Spontaneous bowel perforation due to norovirus: A case report

Abstract

Norovirus is the leading cause of epidemic gastroenteritis worldwide but the disease is usually self-limiting and generally only causes serious health problems in the young, elderly and immunocompromised. The authors report a case of bowel perforation in an elderly Caucasian lady with confirmed infection with Norovirus genogroup II and no other presumptive cause. To the authors' knowledge this is the first such case of bowel perforation due to Norovirus. Viral gastroenteritis should be considered in the list of differentials when no obvious cause of bowel perforation can be identified to minimise morbidity and mortality.

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Cases Journal
Open Access
Case Report
Spontaneous bowel perforation due to norovirus: a case report
Nikhil Pawa, Andrew P Vanezis* and Matthew G Tutton
Address: Department of General Surgery, Colchester University Hospital, Turner Road, Colchester, Essex, CO4 5JL, UK
Email: Nikhil Pawa - nikhil@pawa.me.uk; Andrew P Vanezis* - andrewvanezis@doctors.org.uk; Matthew G Tutton - info@matthewtutton.co.uk
* Corresponding author
Abstract
Norovirus is the leading cause of epidemic gastroenteritis worldwide but the disease is usually self-
limiting and generally only causes serious health problems in the young, elderly and
immunocompromised. The authors report a case of bowel perforation in an elderly Caucasian lady
with confirmed infection with Norovirus genogroup II and no other presumptive cause. To the
authors' knowledge this is the first such case of bowel perforation due to Norovirus. Viral
gastroenteritis should be considered in the list of differentials when no obvious cause of bowel
perforation can be identified to minimise morbidity and mortality.
Introduction
Since the developments of molecular diagnostic methods,
Noroviruses have been documented as the leading cause
of epidemic gastroenteritis in all age groups, causing
greater than 90% of non-bacterial and approximately
50% of all epidemic gastroenteritis worldwide [1].
Colloquially known as 'gastric flu' or the 'winter vomiting
bug', Norovirus is a member of the Caliciviridae family of
viruses and is thought to be the leading cause of infectious
gastroenteritis in England and Wales [2]. Initially coined
'Norwalk' virus after the small town of Norwalk in Ohio
where an outbreak of acute gastroenteritis struck a pri-
mary school in the late 1960s, the virus was given its cur-
rent name in 2002 by the International Committee on
Taxonomy of Viruses [3].
The virus is spread by the vomitus and faecal routes and as
such, there is a tendency for outbreaks to occur in
enclosed spaces, namely hospitals, nursing homes,
schools, offices and even cruises ships; in 2006, 679 peo-
ple on the cruise ship 'Carnival Liberty' contracted the
virus [4] and more recently in July 2009, 380 of the 769
passengers aboard the US cruise ship 'MS Marco Polo' on
a UK round-tour contracted the virus.
The norovirus group are singled stranded RNA viruses
with two main strains of the virus affecting humans.
Within these two groups numerous genotypes have been
detected, however it is thought that the genotype II.4 has
been the culprit for a predominant number of viral gastro-
enteritis in the last decade [5]. The numbers of laboratory
reported cases of norovirus infection shows considerable
yearly fluctuation but it is thought that the vast majority
of cases go unreported and as such it is difficult to deter-
mine the true scale of the disease. The majority of cases
occur in the winter period. In a 12 week period in winter
2007 there were 1325 laboratory reported cases in Eng-
land and Wales compared to 1845 cases in a similar time
period in 2002 [6].
Norovirus gastroenteritis is usually mild and self-limiting.
Studies on healthy adults demonstrate a short incubation
period (24-60 hours) and infection duration (12-60
Published: 27 November 2009
Cases Journal 2009, 2:9101 doi:10.1186/1757-1626-2-9101
Received: 1 November 2009
Accepted: 27 November 2009
This article is available from: http://www.casesjournal.com/content/2/1/9101
© 2009 Pawa et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cases Journal 2009, 2:9101 http://www.casesjournal.com/content/2/1/9101
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hours) with a high frequency of vomiting and diarrhoea
[7]. Other symptoms attributed to the disease include
headaches, low grade pyrexia, abdominal cramps and in
rare cases, seizures.
Case presentation
An 83 year old retired Caucasian lady was admitted to a
UK hospital with a recent history of back pain without any
trauma. She had no significant past medical history of
