key: cord-0757529-f3j3ror7 authors: Sarode, Gargi S.; Sarode, Sachin C.; Gadbail, Amol R.; Gondivkar, Shailesh; Sharma, Nilesh Kumar; Patil, Shankargouda title: Are oral manifestations related to SARS-CoV-2 mediated hemolysis and anemia? date: 2020-11-22 journal: Med Hypotheses DOI: 10.1016/j.mehy.2020.110413 sha: 382ee25a3136c39d8260a33f11b3fd80b0da50aa doc_id: 757529 cord_uid: f3j3ror7 nan COVID-19 has displayed heterogeneity in the clinical manifestations ranging from asymptomatic state to life treating severe acute respiratory distress syndrome. Gustatory impairment (45%) in the form of dysgeusia (38%), hypogeusia (35%) and ageusia (24%) are the most common manifestation followed by the mucosal erythema or ulcerations. 1 Apart from these two, literature also reported anosmia as one of the most common manifestations of COVID-19. 2 Majority of the patients showed only gustatory and olfactory manifestations without any evidence of respiratory symptoms. 2 Many hypotheses have been proposed to envisage oral manifestations seen in COVID-19 patients but none has been tested and proved with appropriate scientific experimentations. A brief overview of proposed pathogenesis is reflected in Table 1 . [4] [5] [6] [7] In the present letter, we proposed a novel hypothesis that links the SARS-CoV-2 with anemia and oral manifestations. Hypothesis: Anemia related to SARS-CoV-2 mediated hemolysis causes the oral manifestations. ACE2, CD147, and CD26 receptors present on the erythrocytes are potential targets for SARS-CoV-2 attachment, which can lead to hemolysis. 8 Moreover, SARS-CoV-2 may mimic the action of hepcidin, which increases circulating and tissue ferritin leading to serum iron deficiency and anemia. 8 In support of this contention, significantly higher number of COVID-19 patients demonstrated severe anemia and hyperferritenemia. 9, 10 Intriguingly, gustatory impairment and mucosal ulcerations including anosmia are the prime manifestations of iron deficiency anemia. 11 These manifestations are results of the impaired oxygen supply and related cellular atrophy in the taste buds, oral epithelium and olfactory epithelium. Thus, we strongly believe that pathogenesis for oral manifestations seen in COVID-19 could be related to SARS-CoV-2 induced anemia. Burning sensation of oral cavity, canker sores and pale oral mucosa are other manifestations associated with iron deficiency anemia and they should also be investigated in COVID-19 patients. We believe that they could be missed out due to mild nature of these symptoms or unawareness among the healthcare workers. To prove the proposition, a correlative study of total iron binding capacity or hemoglobin level and oral manifestations is warranted in COVID-19 patients. If this proposition holds true then it will help in effective management of oral health of COVID-19 patients. Oral Manifestations in Patients with COVID-19: A Living Systematic Review Anosmia and Ageusia: Common Findings in COVID-19 Patients Causes of hypogeusia/hyposmia in SARSCoV2 infected patients Potential pathogenesis of ageusia and anosmia in COVID-19 patients. Int Forum Allergy Rhinol An alteration of the dopamine synthetic pathway is possibly involved in the pathophysiology of COVID-19 New insights for the pathogenesis of COVID-19-related dysgeusia Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases COVID-19: hemoglobin, iron, and hypoxia beyond inflammation. A narrative review Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area Does iron deficiency anemia affect olfactory function? Conflict of interest: All the author associated with present manuscript declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author received no specific funding for this work.