COVID-19 : gastrointestinal symptoms first suffered by some children hints at potential infection through the digestive tract

Children suffering from sickness and diarrhea, coupled with a fever or history of exposure to coronavirus, should be suspected of being infected with COVID-19, recommends a new study published in Frontiers in Pediatrics.

The research also suggests that the gastrointestinal symptoms first suffered by some children hints at potential infection through the digestive tract, as the type of receptors in cells in the lungs targeted by the virus can also be found in the intestines.

“Most children are only mildly affected by COVID-19 and the few severe cases often have underlying health issues. It is easy to miss its diagnosis in the early stage, when a child has non-respiratory symptoms or suffers from another illness,” says author of this study, Dr. Wenbin Li, who works at the Department of Pediatrics, Tongji Hospital, Wuhan, China.

He continues, “Based on our experience of dealing with COVID-19, in regions where this virus is epidemic, children suffering from digestive tract symptoms, especially with fever and/or a history of exposure to this disease, should be suspected of being infected with this virus.”

In this study, Li and his colleagues detail the clinical features of children admitted to hospital with non-respiratory symptoms, which were subsequently diagnosed with pneumonia and COVID-19.

“These children were seeking medical advice in the emergency department for unrelated problems, for example, one had a kidney stone, another a head trauma. All had pneumonia confirmed by chest CT scan before or soon after admission and then confirmed to have COVID-19.

While their initial symptoms may have been unrelated, or their COVID-19 symptoms were initially mild or relatively hidden before their admission to hospital, importantly, 4 of the 5 cases had digestive tract symptoms as the first manifestation of this disease.”

By highlighting these cases, Li hopes that doctors will use this information to quickly diagnose and isolate patients with similar symptoms, which will aid early treatment and reduce transmission.

The researchers also link the children’s gastrointestinal symptoms, which have been recorded in adult patients, to an additional potential route of infection.

Li explains, “The gastro-intestinal symptoms experienced by these children may be related to the distribution of receptors and the transmission pathway associated with COVID-19 infection in humans.

The virus infects people via the ACE2 receptor, which can be found in certain cells in the lungs as well as the intestines.

This suggests that COVID-19 might infect patients not only through the respiratory tract in the form of air droplets, but also through the digestive tract by contact or fecal-oral transmission.”

While COVID-19 tests can occasionally produce false positive readings, Li is certain all these five children were infected with the disease, but he cautions that more research is needed to confirm their findings.

“We report five cases of COVID-19 in children showing non-respiratory symptoms as the first manifestation after admission to hospital. The incidence and clinical features of similar cases needs further study in more patients.”

Enteric Involvement of Coronavirus

Novel coronavirus symptoms seem to be mostly focused on fever and cough, but gastrointestinal symptoms should be a new focus for clinicians, according to two new papers published online in Gastroenterology, Jinyang Gu et al. describe how investigators from Shanghai, China, sought to document the symptoms of the novel coronavirus.

Although fever, dry cough, and dyspnea present in most cases, they wanted to understand what impact the virus had on symptoms such as diarrhea, nausea, vomiting, and abdominal discomfort. So far, those symptoms have varied among different study populations.

Former studies on SARS, which is related to the coronavirus and can present with similar symptoms, showed that SARS was verified in patients after detection in biopsy specimens and stool.

This was true even after the patients had been discharged from the hospital. The study authors noted that the first US patient admitted to a hospital with confirmed coronavirus had a loose bowel movement on hospital day two [19].

Labs in China have been able to isolate the live coronavirus from the stool of patients, the authors said (unpublished). These factors brought the gastrointestinal tract to the forefront of investigators’ minds and suggest that clinicians should identify patients with gastrointestinal symptoms and carefully monitor those patients [24].

Another similarity that may be noted between SARS and COVID-19 is that mild to moderate liver injury has existed in patients [25]. Xiao F et al. examined the viral RNA in feces from 71 patients with confirmed COVID-19 during their hospitalization from February 1-14, 2020 [26].

They collected serum, nasopharyngeal and oropharyngeal swabs, urine, stool, and tissues (from endoscopy) from the patients. The age of the patients ranged from 10 months to 78 years. The duration of positive stool tests ranged from 1 to 12 days, they added, and patients remained positive via stool tests after showing negative in respiratory samples.

The researchers found that 53.4% of patients had SARS-CoV-2 RNA in their stool and 23% of patients tested positive in their stool despite testing negative for the virus in respiratory samples. This finding indicates that viral gastrointestinal infection and the potential fecal-oral transmission can last even after viral clearance in the respiratory tract.

The author strongly recommends that rRT-PCR testing for SARS-CoV-2 from feces should be performed routinely in SARS-CoV-2 patients, and transmission-based precautions for hospitalized SARS-CoV-2 patients should continue if the feces tests positive by rRT-PCR testing. Table 1 provides a brief review of the study by Yu He et al. of COVID-19 while Table 2 summarizes all the included clinical studies to date [27-28].

19. Holshue ML, DeBolt C, Lindquist S, et al.: First case of 2019 novel coronavirus in the United States. N Engl J Med. 2020, 382:929-936. 10.1056/NEJMoa2001191

24 Gu J, Han B, Wang J: COVID-19: gastrointestinal manifestations and potential fecal-oral transmission [Epub ahead of print]. Gastroenterology. 2020, 10.1053/j.gastro.2020.02.054

25 Chau TN, Lee KC, Yao H, et al.: SARS-associated viral hepatitis caused by a novel coronavirus: report of three cases. Hepatology. 2004, 39:302-310. 10.1002/hep.20111

26 Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H: Evidence for gastrointestinal infection of SARS- CoV-2 [Epub ahead of print]. Gastroenterology. 2020, 10.1053/j.gastro.2020.02.055

27 He Y, Wang Z, Li F, Shi Y: Public health might be endangered by possible prolonged discharge of SARS-CoV-2 in stool [Epub ahead of print]. J Infect. 2020, 10.1016/j.jinf.2020.02.031

28 Jiang F, Deng L, Zhang L, Cai Y, Cheung CW, Xia Z: Review of the clinical characteristics of coronavirus disease 2019 (COVID-19) [Epub ahead of print]. J Gen Intern Med. 2020, 10.1007/s11606-020-05762-w

More information:Frontiers in Pediatrics, DOI: 10.3389/fped.2020.00258 , www.frontiersin.org/articles/1 … fped.2020.00258/full