key: cord-353228-fxrf5wsp authors: Xiao, Yaru; Huang, Sufang; Yan, Li; Wang, Hui; Wang, Fang; Zhou, Ting; Deng, Juan; He, Mei title: Clinical characteristics of diarrhea in 90 cases with COVID-19: a descriptive study date: 2020-08-08 journal: Int Emerg Nurs DOI: 10.1016/j.ienj.2020.100912 sha: doc_id: 353228 cord_uid: fxrf5wsp BACKGROUND: The novel coronavirus disease (COVID-19) has spread worldwide. Herein, we aimed to clarify the epidemiological and clinical characteristics of patients presenting with diarrhea. METHODS: A descriptive design was adopted from Jan 10 to Feb 17, 2020. All the cases included were diagnosed with COVID-19 under the interim guidance of the WHO. RESULTS: 912 patients with COVID-19 were admitted to hospital, in which, 90 cases (9.87％) presented with diarrhea. Among the 90 cases, 8 cases (9％) presented with diarrhea as the initial symptom, and 24%, 17%, and 24% of the patients complained of nausea, vomiting, and poor appetite, respectively. The most common fecal characteristics on admission were watery stool (64%) and mushy stool (28%). For the defecation frequency, 37% of the cases defecated over three times a day. The median time from illness onset to diarrhea was 3.0 days (IQR 0.0-5.0) and the median duration of diarrhea was 5.0 days (IQR 2.0-9.3). CONCLUSION: Clinicians are required to promptly identify the patients with initial diarrhea symptoms and pay adequate attention to the nutrient requirements of the patients with diarrhea during hospitalization. Standardized management is also recommended for the discharge of the patients to avoid potential fecal-oral transmission. No conflict of interest relevant to this study exist. This study was approved by the Medical Ethical Committee of Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology (No.TJ-C20200136). This work was supported by the special fund for novel coronavirus pneumonia from Huazhong University of Science and Technology (Grant No.2020kfyXGYJ023). The novel coronavirus disease (COVID-19) has spread worldwide. Herein, we aimed to clarify the epidemiological and clinical characteristics of patients presenting with diarrhea. A descriptive design was adopted from Jan 10 to Feb 17, 2020. All the cases included were diagnosed with COVID-19 under the interim guidance of the WHO. 912 patients with COVID-19 were admitted to hospital, in which, 90 cases (9.87％) The novel coronavirus disease (COVID-19) has spread worldwide and the rapidly increasing cases indicate that COVID-19 can be transmitted from person to person 1 . During the current pandemic, droplets and contact are considered the main transmission routes of the novel coronavirus. Although fever and respiratory signs are the common initial and major symptoms, gastrointestinal (GI) symptoms (i.e. diarrhea) have also been observed in 2％-18.1％of the patients 2-7 . It has been reported that some patients showed only gastrointestinal symptoms without other typical manifestations of the COVID-19 infection but were subsequently confirmed to be infected by testing the collected fecal samples [7] [8] [9] , suggesting the potential occurrence of fecal-oral transmission. Therefore, it is speculated that the digestive system may serve as an alternative infection route. Among the gastrointestinal symptoms in COVID-19 cases including diarrhea, nausea, vomiting, and abdominal pain, diarrhea is the one that possibly increases the chance of potential fecal-oral transmission but could be easily overlooked by health care workers. Herein, we conducted a comprehensive study on the clinical features of ninety COVID-19 patients with diarrhea as the symptom before admission based on our first-hand experience, aiming to achieve a better understanding of the clinical manifestations of COVID-19 and help the clinicians accurately and promptly identify infected cases. This study was approved by the Medical Ethical Committee of Tongji Hospital (No.TJ-C20200136). We enrolled 90 cases of COVID-19 admitted to our hospital from Jan 10 to Feb 17, 2020, whose diagnosis of COVID-19 was based on the WHO interim guidance. The outcomes of all patients were recorded. The clinical, laboratory, and treatment outcome data were collected from electronic medical records. The recorded information included demographic data, medical history, underlying comorbidities, symptoms, signs, and laboratory findings. Disease onset was defined as the day when the symptom was noticed. Fecal characteristics during hospitalization were also included. Categorical variables were represented by frequency and percentages, and continuous variables were described by mean (SD) if they were normally distributed otherwise by median (IQR). For laboratory results, we had assessed whether the measurements were outside the normal range of laboratory standards of Tongji Hospital. SPSS (version 19.0) was used for all analysis. Among the 912 cases with COVID-19 we retrieved, 90 patients (9.87％) presented with diarrhea, and their demographics, clinical characteristics, and outcomes were