Re: Jan-Niclas Mumm, Andreas Osterman, Michael Ruzicka, et al. Urinary Frequency as a Possible Overlooked Symptom in COVID-19 Patients: Does SARS-CoV-2 Cause Viral Cystitis? Eur Urol. In press. https://doi.org/10.1016/j.eururo.2020.05.013 : Severe Involvement of the Urinary Tract During COVID-19 Infection

Abstract

Mumm et al [1] reported that urinary frequency might be a symptom of SARS-CoV-2. This assumption is based on the finding that the bladder urothelium, as well as the kidney, harbors cells expressing ACE2, the receptor for the viral spike protein [2], [3]. Our experience appears to confirm their suspicion, further suggesting that the urinary tract may become the target of life-threatening involvement by SARS-CoV-2. We report three cases of gross hematuria admitted to two hospitals in Northern Italy between February 26 and March 29, 2020. The severity of hematuria greatly worsened after contracting symptomatic COVID-19 infection during hospitalization. Clinical and laboratory details are summarized in Table 1 . The clinical scenario in one representative patient is described. Table 1 Reason for admission, pre-existing urologic condition, and characteristics of patients at the onset of COVID-19 symptoms Table 1 Patient 1 Patient 2 Patient 3 Age (yr) 66 72 84 Sex Male Male Male Reason for admission Hematuria, urinary retention Hematuria Hematuria Urologic condition Radiation cystitis Benign prostate hyperplasia Benign prostate hyperplasia COVID-19 symptoms Fever 38 °C, diarrhea Fever 39 °C, cough Fever 38 °C, cough Time from exposure (d) 6–8 7 5 Oxygen saturation (%) 98 95 95 Radiography of chest Normal Bilateral opacities Bilateral opacities C-reactive protein (mg/l) 180 125 38 Procalcitonin (ng/ml) 2.0 0.05 0.37 White blood cells (/mm3) 3600 4700 3300 International normalized ratio 1.45 1.25 1.54 Serum creatinine (mg/dl) 1.3 0.9 1.4 Swab for COVID-19 Positive Positive Positive Treatment of hematuria Endoscopic Embolization Conservative Respiratory support Noninvasive ventilation High-flow oxygen High-flow oxygen Anticoagulants None None Low-dose aspirin A 66-yr-old man (Patient 1) with a history of nonsevere radiation-induced hemorrhagic cystitis after radical prostatectomy and radiation therapy for pT3b prostate cancer in 2005 was admitted to an external hospital for recurring hematuria. On hospital day 23, after a course characterized by mild hematuria and anemia and negative abdominal computed tomography (CT), he developed hypotension and fever. A blood culture tested positive for a methicillin-resistant Staphyloccus aureus and repeat CT imaging showed a 3-cm renal abscess; systemic therapy with piperacillin/tazobactam was initiated. On hospital day 25, owing to worsening hematuria with severe anemia requiring multiple transfusions, the patient was transferred to the Department of Urology in a tertiary referral hospital. In addition to persisting hematuria and fever, the patient developed diarrhea. A chest X-ray was negative and his O2 saturation was 98%. A test to detect SARS-CoV-2 infection was positive. The patient was transferred to an intermediate care unit because of respiratory deterioration. After 3 wk of noninvasive ventilation, his laboratory and clinical parameters improved. Imaging confirmed that the renal abscess cleared following a 2-wk course of meropenem. The patient underwent cystoscopy, which revealed coagulation of bleeding foci. Biopsy of bladder tissue was consistent with radiation cystitis. He was discharged with clear urine. Patients 2 and 3 were admitted for mild anemia and hematuria related to their benign prostate hyperplasia. Similarly, severe hematuria developed after the onset of symptomatic confirmed COVID-19, requiring multiple blood transfusions, prolonged bladder irrigation, and embolization of hypogastric arteries in one case. Our experience suggests that SARS-CoV-2 can severely impair the urinary system. The time from suspected exposure to the onset of COVID-19 and worsening hematuria ranged between 5 and 8 d in the reported cases. In the face of a possible second wave of the pandemic, clinicians should be aware that a nontypical course of hematuria or other urinary symptoms might be related to a COVID-19 infection, especially in patients with a pre-existing condition of the urinary tract. Conflicts of interest : The authors have nothing to disclose.