A preprint study published in the American Journal of Gastroenterology suggests patients with new-onset digestive symptoms after a possible COVID-19 contact should be suspected for the illness, even in the absence of cough, shortness of breath, sore throat, or fever.

This is the first analysis of gastrointestinal symptoms reported by COVID-19 patients with mild disease rather than those with moderate or critical illness and finds a unique subgroup with low-severity disease marked by presence of digestive symptoms, most notably diarrhea. The authors from Union Hospital and Tongji Medical College in Wuhan, China, report that among some of the patients included in the study, these digestive symptoms, particularly diarrhea, were the presentation of COVID-19, and were only later, or never, present with respiratory symptoms or fever. The study represents the 80% or more of patients who do not have severe or critical disease. This is about people in the community struggling to determine if they might have COVID-19 because of new-onset diarrhea, nausea, or vomiting.

The analysis included 206 patients with low-severity COVID-19, including 48 presenting with a digestive symptom alone, 69 with both digestive and respiratory symptoms, and 89 with respiratory symptoms alone. Between the two groups with digestive symptoms, 67 presented with diarrhea, of whom about one in five experienced diarrhea as the first symptom in their illness course. The diarrhea lasted from 1 to 14 days, with an average duration of over 5 days and a frequency around four bowel movements per day. Concurrent fever was found in 62% of patients with a digestive symptom, meaning that nearly one-third did not have a fever. Patients with digestive symptoms presented for care later than those with respiratory symptoms (16 day vs 11 day delay, P < 0.001).

Authors concluded:

• Digestive symptoms are common in the community, and most instances of new-onset diarrhea, nausea, vomiting, or low appetite are not from COVID-19.
• Nonetheless, clinicians should recognize that new-onset, acute digestive symptoms in a patient with a possible COVID-19 contact should at least prompt consideration of the illness, particularly during times of high COVID-19 incidence and prevalence.
• Failure to recognize these patients early and often may lead to unwitting spread of the disease among outpatients with mild illness who remain undiagnosed and unaware of their potential to infect others.
• The data in this study highlight the presence and features of this subgroup of COVID-19 patients and should be confirmed in larger international studies.

The preprint study, “Digestive symptoms in COVID-19 patients with mild disease severity: Clinical presentation, stool viral RNA testing, and outcomes,” is available at https://journals.lww.com/ajg/Documents/COVID19_Han_et_al_AJG_Preproof.pdf [9].