summarized, as shown in Table 1 . The median age was 61.0 years (IQR 48.3-69.0), ranging from 22 to 82 years, with the number of male cases slightly outnumbering that of female cases. The top two common initial symptoms were fever and cough, followed by diarrhea which occurred in 8 cases (9％). Besides, 24%, 17%, and 24% of the patients complained of nausea, vomiting, and poor appetite, respectively. Comorbidities were presented in over half of the patients, with hypertension being the most common comorbidity, followed by diabetes and coronary heart disease. The most common fecal characteristics on admission were watery stool (64%) and mushy stool (28%). As for the frequency of diarrhea, 23 (37%) out of 63 cases defecated over three times a day. The number of cases receiving general diet, enteral nutrition, and parenteral nutrition was 89 (99%), 4 (4%), and 2 (2%), respectively ( Table 1) Table 1 for details. Laboratory findings are shown in Table 2 . Lymphocyte and albumin counts were below normal in 43% and 46% of all the cases, respectively. C-reactive protein levels were elevated in more than two-thirds of all cases. Routine stool examinations showed normal in most of the cases. Hyponatremia and hypokalemia occurred in 10 (11%) and 7 (8%) cases, respectively. In this study, 9% and 2% of the 90 patients showed initial symptoms of diarrhea and poor appetite, respectively. Additionally, the first COVID-19 case in the United States also reported a 2-day history of nausea and vomiting on admission, and both the virus nucleic acid tests of the stool and respiratory samples were subsequently confirmed as positive 10 . Such patients might be overlooked, resulting in potentially serious consequences to the patients and a high risk of infecting more people. Thus, it is vital that clinicians are aware of that COVID-19 patients may present with initial gastrointestinal symptoms such as diarrhea, keep appropriate vigilance, and maintain an index of suspicion for early detections, early diagnoses, early isolations, and early interventions. It is worth noting that COVID-19 patients with mild to moderate liver injuries, including elevated aminotransferases and hypoproteinemia, have also been reported, and some of the patients had digestive system impairment 11 . In our study, 24% of the patients showed clinical signs of poor nutrition. The reduced susceptibility of albumin to viral infections could be attributed to the loss of nutrients and liver damage. There is a clinical problem in how to meet the nutritional needs of patients, especially severely ill ones. Seriously ill patients who had interrupted oxygen administration when having a meal or going out to the bathroom were found to have repeated drops in oxygen saturation to less than 80%. Severe hypoxia attacks made the condition turn down rapidly since it was difficult to be recovered, resulting in a subsequent multi-organ failure or even sudden death 12 . In fact, these patients generally had difficulty in eating, thus some experts recommend a five-step nutritional therapy 13 . Clinicians are required to promptly identify the patients with initial diarrhea symptoms and pay adequate attention to the nutrient requirements of the patients with diarrhea during hospitalization. Standardized management is also recommended for the discharge of the patients to avoid potential fecal-oral transmission. There are also several limitations in this study. Firstly, there were no nucleic acid tests carried out in the fecal samples of all the 90 cases. Secondly, in view of a retrospective study, specific diarrhea conditions in some patients were unknown from the electronic medical records. Further studies need to be conducted on the viability and infectivity of 2019-nCOV in feces. There is no conflict of interest relevant to this study.  There were 9.87％of COVID-19 patients presenting with diarrhea.  The initial symptom was diarrhea observed in 9％of 90 cases.  The most common fecal characteristics on admission were watery stool (64%).  Clinicians should be careful to promptly identify the patients with initial diarrhea symptom. 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New coronavirus pneumonia prevention and control program Chinese society of parenteral nutrition. Covid-19 enteral parenteral nutrition therapy for critically ill patients Committee of tumor nutrition and supportive therapy, Chinese association against cancer. Five-step therapy for malnutrition Prolonged presence of SARS-CoV-2 viral RNA in faecal samples Rigidity of the outer shell predicted by a protein intrinsic disorder model sheds light on the COVID-19 (Wuhan-2019-nCoV) infectivity Presumed asymptomatic carrier transmission of COVID-19 Positive RT-PCR Test Results in Patients Recovered From COVID-19 BNP(pg/mL ) Conceptualization, Methodology, Software Priya Singh.: Data curation, Writing-Original draft preparation. Wang Wu: Visualization, Investigation. Jan Jansen: Supervision.: Ajay Kumar: Software, Validation.: Sun Qi: Writing-Reviewing and Editing