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Gastrointestinal symptoms of 95 cases with SARS-CoV-2 infection

Our take —

SARS-CoV-2 infection was found in nearly half of fecal samples from infected patients with COVID-19 disease, and this proportion did not significantly differ by presence or absence of GI symptoms. GI tissues showed the presence of infection in two severe cases, but not in four non-severe cases. These results provide evidence that the GI tract may serve as a target of viral activity, though its role as a possible source of transmission is still unclear.

Study design

Case Series

Study population and setting

95 patients with laboratory-confirmed SARS-CoV-2 infections admitted to a single hospital in Zhuhai, China, from January 17, 2020 to February 15, 2020 (mean age 45 years, 47% male). 21% of patients had severe clinical disease. Fecal samples were tested for SARS-CoV-2 infection in 65 patients. Gastroscopy was performed on 6 patients (4 without severe disease and 2 with severe disease, who also had proctoscopy performed). Samples from esophagus, stomach, duodenum, and rectum were tested for SARS-CoV-2 infection.

Summary of Main Findings

58/95 (61%) of patients exhibited GI symptoms (most commonly diarrhea [24%], nausea [18%], and anorexia [18%]. Among these, 19% exhibited symptoms at admission, and 81% developed symptoms after admission. 30 of these 58 patients developed hepatic impairment during hospitalization. 52% of fecal samples from patients with GI symptoms, and 39% from those without, tested positive for SARS-CoV-2 infection (p=0.31). SARS-Cov-2 was detected in tissue from the esophagus, stomach, duodenum, and rectum from the two sampled patients with severe disease. Among four patients without severe disease, SARS-CoV-2 was not detected in esophagus, stomach, and duodenum samples.

Study Strengths

Patient presentations were well characterized. PCR testing for SARS-CoV-2 infection in fecal samples and tissue provides useful evidence for potential GI involvement in transmission.

Limitations

There is no information provided on how these individuals were selected from the broader population of COVID-19 patients. A small number of patients (n=6) were tested for presence of SARS-CoV-2 infection in GI tissue. Nearly one-third of COVID-19 patients did not have fecal samples tested. Treatments such as antibiotics may have contributed to GI symptoms after admission, as noted by authors. There is not sufficient information presented regarding how GI symptoms were ascertained; self-report is subject to recall bias. Finally, there is no information regarding the timing of onset for patients presenting with GI symptoms; these may be unrelated to SARS-CoV-2 infection.

Value added

Although it has previously been reported that SARS-CoV-2 infection can be found in stool, this is one of the only published studies to date reporting on the prevalence of SARS-CoV-2 infection in a case series of fecal and GI tissue samples. The presence of virus in these tissues may suggest new mechanisms of infection and disease.