COVID-19 Inpatients with Gastrointestinal Onset

Greco et al. BMC Infect Dis (2021) 21:739 https://doi.org/10.1186/s12879-021-06476-y RESEARCH ARTICLE Open Access COVID-19 inpatients with gastrointestinal onset: sex and care needs’ diferences in the district of Ferrara, Italy Salvatore Greco1†, Nicolò Fabbri2†, Alessandro Bella1, Beatrice Bonsi1, Stefano Parini3, Cindy Rocchi3, Sara Giaccari3, Manuel Gavioli3, Angelina Passaro1,4,5* and Carlo V. Feo2 Abstract Background: COVID-19 is characterized by interstitial pneumonia, but a presentation of the disease with digestive symptoms only may occur. This work was aimed at evaluating: (1) the prevalence of presentation with digestive symptoms only in our cohort of COVID-19 inpatients; (2) diferences between patients with and without gastrointestinal onset; (3) diferences among males and females with gastrointestinal presentation; (4) outcomes of the groups of subjects with and without gastrointestinal onset. Method: We retrospectively divided the patients hospitalized with COVID-19 into two groups: (1) the one with digestive symptoms (DSG) and (2) the other without digestive symptoms (NDSG). We compared the subjects of DSG with those of NDSG and males with females in the DSG group only, in terms of demographics (age, sex), infammation and organ damage indexes, length of stay, in-hospital and 100-day mortality. Results: The prevalence of gastrointestinal symptoms at presentation was 12.5%. The DSG group showed a prevalence of females, and these tended to a shorter hospital stay; DSG patients were younger and with a higher load of comorbidities, but no diferences concerning infammation and organ damage indexes, need for intensifcation of care, in-hospital and 100-day mortality were detected. Among DSG patients, males were younger than females, more comorbid, with higher serum CRP and showed a longer length of hospital stay. Survival functions of DSG patients, in general, are more favourable than those of NDSG if adjusted for sex, age and comorbidities. Conclusions: (1) The prevalence of gastrointestinal presentation among hospitalized COVID-19 patients was 12.5%; (2) DSG patients were on average younger, more comorbid and with a prevalence of females, with a shorter hospital stay; (3) in the DSG group, males had a higher Charlson Comorbidity Score and needed a longer hospital stay; (4) DSG subjects seem to survive longer than those of the NDSG group. Keywords: SARS-CoV-2, Coronavirus infection, COVID-19, Digestive symptoms, Gastrointestinal onset Background Coronaviruses are a group of related RNA-viruses that *Correspondence: [email protected] cause diseases in mammals and birds and they are dis- †Salvatore Greco and Nicolò Fabbri contributed equally to the article tributed all over the world; in the late 2019, the third 5 Department of Translational Medicine and Medical Department, member of this family after SARS-CoV-1(Severe Acute University of Ferrara, University Hospital of Ferrara Arcispedale Sant’Anna, Via Aldo Moro, 8, 44124 Ferrara, Emilia Romagna, Italy Respiratory Syndrome CoronaVirus 1) and MERS- Full list of author information is available at the end of the article CoV (Middle East Respiratory Syndrome CoronaVirus) © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Greco et al. BMC Infect Dis (2021) 21:739 Page 2 of 8 appeared for the frst time, causing two cases of intersti- were evaluated singularly and the weighted prevalence tial pneumonia [1]. of diarrhea was 12.4%, nausea and/or vomiting 9.0%, loss SARS-CoV-2 infection can manifest itself in many of appetite 22.3%, and abdominal pain 6.2%. Anyway, the ways and the set of symptoms (COVID-19, COronaVI- mortality rate among patients with GI symptoms was rus Disease 2019) ranges from infuenza-like symptoms similar to the overall mortality [15, 16]. (in 80% of cases) to a severe form of pneumonia (dyspnea A meta-analysis by Hayashi et al. on 4 studies com- or tachypnea with a PaO2/FiO2 ratio < 300 at the blood pared COVID-19 patients with and without digestive gas assay and a pulmonary infltration > 50%). Up to 5% symptoms; they found abdominal pain to be more fre- of patients develop rapidly an Acute Respiratory Distress quent in patients with a severe form of disease (OR 2.70), Syndrome (ARDS), with or without acute cardiac dam- suggesting how this kind of symptom could somehow age, related to an underlying systemic hyperinfamma- predict a greater degree of severity of disease [17]. tion [2, 3] that can hesitate in