Initial Gastrointestinal Manifestations in Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection in 112 Patients From Veracruz in Southeastern Mexico.

Since it first appeared, coronavirus disease 2019 (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 indicated that gastrointestinal (GI) symptoms may also be part of the spectrum of severe acute respiratory syndrome coronavirus 2 (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. 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 in southeastern Mexico.

Methods

We describe 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′′N, and during the months of April and May, the mean temperature ranges from 78°F to 88°F. Within the time frame of April 1 to May 5, 2020, the consecutive adult patients (age ≥18 y) who presented with laboratory-confirmed SARS-CoV-2 through polymerase chain reaction 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.

Results

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 d). 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 intensive care unit. The median length of stay for patients admitted solely to the COVID unit was 5.0 days (range, 3–7 d) vs 11 days (range, 6–12 d) for patients who required ICU care. Three patients (2.6%) died.

Table 1

Sociodemographic Data, Comorbidities, and Initial Symptoms in 112 Mexican Patients

Characteristics	Value
Age, y, mean ± SD	43.72 ± 15
Sex, n (%)
Male	81 (72.3)
Female	31 (27.7)
Admission status, n (%)
Ambulatory	97 (86.7)
COVID unit	10 (8.9)
ICU	5 (4.4)
Comorbidities, n (%)
Yes	75 (67)
Hypertension	33 (29)
Obesity/overweight	20 (17.8)
Diabetes	15 (13.3)
COPD	13 (11.6)
Heavy smoker	6 (5.3)
Cancer	2 (1.7)
Chronic kidney disease	2 (1.7)
IBD	1 (0.8)
Asthma	1 (0.8)
CVAD	1 (0.8)
Immunosuppression	1 (0.8)
Non-GI COVID symptoms, n (%)
Fever	97 (86.6)
Cough	90 (80.3)
Headache	66 (58.9)
Myalgias	75 (66.9)
Odynophagia	35 (31.2)
Dyspnea	29 (25.6)
Chest pain	17 (15.1)
Ageusia	8 (7.1)
Anosmia	8 (7.1)
GI symptoms, n (%)	23 (20.5)
Diarrhea	20 (17.8)
Vomiting	8 (7.1)
Abdominal pain	11 (9.8)
Exclusive presentation of GI symptoms, n (%)	7 (6.2)
Mortality, n (%)	3 (2.6)

COPD, chronic obstructive pulmonary disease; CVAD, coronary vascular arterial disease; IBD, inflammatory bowel disease; ICU, intensive care unit; SD, standard deviation.

Twenty-three (20.5%) patients reported at least 1 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 d), and the median number of evacuations per day was 4 (range, 2–6). Abdominal pain was described as diffuse colicky pain in 5 patients and as epigastric pain in 4. Gastrointestinal symptoms were the only manifestation of COVID-19 in 6.25% (n = 7) of patients. Patients with gastrointestinal symptoms also reported significantly higher rates of fatigue (82.6% vs 40.4%; P = .0003), chest pain (30.4% vs 4.4%; P = .0013), and loss of smell or taste (17.4% vs 2.2%; P = .018). Fifty-nine patients underwent laboratory testing that included liver enzyme levels, which were abnormal compared with normal limits in 20 (33%) of those patients. Abnormal aspartate aminotransferase level (defined as any value above the upper limit of normal) was reported in 16.9% (n = 10) of the patients and abnormal alanine aminotransferase level in 15.2% (n = 9). Two of the 3 patients who died had liver abnormalities. No other variables, including the presence of GI disease, correlated with disease severity.

Discussion

In our Mexican cohort, SARS-CoV-2 was shown to affect the GI tract, causing symptoms, which concurs with reports from other parts of the world. Specifically, 1 out of 5 patients with COVID-19 may initially present with GI symptoms, the most frequent of which is diarrhea. COVID-19–related diarrhea is multifactorial. Several studies have described the development of diarrhea during hospitalization in a majority of patients, which could have been attributable to other medications or other infections, such as Clostridium difficile. 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 angiotensin-converting enzyme 2 (ACE2). The prevalence of diarrhea (17.8%) in our patients is remarkably similar to that reported by Sultan et al in studies from countries other than China (18.3%). , Although 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 (range, 3.6%–5.3%). However, a recent study from England showed that 9 of 76 (11.8%) patients were hospitalized with acute abdominal pain as their main complaint. The pathophysiology of abdominal pain and its relation to SARS-CoV-2 is unknown and needs to be clarified. The prevalences of vomiting and abnormal liver test results are 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.

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; and 3) the study was conducted at a private hospital, making it possible for selection bias to have occurred. Despite these 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 5 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 are similar to those reported in patients outside of China, specifically data from patients in the United States.