note and her only regular medication included a statin for
cholesterol. She was a non-smoker and drunk only mini-
mal amounts of alcohol. X-rays on admission demon-
strated severe osteoporosis with multiple collapsed
lumbar vertebrae. Whilst awaiting a brace and social sup-
port she developed diarrhoea and vomiting. An initial
stool sample was negative for clostridium difficile sero-
toxin. Over the next few days her clinical condition dete-
riorated and by day 6 her C-reactive protein was 357. She
developed abdominal distension, pain and a plain x-ray
showed centralised dilated small bowel loops. A subse-
quent CT scan of her abdomen revealed small bowel
obstruction together with mural thickening of the distal
ileum (see Figure 1).
Following CT the patient developed signs of localised
peritonitis and underwent a laparotomy. At surgery necro-
sis and ischaemia was seen in a large portion of mid-ileum
together with large quantities of pus and a localised perfo-
ration. A small bowel resection of 60 cm was performed.
Histology revealed an acute gangrenous ileitis. Blood,
urine and stool cultures were all negative but reverse tran-
scription polymerase chain reaction (RT-PCR) of stool
cultures revealed Norovirus genogroup II. Immunoassay
of the stool was negative for rotavirus and adenovirus. No
specific testing for astrovirus was performed. Immunolog-
ical testing of the histological specimens was not per-
formed.
The patient had no prior history of vascular disease to sug-
gest the cause of the ileitis was ischaemic enterocolitis.
Furthermore despite the patient's back pain she had been
mobilising around her bed in the hospital therefore it is
unlikely that the cause of the ileitis was paralytic ileus sec-
ondary to immobility. The patient received only as
required opiate analgesia and this was co-administered
with appropriate laxative cover to avoid constipation. A
diagnosis of acute gangrenous ileitis secondary to Norovi-
rus was therefore made. It was postulated that the virus
had triggered a localised inflammatory response leading
to necrosis which had continued despite clearing of the
virus by host immune responses. The virus was thought to
be a nosocomial infection as there was no recent history
of foreign travel or contact with individuals demonstrat-
ing the symptoms of gastro-enteric disease prior to admis-
sion. However antibody testing for IgG and IgM was not
performed therefore the length of infection with the virus
was unclear.
Following surgery the patient developed a pelvic collec-
tion requiring CT guided drainage which matured into an
enterocutaneous fistula. The fistula was treated conserva-
tively and sealed spontaneously at 10 weeks at which
point she was discharged.
Discussion
To the best of our knowledge this is the first reported case
of a small bowel perforation secondary to Norovirus
infection. Even so it must be noted that many infected
individuals remain asymptomatic. This is thought to be
due to acquired immunity as well as the body's innate
immunity. However most individuals' acquired immunity
does not last through to the next season of the disease
where they are again at risk of infection, thus explaining
the high rates of infection in all ages [8]. Studies have now
shown asymptomatic individuals to have mean viral
loads similar to those of symptomatic individuals, possi-
bly accounting for the increased number of infections and
the predominance of an asymptomatic transmission route
[9]. This is further supported by excretion studies per-
formed at an aged-care facility, revealing viral shedding
continuing for an average of 28.7 days [10]. Despite this
the mortality rates in healthy adults is low, with most
deaths occurring in the elderly, the young and the immu-
nocompromised.
Conclusion
The inclusion of viral gastroenteritis in the differential
diagnosis of patients presenting with an acute abdomen is
paramount. Potential surgical complications, particularly
in high risk groups, must always be considered early to
minimise morbidity and mortality.
Abdominal CT scan revealing small bowel obstruction together with mural thickening of the distal ileumFigure 1
Abdominal CT scan revealing small bowel obstruc-
tion together with mural thickening of the distal
ileum.

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Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MT was the chief clinician looking after the patient. NP
contributed to writing the case presentation and AV con-
tributed to writing the literature review and discussion. All
authors read and approved the final manuscript.
Acknowledgements
None
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