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Am Fam Physician. 2022;106(4):362

Original Article: Ulcerative Colitis: Rapid Evidence Review

Issue Date: April 2022

To the Editor: Dr. Adams and colleagues note that certain infections may be predisposed to the development of ulcerative colitis and concisely summarize evidence on the treatment of patients with ulcerative colitis who become infected with SARS-CoV-2. However, it is important to be aware that there is also evidence to suggest that COVID-19 might lead to ulcerative colitis.

Published case reports include ulcerative colitis confirmed by colonoscopy in a 19-year-old woman who presented to the hospital with gastrointestinal COVID-19,1 a 51-year-old man hospitalized for COVID-19 pneumonia who developed colitis two weeks after discharge,2 a “young female” who developed new colitis one month after hospitalization for COVID-19,3 a 55-year-old man who developed new colitis three months after hospitalization for respiratory COVID-19,4 a 37-year-old man who developed colitis two months after recovery from moderately severe respiratory COVID-19,5 a 64-year-old man who developed colitis three weeks after recovery from mild respiratory COVID-19,5 and a 71-year-old woman with no history of inflammatory bowel disease who died from complications of acute ulcerative colitis following admission to the hospital for COVID-19 pneumonia.6

The mechanisms by which infection with SARS-CoV-2 might induce new-onset ulcerative colitis in a previously healthy patient are unclear. The presence of angiotensin-converting enzyme 2 receptors in the intestinal epithelium may allow binding of the viral spike protein and cellular entry,1,2,4 generalized intestinal inflammation in response to infection may play a role,3 and tumor necrosis factor (part of the cytokine storm characteristic of severe COVID-19 and part of the inflammatory response in ulcerative colitis) may play a role.5 Physicians should be aware that new-onset diarrhea in patients recovering or recovered from COVID-19 could represent new-onset ulcerative colitis rather than a transient intestinal upset or viral gastroenteritis.

Editor's Note: This letter was sent to the authors of “Ulcerative Colitis: Rapid Evidence Review,” who declined to reply.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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