key: cord-309608-oal60som authors: Luo, Shihua; Zhang, Xiaochun; Xu, Haibo title: Don't Overlook Digestive Symptoms in Patients With 2019 Novel Coronavirus Disease (COVID-19) date: 2020-03-20 journal: Clin Gastroenterol Hepatol DOI: 10.1016/j.cgh.2020.03.043 sha: doc_id: 309608 cord_uid: oal60som nan I n late December 2019, a cluster of patients with pneumonia of unknown cause was linked epidemiologically to a seafood and wet animal wholesale market in Wuhan City, China. The causative pathogen subsequently was identified as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 1 Over the course of the current pandemic, it became apparent that some patients can present with abdominal symptoms without fever or respiratory manifestations, and could be overlooked by health care providers. We present a case series of hospitalized patients with SARS-CoV-2 infection whose initial symptoms were gastrointestinal. This retrospective study was approved by the Medical Ethical Committee of Zhongnan Hospital of Wuhan University. We evaluated all 1141 cases of 2019 novel coronavirus disease (COVID-19) admitted to Zhongnan Hospital of Wuhan University from January 1, 2020, to February 20, 2020. A diagnosis of COVID-19 pneumonia was based on the COVID-19 Prevention and Control Program (4th edition) published by the National Health Commission of China. 2 All patients received chest computed tomography (CT) and had throat-swab specimens obtained and maintained in viral-transport media. Reversetranscription polymerase chain reaction detection reagents were provided by the Center for Disease Control and Prevention, Wuhan, Hubei Province. Laboratory confirmation of COVID-19 was performed both in our hospital and the Center for Disease Control and Prevention laboratory of Hubei Province. Confirmed cases of COVID-19 infection were defined as those with a positive test result from either laboratory. 3 Of 1141 confirmed COVID-19 cases, 183 (16%) presented with gastrointestinal symptoms only, and their clinical characteristics are summarized in Table 1 . Men slightly outnumbered women, and the most common gastrointestinal symptom was loss of appetite, followed by nausea and vomiting, which occurred in approximately two thirds of cases. Diarrhea and abdominal pain were the presenting symptom in 37% and 25% of patients, respectively. Laboratory testing showed that mean leukocyte (2.7 AE 0.2 Â10 9 /L) and lymphocyte (0.53 AE 0.014 Â10 9 /L) counts were below normal, and C-reactive protein levels were increased (18.7 AE 6.8 mg/L). Mild increases in serum aminotransferases were noted (aspartate aminotransferase, 65.8 AE 12.7 U/L; alanine aminotransferase, 66.4 AE 13.2 U/L), but renal function generally was intact. At the onset of their illness, 175 of 183 (96%) of patients had lung lesions on chest CT, which were unilateral in 61% of cases. The most common CT findings were abnormal lung texture (83%), ground-glass densities (73%), consolidation (27%), and pleural effusion (11%). The mean time elapsed for confirmation of COVID-19 was 3.5 days from the onset of symptoms. Of the 183 patients, 7 died of progressive respiratory failure, and 176 recovered. Patients with COVID-19 typically present with fever or a respiratory syndrome. Our case series shows that some patients can present with gastrointestinal symptoms, with a paucity of other manifestations. Such patients could be overlooked, leading to potentially serious consequences to them and their contacts. It is important that clinicians are aware that COVID-19 can present with predominantly gastrointestinal symptoms, and maintain appropriate vigilance and a high index of suspicion. SARS-CoV-2 can enter angiotensin converting enzyme II (ACE2)-expressing cells. ACE2 is expressed not only in lung AT2 cells, but also can be found in the upper esophagus, and in stratified epithelial cells and absorptive enterocytes in the ileum and colon. 4 The enteric symptoms of SARS-CoV-2 may be associated with invaded ACE2-expressing enterocytes. 5 These findings 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 suggest that the digestive system, along with the respiratory tract, may be a potential route for SARS-CoV-2 infection, and could explain why some patients present with gastrointestinal symptoms. Much still needs to be learned about this zoonotic coronavirus that has crossed species to infect human populations, 6 and its spectrum of disease. 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 New coronavirus pneumonia prevention and control program (in Chinese) WHO. Laboratory testing for 2019 novel coronavirus (2019-nCoV) in suspected human cases. Interim guidance Cryo-electron microscopy structures of the SARS-CoV spike glycoprotein reveal a prerequisite conformational state for receptor binding Discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin A novel coronavirus from patients with pneumonia in China