S3026 COVID-19 Infection Presenting With Only Gastrointestinal Symptoms

Abstract

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a pandemic that has currently spread to approximately 188 countries with current estimates of over 427,000 fatalities worldwide. It largely presents with respiratory symptoms including cough and shortness of breath. Gastrointestinal (GI) symptoms are not common leading to delayed diagnosis. We present a case of an obese young man with no past medical history presenting with GI symptoms who was found to be COVID-19 positive. CASE DESCRIPTION/METHODS: A 32-year-old obese male with no past medical history presented to the emergency department with persistent nausea with nonbloody emesis, diarrhea, vague abdominal pain, and fever. He reported that a coworker had recently tested positive for COVID19. Significant labs on admission included AST 67 U/L, ALT 67 U/L, D-dimer 708.5 ng/ml, CRP 3.4 mg/dL, LDH 341 U/L, ferritin 1,781 ng/mL, procalcitonin <0.05 ng/mL. Lipase was normal. Chest X-ray without acute pathology. Chest CT with contrast revealed nonspecific bilateral pneumonitis. Abdominal US revealed hepatic steatosis. With conservative measures including fluid resuscitation, patient’s symptoms improved and he was discharged home to self-quarantine. DISCUSSION: It appears that COVID-19-related GI symptoms are due to the virus entering target cells via angiotensin-converting enzyme 2 receptor, which is found throughout the digestive tract. This receptor is found at nearly 100-fold the amount in the GI tract as compared to the respiratory system. In a retrospective study of 206 patients with COVID-19 infection in Wuhan, China, it was found that those with GI symptoms demonstrated a longer duration between symptom onset and viral clearance. Additionally, it was found that such patients are more likely to have positive results on fecal testing as compared to those with predominantly respiratory symptoms. Those with both upper and lower digestive symptoms were more likely to present with fever as opposed to either alone which can delay timely diagnosis. In a meta-analysis of data from 29 COVID-19 studies with GI symptoms, prevalence was 15% and about 10% of patients presented with GI symptoms alone with the most common symptoms being nausea or vomiting, diarrhea, and decreased appetite. We live in unprecedented times, and should be wholly aware that COVID-19 infections can also present predominantly with gastrointestinal symptoms as delayed diagnosis is a major driver of this current COVID-19 pandemic.Figure 1.: Chest CT with contrast demonstrating nonspecific bilateral pneumonitis with patchy infiltrates.