key: cord-0840939-c0qtte5h
authors: Remes-Troche, Jose María; Ramos-de-la-Medina, Antonio; Manríquez-Reyes, Marisol; Martínez-Pérez-Maldonado, Laura; Lara, Elizabeth Lagunes; Solís-González., María Antonieta
title: Initial Gastrointestinal Manifestations in Patients with SARS-CoV-2 in 112 patients from Veracruz (Southeastern Mexico).
date: 2020-05-21
journal: Gastroenterology
DOI: 10.1053/j.gastro.2020.05.055
sha: b93ce22fd7598488e9ab6a685be6905b6424a19e
doc_id: 840939
cord_uid: c0qtte5h

nan

Since it first appeared, COVID-19 has been a highly contagious disease. The virus spread rapidly across the planet, and by early May 2020, it had infected more than 4 million people in 187 countries. Although respiratory symptoms predominate, early reports from Asia revealed that gastrointestinal (GI) symptoms may also be part of the spectrum of SARS-CoV-2 infection. 1, 2, 3 In a recent meta-analysis of 47 studies that included 10,890 patients, prevalence estimates of GI symptoms were 7.7% for diarrhea, 7.8% for nausea/vomiting, and 2.7% for abdominal pain. 4 Most of the studies in that meta-analysis were from Asia (China, Japan, South Korea, Singapore), Europe (Italy, Germany, the Netherlands), Australia, and the United States.

After the United States, Latin America is estimated to be the next epicenter of the pandemic, and Mexico (the 10th most populous country, with 128,649,565 inhabitants) is projected to be one of the most affected countries. Thus, our aim was to analyze the prevalence and features of gastrointestinal manifestations of COVID-19 in a cohort of Mexican adults living in the city of Veracruz (Southeastern Mexico).

We describe herein the experience of a single private hospital center (Hospital Español de Veracruz, Veracruz, Mexico). The city of Veracruz is located at latitude 19° 10' 51.42", and during the months of April and May, the mean temperature ranges from 78 to 88°F. Within the time frame of April 1 to May 5, 2020, the consecutive adult patients (age ≥18 years) that presented with laboratory-confirmed SARS-CoV-2 through polymerasechain reaction (PCR) nasopharyngeal swab testing were included in the study. Patient demographics, systemic, respiratory, and gastrointestinal symptoms, comorbid conditions, laboratory data, and clinically relevant hospitalization outcomes were obtained.

The clinical characteristics and demographic data are described in Table 1 . A total of 72.3% of the patients were men, and the mean patient age was 43.72 ± 15 years.

Seventy-five patients (67%) had risk factors or comorbid conditions. Hypertension (29%) was the most common, followed by obesity/overweight (18%) and diabetes (14%) ( Table   1 ). The most common symptoms at presentation included fever (87%), cough (80%), myalgias (67%), and headache (59%). The median symptom duration was 6.0 days (range 1-11). Regarding admission status, 97 (86.7%) of the patients were evaluated and received ambulatory treatment, and 15 (13.3%) were admitted to the hospital: 10 (8.9%) to the COVID unit and 5 (4.4%) to the ICU. The median length of stay for patients admitted solely to the COVID unit was 5.0 days (range 3-7), vs. 11 days (range 6-12) for patients that required ICU care. Three subjects (2.6%) died.

Twenty-three (20.5%) patients reported at least one gastrointestinal symptom at the onset of the SARS-CoV-2 infection, and the most common manifestations were diarrhea (17.8%), abdominal pain (9.8%), and vomiting (7.1%) ( Table 1 ). The median duration of diarrhea was 3 days (range 1-4) and the median number of evacuations per day was 4 (range 2-6). Abdominal pain was described as diffuse colicky pain in 5 subjects and as difficile. 4 However, in our case series, we recorded GI symptoms at the initial phase of the infection, thus it is likely that new-onset diarrhea is the consequence of SARS-CoV-2 entering intestinal cells through the angiotensin-converting enzyme 2 (ACE2). 5 The prevalence of diarrhea (17.8%) in our patients is remarkably similar to that reported by Sultan et al., 4 in studies from countries other than China (18.3%). 4, 6 Albeit unusual, some of our patients (6%) had GI symptoms as the exclusive manifestation of COVID-19. With respect to the prevalence of abdominal pain, it was considerably high (10%) in our cohort, compared with that reported in the abovementioned meta-analysis (3-6%-5.3%). 4 However, a recent study from England revealed that 9 out of 76 (11.8%) patients were hospitalized, with acute abdominal pain as their main complaint. 7 The pathophysiology of abdominal pain and its relation to SARS-CoV-2 is unknown and needs to be clarified. The prevalence of vomiting and abnormal liver tests is consistent with the results of previous reports.

Interestingly, we found that patients with GI symptoms had a higher prevalence of loss of taste and smell, concurring with that reported in a large multicenter cohort in the United States. 8 Our study has the following limitations: 1) we focused on initial GI symptoms and a proper follow-up of those manifestations was not carried out, 2) sample size, 3) the study was conducted at a private hospital, making it possible for selection bias to have occurred.

Despite those limitations, the present study is one of the first conducted in Latin America, specifically in Southeastern Mexico, to assess GI manifestations of SARS-CoV-2 infection.

It is also crucial to comment that Veracruz, which is a city with a warm temperature and high humidity, is presently one of the top five cities with the highest number of COVID-19 cases in Mexico. Thus, other factors besides warmer temperature are related to COVID-19 spread, and clinicians must be aware of new-onset diarrhea as part of the SAR-CoV-2 infection spectrum.

In conclusion, our clinical data regarding GI manifestations in Mexican patients with COVID-19 is similar to those reported in patients outside of China, specifically to data from patients in the United States. 

Evidence for gastrointestinal infection of SARS-CoV-2

Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: A descriptive, cross-sectional, multicenter study

Gastrointestinal manifestations of SARS-CoV-2 infection and virus load in fecal samples from the Hong Kong cohort and systematic review and meta-analysis

AGA Institute rapid review of the GI and liver manifestations of COVID-19, metanalysis of international data, and recommendations for the consultative management of patients with COVID-19

Is SARS-CoV-2 also an enteric pathogen with potential fecal-oral transmission: A COVID-19 virological and clinical review

Gastrointestinal symptoms and COVID-19: case-control study from the United States

Covid-19 may present with acute abdominal pain

Prevalence and characteristics of gastrointestinal symptoms in patients with SARS-CoV-2 infection in the United States: A multicenter cohort study