systemic shock (cytokine Our study aimed at evaluating diferences between storm), multiorgan failure, and death. patients with and without digestive symptoms in terms of Fever is the most frequent sign: it may be absent in up personal, clinical and laboratory parameters; moreover, to 50% of patients at the frst physical examination, but we tried to understand whether digestive symptoms, in it seems to be present in more than 90% of cases during general, could somehow be predictive of diferent out- hospitalization; cough is present in 67% of cases. Atypi- comes of COVID-19. cal symptoms of systemic involvement can be noticed, such as arthralgia, myalgia, asthenia, headache, upper Materials and methods respiratory tract symptoms, and gastrointestinal symp- Tis is a two single-center retrospective cohort study. toms (nausea, vomiting, and diarrhea up to 5% of cases We enrolled 495 adult inpatients (≥ 18 years old) who in some experiences, especially during the frst periods were consecutively hospitalized with SARS-CoV-2 infec- of pandemic; generalized abdominal pain, anorexia and tion, between March and July 2020, in the “Arcispedale taste changes were also reported as possible digestive S. Anna” in Cona (Fe) and in the “Ospedale del Delta” symptoms following SARS-CoV-2 infection) [4, 5]. in Lagosanto (Fe), the two main hospitals serving the Further data confrmed that approximately 50% of Province of Ferrara. Te diagnosis of COVID-19 was patients with COVID-19 have detectable viral RNA in determined by at least one SARS-CoV-2 RNA detection the stool [6–8] and the prevalence of gastrointestinal at oro- and naso-pharyngeal swab and the presence of symptoms can be up to 50%. Digestive symptoms were symptoms clearly related to the infection itself. also reported during the epidemics by SARS-CoV-1 and Te exclusion criteria were: age (subjects younger than MERS-CoV [9]. 18 years were excluded), the negativity of swabs to viral As of May 2021, almost 170 million cases of COVID- detection and/or the positivity of stool cultures to the 19 confrmed cases and more than 3.5 million deaths in most common gastrointestinal microorganisms. more than 200 countries and territories were reported Te study population was divided into two groups: the (source https:// www. world omete rs. info/ coron avirus/). “case” group, that was constituted by patients with a gas- Te pathophysiology of digestive symptoms associated trointestinal onset and symptoms such as nausea, vom- with COVID-19 remains partially unexplained. It seems iting and/or diarrhea (Digestive Symptoms Group, DSG) that they likely occur because the virus enters the target and the “control” group, composed by patients who pre- cells through angiotensin-converting enzyme 2 (ACE2) sented without digestive symptoms at the onset of the [10], a receptor found in both the upper and lower gas- disease (Non-Digestive Symptoms Group, NDSG). We trointestinal tract where it is expressed at nearly 100-fold did not make any distinction among patients in terms of higher levels than in respiratory organs [11, 12]. digestive fndings, but we calculated a composite gastro- Most studies focused on the respiratory involvement of intestinal symptoms’ prevalence. SARS-CoV-2 infection and the majority of patients with Patients’ demographic (age, sex), clinical (number of a severe form of COVID-19 faced respiratory symptoms comorbidities) and laboratory data (infammation and only, without digestive symptomatology [13]. It is likely, organ damage indexes, samples for viral RNA detec- however, that a large cohort of undiagnosed patients with tion) were extracted from their electronic health records a lower severity illness but with digestive symptoms (e.g. and registered into an electronic database available only diarrhoea, vomiting) may have spread the virus without to the authors. Data were later anonymized so that no respiratory involvement [14]. patient could be identifed anymore. A recent systematic review evaluating a cohort of more We evaluated the load of comorbidities by using the than 12,500 patients from 78 studies, found that the Charlson Comorbidity Index (CCI) which already showed pooled prevalence of GI symptoms was 17%; symptoms a certain degree of reliability in some studies towards Greco et al. BMC Infect Dis (2021) 21:739 Page 3 of 8 mortality by COVID-19 [18, 19]; the items considered by for evaluating the survival functions of both the groups of the CCI are shown in Additional fle 1: Table S1.

Load more