Rectum necrosis in a patient with severe COVID19 infection after CAR-T therapy: a case report.

BACKGROUND: Coronavirus disease 2019 (COVID19) can cause gastrointestinal complications as well as respiratory tract disease. Coagulation abnormalities and thrombosis frequently occur in COVID19, especially in cases with severe clinical outcome. The relationship between gastrointestinal perforation and coagulopathy due to COVID19 remains unclear. CASE PRESENTATION: A 49-year-old female received Chimeric antigen receptor T (CAR-T) therapy for an early recurrence of diffuse large B-cell lymphoma (DLBCL) that was refractory to chemotherapy. She was diagnosed with cytokine release syndrome (CRS) because of a fever and oxygen desaturation, and administered tocilizumab. Forty days after completing CAR-T therapy, she was infected with COVID19 and transferred to our hospital. Her general condition worsened and she developed COVID19 pneumonia, and then steroid pulse therapy was started. While her respiratory condition improved, she experienced pain in the anal region and computed tomography (CT) revealed a rectal perforation. An emergency surgery was undertaken, and the lower rectum wall was found to be completely necrotic. Removal of the necrotic part of the rectum tissue, and drainage and lavage of necrotic tissue in the pelvic cavity were performed. The remaining rectum was resected with partial sigmoidectomy, but we could not make the anal stump closed. In addition, an end colostomy in the sigmoid colon was performed. Histopathological findings showed thromboses in the rectal mesentery veins. After the first surgery, the pelvic abscess cavity persisted and her high-grade fever continued. Reoperation was laparoscopically performed, and she underwent a resection of anal canal with residual necrotic rectal and mesorectal tissue, and a drainage of the pelvic abscess. After the reoperation, her general condition improved and CT showed that the abscess cavity had significantly improved. CONCLUSIONS: Gastrointestinal perforation, especially rectal necrosis due to coagulopathy caused by severe COVID19 infection, is a rare but life-threatening complication. Physicians should have a high degree of clinical suspicion for timely diagnosis and management, and surgical intervention is necessary in cases of rectal necrosis.

[Congenital thrombotic thrombocytopenic purpura diagnosed in adulthood after repeated thrombocytopenia since neonatal period].

A 27-year-old woman was diagnosed with idiopathic thrombocytopenic purpura in the neonatal period, and was admitted to our hospital after presenting with impaired consciousness, purpura, nausea and vomiting, with a platelet count of 10×109/l. Congenital thrombotic thrombocytopenic purpura (cTTP) was suspected on the basis of recurrent thrombocytopenia and impaired consciousness, so tests for ADAMTS13 activity and inhibitor were performed. ADAMTS13 activity was severely decreased, ADAMTS13 inhibitor was negative, and platelet count increased after transfusion of fresh frozen plasma. These findings and the results of genetic testing done on all family members led to a diagnosis of cTTP. cTTP requires differential diagnosis even in adults. If a patient diagnosed with ITP in childhood has a history or findings that suggest cTTP during follow-up observation, it is necessary to actively consider ADAMTS13 testing.

Liquid tissue adhesive, subcuticular suture and subcutaneous closed suction drain for wound closure as measures for wound infection in a colorectal cancer surgery with stoma creation.

BACKGROUND/AIMS: Stoma creation is one of the risk factors for the incisional surgical site infection (SSI) which can develop the patient's pain in a colorectal surgery. METHODOLOGY: We performed the subcuticular suture with subcutaneous negative pressure drainage and sealing with liquid tissue adhesive for the prevention of wound infection at the stoma creation. RESULTS: A total of 72 patients between January 2006 and December 2012 were retrospectively analyzed. Up to December 2008, the wound closure was performed by the percutaneous transdermal interrupted suture with monofilament nylon sutures (conventional procedure). From January 2009, the 10-Fr silastic flexible drains were placed at the subcutaneous space and subcuticular suture using a monofilament absorption string was performed. A liquid tissue adhesive was used to seal the skin wound (revised procedure). There was no difference between the conventional group and the revised group in age and gender. Risk factors in two groups were not found the significant difference except diabetes mellitus. Incisional SSI was observed in 23 patients out of 72 patients (31.9%). There was no significant difference in incidence in clinicopathological factors. Only the revised procedure of wound closure significantly decreased 13.8% of incisional SSI rate from 44.2% in the conventional procedure. CONCLUSIONS: Our several changes of wound closure including tissue adhesive, subcuticular suture and subcuticular closed suction drainage reduced incisional SSI.