Severe GI complications are seen in critically ill subjects which include paralytic ileus, bowel ischemia/ bleed, acute pancreatitis, and elevated aminotransferase levels. Patients with COVID-19-related ARDS had higher rates of GI complications as compared to non-COVID-19 matched ARDS.8

Sclerosing mesenteritis is a broadly given term for a group of three similar clinical entities including MP, retractile mesenteritis, and mesenteric lipodystrophy. The nomenclature is based upon the pathologic findings found on biopsy which vary from fatty necrosis, and inflammation to fibrosis.9

It is not clear whether these three patterns are a part of the progressive disease process or separate entities. The etiology and pathogenetic mechanisms are not well known till now. The pathologic processes proposed as etiologies include abdominal surgery/trauma, autoimmune phenomenon, paraneoplastic process, and ischemia/infarction.

Infections triggering the mesenteric inflammation are very rare, reported in association with abdominal tuberculous lymphadenitis, cholera, schistosomiasis, HIV infection, and cryptococcosis.10

There is a case report published previously showing an association between mild COVID-19 disease and MP.11 Our first case underwent abdominal surgery 10 years back, unlikely to correlate with the current illness. Mesenteric inflammation either could be due to direct viral infection of the adipose tissue or inflammation secondary to immune system activation.

The human angiotensin-converting enzyme 2 (ACE2) has a remarkably high affinity binding to SARS-CoV-2.

The level of ACE2 expression in adipose tissue was found to be higher than that in lung tissue, indicating the adipose tissue
might be vulnerable to SARS-CoV-2 as well.12
The clinical features in symptomatic individuals can be acute or chronic in nature.

The common presenting symptom is abdominal pain seen in up to 78% of patients.10

Other symptoms include fever, weight loss, diarrhea, vomiting, constipation, anorexia, and malaise. Abdominal tenderness, palpable mass, and distended abdomen are the examination findings.

An abdominal CT scan is the best modality for the diagnosis of this condition. The findings include increased thickness of mesentery, increased fat density due to infiltration of inflammatory cells (misty mesentery sign), a halo of fat surrounding the mesenteric vessels (fat halo sign), pseudocapsule of peripheral band limiting the inflammatory mass, and displacement of bowel loops with variable degrees of bowel obstruction.13

These radiologic findings when incidentally diagnosed on abdominal CT scans have debatable clinical significance.
Misty mesentery has also been detected incidentally in abdominal cuts of CT thorax in patients with COVID-19 infection. These patients seem to have a high level of inflammation when compared to those without misty mesentery.14

Although biopsy of the lesion is confirmatory, it is not usually indicated in every patient. It is considered in cases with strong clinical suspicion of malignancy. Both our cases presented with abdominal symptoms (pain and tenderness) and had increased fat density of the mesentery, one case had a pseudocapsule sign on CT.

There are no standard treatment protocols followed in the management of the disease. The evidence comes primarily from the previous case reports and case series. Asymptomatic cases usually do not require any treatment. Glucocorticoids and tamoxifen are the commonly used drug in medical therapy. Surgical resection or debulking is indicated in extensive fibrosis and bowel obstruction.10,15

The clinical outcomes of the disease are usually good. However, few patients have a chronic debilitating course with a fatal outcome.15 Both index cases had a good clinical recovery after a course of steroids.

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