PMC8212022_01
(A-D) Case presentation of 65-year-old male patient with COVID-19, 5 days after tocilizumab (TCZ), non-contrast abdominal CT. (A,B) Axial, (C) coronal, and (D) 3D reconstruction, pneumatosis intestinalis (PI) involving ascending colon (yellow arrows), with dilated multiple right lower quadrant small bowel loops with mesenteric and portal venous gas (yellow arrowheads).
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F1
Progressive abdominal distension warranted a CT scan demonstrating extensive colon and small bowel pneumatosis with mesenteric and portal venous gas, raising suspicions of bowel ischemia (Figures 1A-D).
PMC8212022_02
(A-D) Case presentation of a 61-year-old male COVID-19 patient with respiratory failure on TCZ with rising lactate, abdominal ileus, abdominal CT with intravenous and oral contrast, (A) axial, (B) coronal, (C) sagittal, and (D) 3D reconstruction, with ileus and small and large bowel dilatation, with small bowel and cecal pneumatosis (yellow arrows) with portal gas (yellow arrowheads), and splenic and mesenteric vein gas.
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F2
Abdominal CT scan reported gas in the portal vein and superior mesenteric artery, as well as cecal and small bowel pneumatosis (Figures 2A-D).
PMC8212022_03
(A-D) Case presentation of a 63-year-old male patient, with dyspnea, cough, fever from COVID-19, with bloody diarrhea, and abdominal distention 3 days after receiving TCZ, abdominal CT with oral contrast only, (A) axial, (B) coronal, (C) sagittal, and (D) 3D reconstruction with consolidation seen along lung bases, and pneumatosis of small bowel loops (yellow arrows) with dilated small and large bowel loops consistent with ileus.
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F3
Subsequent CT scan showed diffuse small and large bowel pneumatosis (Figures 3A-D).
PMC8212022_04
(A-D) Case presentation of a 64-year-old male patient, with altered mental status, acute kidney injury, DM2, stroke, bacterial pneumonia with COVID-19, single-dose TCZ, hypotensive, oliguric, non-contrast abdominal CT only, (A) axial, (B) coronal, (C) sagittal, and (D) 3D reconstruction with pneumatosis of distal transverse colon, cecum, terminal ileum, and mesenteric venous gas adjacent to the terminal ileum (yellow arrows) concerning for bowel ischemia. There are foci of air in mesenteric vessels in the right lower quadrant, with portal venous gas (yellow arrowheads).
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F4
One week after the hospital transfer, abdominal distension on physical exam prompted a CT scan that revealed gas in the portal vein and mesentery as well as extensive intestinal pneumatosis (Figures 4A-D).