Diarrhea Likely Underestimated in COVID-19

By Will Boggs MD

March 03, 2020

NEW YORK (Reuters Health) - Diarrhea is likely underestimated as a feature of disease caused by the 2019 novel coronavirus (COVID-19), researchers from China report.

Most patients with COVID-19 present with fever and cough, but the incidence of other clinical features varies across reports.

Dr. Wei Qi from The Second Hospital of Hebei Medical University, Shijiazhuang, China and colleagues, using data from three reported studies, found that the incidence of leukopenia, fever, and diarrhea differed significantly among the studies, with diarrhea showing the most significant difference.

Because the spike protein of the new coronavirus shares the same cell entry receptor ACE2 as the SARS coronavirus (known to exhibit fecal-oral transmission), they examined the expression profiles of ACE2 in various human tissues.

ACE2 was highly expressed in proximal and distal enterocytes in the small intestine, as were two entry receptors for other coronaviruses, according to the online report in Gut.

Based on these findings, the researchers propose that the incidence of diarrhea may be underestimated in previous investigations and that ACE2-expressing small intestinal epithelial cells might be more vulnerable to attack by the 2019 coronavirus.

They note that the 2019 coronavirus, which shares epidemiological features of SARS, might also use fecal-oral transmission. "Thus," the authors conclude, "future efforts at prevention and control must take into consideration the potential for fecal-mediated spread of this virus."

A recent online commentary in Lancet Gastroenterology and Hepatology also postulated enteric involvement of coronaviruses. Dr. Danson Yeo from Tan Tock Seng Hospital, Singapore, one of the co-authors of that commentary, told Reuters Health by email, "Early reports of COVID-19 suggest approximately 10% present with gastrointestinal symptoms. Until more data emerge, physicians should have a high degree of suspicion in anyone with fever, gastrointestinal symptoms, and significant contact/travel history."

The possibility of enteric involvement has important infection control implications. "Coronaviruses are susceptible to antiseptics containing ethanol and disinfectants containing chlorine or bleach," Dr. Yeo said. "This should be borne in mind when using hand-rub for cleaning of hands or using disinfectants for cleaning of the environment. Frequent hand washing and cleaning of the environment should be emphasized."

"We should approach this pandemic based on knowledge from studies that have been performed on previous coronaviruses, instead of waiting for new data to emerge before we react," he said.

Dr. Qi and co-author Dr. Qi Zhang from The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China did not respond to a request for comments.

SOURCE: https://bit.ly/2TiTp6R Gut, online February 26, 2020 and https://bit.ly/2Tt41yR Lancet Gastroenterology and Hepatology, online February 19, 2020.