First description of SARS-CoV-2 in ascites.

Dear Editor,

It is our pleasure to submit this novel report regarding cirrhosis and SARS-CoV-2 infection.

A 71-year-old man was admitted to our intensive care unit because of acute, severe upper-gastrointestinal bleeding requiring an endoscopic procedure. The bleeding resulted from a low esophageal ulcer (Forrest B) that was managed with a clip. The patient was a smoker with alcohol consumption and had been hospitalized 10 days earlier to manage his cirrhosis (Child-Pugh score B). At hospital admission, the liver function was impaired, with a prothrombin ratio at 24 % and a factor V at 41 %. The hemoglobin level was at 7 g/dL. We noted a lymphopenia at 880/μL. Apart from bleeding, the patient was asymptomatic.

After a 24 -h initial recovery period, the patient’s condition progressed to acute respiratory distress syndrome, requiring invasive mechanical ventilation. SARS-CoV-2 RNA was assessed by real-time reverse transcription-PCR (RT-PCR), using a hydrolysis probe–based system that targets the gene encoding the envelope (E) protein [1]. Initial SARS-CoV-2 RT-PCR was positive on nasopharyngeal swab, bronchial aspirate and blood sample. The chest CT scan showed typical Covid-19 imaging in line with severe pulmonary impairment. In accordance with international guidelines, he did not receive antiviral drugs. Simultaneously, ultrasound showed a large ascites, requiring a drainage that provided 6 L of fluid. The protein concentration was 6.3 g/L, and the polymorphonuclear cell count < 250/μL. No red blood cells were found in ascites. The fluid culture was negative, and a SARS-CoV-2 RT-PCR performed on this sample was positive.

To our knowledge, this is the first description of SARS-CoV-2 RNA detection from the ascitic fluid of a Covid-19 patient. While coronavirus RNA detection from peritoneal fluid has already been shown in animal models [2], no data are available on the presence of enveloped viruses in human ascites.

Regarding SARS-CoV-2, infectious virus has been readily isolated from nasopharyngal- and lung-derived samples but not from stool samples – in spite of high virus RNA concentration – or from blood samples [3]. However, until further knowledge on virus viability in ascites fluid can be attained, we suggest that healthcare workers with exposure to ascitic fluid from Covid-19 patients should utilize high-level personal protective equipment.

In this patient, both blood and ascites samples were positive for SARS-CoV-2 RNA. Notably, no blood cells were observed in the transudative ascites, implying an active viral replication in ascites fluid. The ACE2 receptor is highly expressed in esophageal epithelial cells and the absorptive enterocytes from the ileum and colon, suggesting a possible pathway to ascites infection [4]. Whether cirrhosis decompensation is related to the already described SARS-CoV-2 liver damage [5] or ascites infection remains an unresolved issue that needs further research.

Declaration of Competing Interest

We declare no competing interests.