Serial number of this case
Please record this serial number locally with the patient identifiers in case further clinical details will be required
Name of reporting center
Name of treating physician
email address of treating physician
Year of birth
Month of birth January February March April May June July August September October November December
Gender Male
Female
Ethnicity Native American/Canadian
Black/ African American
Arab
Western European
Native Australian
Hispanic
Eastern European
South Asian (Indian)
East Asian
Other
If other, please detail
Country of residence
Smoking status No exposure
Active smoker
Passive exposure
Does the patient suffer from any other chronic disease other than IBD? Yes No
Please detail
Type of IBD Crohn's Disease
Ulcerative Colitis
IBDU
Date of diagnosis
Today D-M-Y
Age at diagnosis
Extent (E) E1 Ulcerative proctitis
E2 Left-sided UC (distal to splenic flexure)
E3 Extensive (distal to hepatic flexure)
E4 Pancolitis (proximal to hepatic flexure)
Severity (S) S0 (never severe*)
S1 (ever severe*)
*Severe defined by PUCAI>=65
Age at Diagnosis (A) A1a (0-< 10 y)
A1b (10-< 17y)
A2 (17-40 y)
A3 (above 40 yrs)
Disease Location (L) L1 (distal 1/3 ileum plus minus limited cecal disease)
L2 (colonic)
L3 (ileocolonic)
L4a (upper disease proximal to ligament of Treitz)*
L4b (upper disease distal to ligament of Treitz and proximal to distal 1/3 ileum)*
*L4 and L4a/L4b may coexist with L1,L2, L3
Behavior (B) B1 (Non-stricturing Non-penetrating)
B2 (Stricturing)
B3 (Penetrating)
P (Perianal disease modifier)**
**P is added to B1-B3 when concomitant perianal disease is present
Growth (G) G0 (no evidence of growth delay)
G1 (growth delay)
Date of lab work
Today D-M-Y
Platelet 10^3/uL Not Done
Platelet result
WBC 10^3/uL Not Done
WBC result
Hemoglobin (gr/L) (gr/dL) Not Done
Hemoglobin result
Standardized Hb Result (gr/dL) View equation
Albumin gr/L gr/dL Not Done
Albumin result
Standardized Albumin Result (gr/dL) View equation
ESR mm/h Not Done
ESR result
CRP mg/L mg/dL mg/% Not Done
CRP Upper Limit of Normal
CRP result
Standardized CRP Result (mg/dL) View equation
Fecal calprotectin ug/g Not Done
Fecal calprotectin result
ug/g
Global assessment of disease activity Complete deep remission (clinically and, as much as known, also endoscopically)
Clinical remission (but, as much as known, endoscopically active)
Mild disease activity
Moderate disease activity
Severe disease activity
Prior to COVID-19 exposure
Longitudinal physician global assessment of the year prior to infection
Longitudinal physician global assessment of the year prior to infection None: IBD in continuous clinical and laboratory remission in the past 12 months (choose this option also if active disease at first visit but rapidly entered sustained remission).
Mild: mild activity at least intermittently (choose this option also if clinically well but constant elevation of serum/fecal biomarkers of inflammation).
Moderate: moderate IBD exacerbation (not requiring hospitalization), but with periods of clinical remissions.
Severe: moderate IBD exacerbation without significant clinical remissions, or subsequent severe exacerbation(s), requiring hospitalization.
wPCDAI score (prior to infection)
Clinical disease activity prior to infection
PUCAI score (prior to infection)
Clinical disease activity prior to infection
Did patient undergo IBD related surgery in the past? Yes No
Type of last imaging prior to COVID-19 infection US MRE CTE
Date of last imaging test
Today D-M-Y
Imaging results
Date of last endoscopic assessment
Today D-M-Y
Assessment of results (based on SESCD or Lewis score in CD and UCEIS in UC) None
Mild
Moderate
Severe
Please describe endoscopic results
Please select current IBD medication (within 3 months of infection) EEN
Steroids
5ASA
6MP/Azathioprine
Mtx
Infliximab
Adalimumab
Golimumab
Cimzia
Vedolizumab
Ustekinumab
Tofacitinib
Other
EEN start date
Today D-M-Y
EEN dose
Was EEN stopped? Yes No
EEN stop date
Today D-M-Y
Steroids start date
Today D-M-Y
Steroids dose
Were steroids stopped? Yes No
Steroids stop date
Today D-M-Y
5ASA start date
Today D-M-Y
5ASA dose
Was 5ASA stopped? Yes No
5ASA stop date
Today D-M-Y
6MP/AZA start date
Today D-M-Y
6MP/AZA dose
Was 6MP/AZA stopped? Yes No
6MP/AZA stop date
Today D-M-Y
Mtx start date
Today D-M-Y
Mtx dose
Was Mtx stopped? Yes No
Mtx stop date
Today D-M-Y
Infliximab start date
Today D-M-Y
Infliximab dose
Was Infliximab stopped? Yes No
Infliximab stop date
Today D-M-Y
Adalimumab start date
Today D-M-Y
Adalimumab dose
Was Adalimumab stopped? Yes No
Adalimumab stop date
Today D-M-Y
Golimumab start date
Today D-M-Y
Golimumab dose
Was Golimumab stopped? Yes No
Golimumab stop date
Today D-M-Y
Cimizia start date
Today D-M-Y
Cimzia dose
Was Cimzia stopped? Yes No
Cimzia stop date
Today D-M-Y
Vedolizumab start date
Today D-M-Y
Vedolizumab dose
Was Vedolizumab stopped? Yes No
Vedolizumab stop date
Today D-M-Y
Ustekinumab start date
Today D-M-Y
Ustekinumab dose
Was Ustekinumab stopped? Yes No
Ustekinumab stop date
Today D-M-Y
Tofacitinib start date
Today D-M-Y
Tofacitinib dose
Was Tofacitinib stopped? Yes No
Tofacitinib stop date
Today D-M-Y
If other, please detail
Other start date
Today D-M-Y
Other dose
Was Other stopped? Yes No
Other stop date
Today D-M-Y
Past IBD medication (discontinued at least 3 months prior to infection) EEN
Steroids
5ASA
6MP/Azathioprine
Mtx
Infliximab
Adalimumab
Golimumab
Cimzia
Vedolizumab
Ustekinumab
Tofacitinib
Other
Was patient receiving any other medication not related to IBD Yes No
Please detail
The COVID-19 diagnosis was Confirmed Suspected
Date of confirmed COVID-19 diagnosis
Today D-M-Y
Why was this suspected case not confirmed by virology testing?
What is the current local testing policy for COVID-19 in children?
Confirmation based on
Patient weight (kg) closest to COVID-19 infection
kg
Patient height (cm) closest to COVID-19 infection
cm
Who was the index contagious case, if known
Presenting symptoms (asymptomatic. highest fever, cough, dyspnea, other)
Severity of COVID 19 infection asymptomatic
mild
moderate
severe
COVID-19 related hospitalization Yes No
Number of hospitalization days
Pediatric Intensive Care Unit admission Yes No
Mechanical ventilation Yes No
ECMO Yes No
Total days from symptoms to clinical resolution of the infection
Were there residual symptoms related to COVID-19 at time of report? Yes No
If yes, please detail
Did the patient receive any antiviral medication Yes No
Name of antiviral medication
Did the infection induce a flare of the IBD? Yes No
If yes, please specify: Mild Moderate Severe
Did you stop the IS medication? Yes No
Which IS medication was stopped?
Date IS medication was stopped?
Today D-M-Y
Date IS medication was re-started?
Today D-M-Y
Death Yes No
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