Thrombosis is one of the rare but serious side effects of SARS-CoV-2 vaccine, and occurs mostly at unusual sites, such as cerebral or abdominal veins and even arteries.1, 2, 3 Recently, we encountered a case of unusual site ischemic colitis after COVID-19 vaccination, and considered it a rare adverse effect of the vaccine. Now it is hereby reported.
A 68-year-old female presented with a history of marked flu-like symptoms and persistent fatigue after receipt of the second dose of COVID-19 vaccine (Sinovac Life Sciences, Beijing, China), and lower abdominal pain associated with transient nausea and diarrhea 10 days after the vaccination. Past medical history included hypertension and diabetes mellitus. Medications included plendil 5mg qd, aspirin 20mg bid, dapagliflozin 5mg qd, metformin hydrochloride 0.5g bid, etc., which she had been taking for several years before the onset of her symptoms. Both blood pressure and glucose levels were daily well controlled.
Abdominal examination was unremarkable except for the right lower quadrant tenderness without spasm or rigidity. Laboratory investigations were normal except mild elevated CRP (61mg/L), a positive fecal occult blood test. Novel coronavirus antibody test showed a positive IgM. Contrast-enhanced CT scan showed heterogeneous enhancement and wall thickening of the ascending colon with compensatory dilated tortuous arterioles. Colonoscopy showed deep solitary ulcer and scattered mucous membrane congestion within ascending colon. The ulcer was 3 cm × 4 cm in size with a thick white coating over the base and edematous surrounding mucosa. Biopsies showed hyperemia, edema, hemorrhage and necrosis of bowel wall with various degrees of nonspecific inflammatory reaction (Fig. 1 ). Colon cancer, lymphoma, Crohn's disease, intestinal tuberculosis, infectious diseases, as well as the systemic autoimmune diseases were all excluded after further laboratory examination of autoantibodies, virological testing, acid-fast staining and immunohistochemical staining. The patient was eventually diagnosed with atypical ischemic colitis at uncommon site, which was suspected to be connected with the COVID-19 vaccination. After 10 days of close observation, liquid diet without specific therapy, she was safely discharged.
Figure.
Radiological, endoscopic and histopathologic features.
A-B. of in contrast-enhanced CT imaging of the ascending colon showed heterogeneous enhancement and wall thickening (red arrow). Compensatory dilated tortuous arterioles were seen. C. FDG PET/CT scan revealed focally increased FDG uptake. D-F. Colonoscopy showed deep solitary ulcer and scattered mucous membrane congestion within ascending colon. G-H. Pathology showed hyperemia, hemorrhage (black arrow), necrosis with various degrees of nonspecific inflammatory reaction (yellow arrow).
Thromboembolic events and hypercoagulability in COVID-19 patients have been described with incidence of 14.7% in venous thromboembolic event (VTE) and 3.9% in arterial thromboembolic event (ATE).4 Vaccine-induced syndrome of severe thrombosis was also reported sporadically, and hence caused a brief pause of vaccination (AZD1222) in a number of European countries.1 , 5, 6, 7, 8 To the best of our knowledge, ischemic colitis related to COVID-19 vaccine-induced thrombosis has never been described. We are unable to attribute the cause of the patient's ischemic colitis to the vaccine unless further data are published. However, given the nature of post-vaccination morbidity, atypical site involvement and the current literature on vaccine-related thrombosis, we highly suspect that COVID-19 vaccine induced ischemic colitis in this patient who had high risk factors such as hypertension and diabetes. Even “benefits still outweigh the risks despite possible link to rare blood clots”6, healthcare providers should stay vigilant for possible cases of thrombotic diseases including this potential side effect — ischemic colitis.
Contributors
XH and CZ cared for the patient, drafted the manuscript, acquired and interpreted the data, and searched the literature. JW acquired and evaluated the clinical pathological data. We all revised the manuscript. Written consent for publication was obtained from the patient.
Declaration of competing interest
We declare no competing interests.
References
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