An 83-year-old man presented to our department with one-day history of increasingly severe, continuous lower abdominal pain, without hyperpirexia, nausea or vomit. At this time, an increasing but still limited number of newly diagnosed COVID-19 patients were admitted on another floor of the same hospital. Patient's comorbidities included chronic obstructive pulmonary disease (COPD), arterial hypertension chronic and ischemic heart disease, previously treated by coronary angioplasty. At physical examination, the patient was eupnoic, blood pressure was 140/85 mmHg and heart rate 100 beats/minute, the abdomen was bloated and presented diffuse rebound tenderness. Blood tests showed hyperleucocytosis (WBC count: 20 x 103/muL) with neutrophilia (90%), and increased CRP (264 mg/L), without any other relevant alteration. Abdominal CT-scan showed free air, liquid collections, and severe inflammatory thickening of the sigmoid colon, presenting multiple diverticula (Fig. 1).
Laparotomy confirmed acute sigmoiditis associated with diffuse purulent peritonitis, and Hartmann's procedure (sigmoid resection and descending colon terminal stoma) was carried out. An otherwise uneventful postoperative course (first flatus on postoperative day (POD) 3, solid food resumption on POD 4, was marked by a persistent hyperleukocytosis, as WBC count ranged between 17 x 103/muL and 20 x 103/muL through POD 8, despite antibiotic therapy (piperacillin/tazobactam and metronidazole).
On POD 8 afternoon, the patient suddenly presented dry cough, sore throat, dyspnea and hyperpirexia (temperature: 38.5  C) and hypoxemia (SaO2: 88-90%) under ambient air. As he was transferred to the ICU for ongoing acute respiratory failure, further imaging examinations were planned for the differential diagnosis, being lobar pneumonitis and/or COPD exacerbation the most likely etiologies suspected. Later that day, the patient reported that his 70-year-old partner, one week before (on patient's POD 2), presented cough and mild hyperpyrexia (T: 37.8  C), was admitted to another hospital and underwent oropharyngeal swab, which later (on POD 7) resulted positive for SARS-CoV-2. Our patient's oropharyngeal swab, by real-time reverse-transcriptase-polymerase-chain-reaction (rRT-PCR), was then collected in accordance with WHO guidelines for the management of the current COVID-19 outbreak. A high-resolution computed tomography (HRCT) scan identified extensive bilateral unusual interstitial pneumonitis (Fig. 2). Owing to rapidly deteriorating respiratory function, on POD 9, the patient underwent intubation and mechanical ventilation, initially in supine position and later in prone position. On POD 10, oropharyngeal swab test resulted positive for SARS-CoV-2. Few hours later, the patient died by respiratory failure refractory to any treatment.
Shortly after SARS-CoV-2 infection was suspected, on POD 9, a retrospective investigation of patient's person-to-person contacts with medical and non-medical personnel was undertaken, in order to identify any possible further contagion. Three days after patient's death, patient's partner died by COVID-19-related respiratory failure, too. One week later, the oropharyngeal swab test of two members of our team resulted positive and three negative; the results of five more are expected.
High-resolution computed tomography scan of lung showing extensive bilateral interstitial pneumonitis.