A School Nurse With Anxiety, Diarrhea, Palpitations, and Cough

Jennifer Wachala, DO; Dushyant Singh Dahiya, MD; Farah Wani, MD; Asim Kichloo, MD

Disclosures

April 19, 2022

Discussion

The patient's clinical presentation of acute diarrhea, generalized weakness, tachycardia, mildly elevated D-dimer level, and recent exposure to sick contacts with SARS-CoV-2 infection raises suspicion of COVID-19. Her chest radiograph shows no lymphadenopathy, masses, opacities, or consolidations. She is most likely exhibiting gastrointestinal manifestations of infection with the Omicron variant of SARS-CoV-2.

Upon further questioning, the patient confirms that she has had no increase in appetite or unintentional weight changes and reports no skin changes, including diaphoresis, or heat intolerance. Results of thyroid function tests are within normal limits. In addition, despite a change in the quality and frequency of bowel movements, the patient reports no change in odor. She denies recent antibiotic use, recent hospitalization, or a prior history of C difficile colitis. The CT scan of the abdomen and pelvis did not show lymphadenopathy, colonic wall thickening, fat stranding, or other acute pathology.

For patients who present with diarrhea, a review of their medical history to assess susceptibility to other diseases is essential. The patient in this case is immunocompromised and is receiving long-term proton pump inhibitor therapy. These factors, in addition to her history of three or more bowel movements per day for more than 2 consecutive days, raise suspicion of C difficile colitis. However, she did not complain of additional abdominal symptoms, such as pain; stool testing for C difficile was negative; and the imaging studies showed no structural changes associated with C difficile colitis.

The patient's palpitations and tachycardia, coupled with new-onset diarrhea, raise concern for hyperthyroidism. This diagnosis is less likely given the chronicity of her symptoms, absence of change from baseline, and negative history and examination findings. In addition, she was not found to have depressed thyroid-stimulating hormone, elevated triiodothyronine, or elevated thyroxine levels.

She had a recent colonoscopy at age 50 years and has not had unintentional weight loss or hematochezia; thus, suspicion for colon adenocarcinoma is low. Finally, owing to the absence of lymphadenopathy and hepatosplenomegaly on both examination and imaging, and the lack of early satiety, fever, or night sweats, lymphoma reactivation seems unlikely. In this case, the patient's presentation is best explained by gastrointestinal complications of COVID-19 caused by the Omicron variant.

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