Gastrointestinal involvement in COVID-19: a systematic review and meta-analysis

Hepatitis B associated with severe COVID-19: a nationwide cohort study in Sweden

PURPOSE

Individuals with severe liver disease are more vulnerable to severe COVID-19, but the association between chronic hepatitis B virus (HBV) infection and severe COVID-19 remains unclear. This study evaluates this relationship.

METHODS

We analysed nationwide Swedish data from national databases and healthcare registers, identifying laboratory-confirmed COVID-19 cases from February 2020 to April 2021. Chronic HBV infection was classified into cases with and without cirrhosis. Multivariable logistic regression assessed the association between HBV and severe COVID-19, adjusting for demographics, comorbidities, vaccination, and socioeconomic factors.

RESULTS

Among 1,057,174 COVID-19 cases, 2,902 had chronic HBV infection, which was associated with increased risk of severe COVID-19 (adjusted odds ratio [aOR] 1.242, 95% confidence interval [CI] 1.097-1.403). This risk was significantly higher in HBV individuals with cirrhosis (aOR 2.463, CI 1.546-3.892) compared to those without cirrhosis (aOR 1.183, CI 1.039-1.343). While overall COVID-19 mortality was not significantly elevated in the HBV cohort, patients with cirrhosis showed a higher, though nonsignificant, mortality risk (aOR 2.350, CI 0.921-5.203).

CONCLUSION

This nationwide study highlights an increased risk of severe COVID-19 in individuals with chronic HBV, particularly those with cirrhosis. Geographic and socioeconomic factors further influence outcomes. These findings underscore the need to consider HBV status in COVID-19 risk assessments. Future studies should explore these associations in the context of evolving SARS-CoV-2 variants and widespread vaccination.

A case of ulcerative colitis in a patient undergoing surgery due to exacerbation resulting in toxic megacolon after SARS-CoV-2 vaccination

We herein report a case involving a patient with quiescent ulcerative colitis (UC) in long-term clinical remission whose condition rapidly worsened after receiving a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, leading to colectomy due to toxic megacolon. The patient received the fifth dose of the Spikevax (mRNA-1273) vaccine and experienced a severe flare-up of UC 6 days later. Pathologic findings of the surgical specimens were consistent with severe active UC concomitant with cytomegalovirus infection. Because mRNA vaccines stimulate both humoral and cellular immunogenicity, it is important to note that they can be a triggering factor for the relapse of UC.

H. Pylori Treatment in the COVID-19 Era. What Have We Learned So Far?

PURPOSE OF REVIEW

CoronaVirus Disease of 2019 (COVID-19) has negatively influenced the management of multiple conditions in regards to the gastroenterology patient. An equivalent change in the management of Helicobacter pylori (H. pylori)-related diseases was reported, as practically no eradication treatment was offered during most of the pandemic. Given the scarcity of published data, we performed a literature review trying to elucidate the effect of COVID-19 on H. pylori treatment.

RECENT FINDINGS

COVID-19 has produced more questions than answers as to the outcome of COVID-19 in H. Pylori infected patients, post-COVID-19 patients treated for H. pylori, acid suppression and COVID-19 incidence and outcomes, and H. pylori eradication treatment in patients having recovered from COVID-19. We strongly believe that this scientific uncertainty produced by the COVID-19 pandemic has set up the stage for an incremental change in H. pylori treatment as COVID-19 has offered us the chance to speed up how we will, in the near future, approach patients with a possible Η. pylori infection.

Risks of digestive diseases in long COVID: evidence from a population-based cohort study

BACKGROUND

In the post-pandemic era, a wide range of COVID-19 sequelae is of growing health concern. However, the risks of digestive diseases in long COVID have not been comprehensively understood. To investigate the long-term risk of digestive diseases among COVID patients.

METHODS

In this large-scale retrospective cohort study with up to 2.6 years follow-up (median follow-up: 0.7 years), the COVID-19 group (n = 112,311), the contemporary comparison group (n = 359,671) and the historical comparison group (n = 370,979) predated the COVID-19 outbreak were built using UK Biobank database. Each digestive outcome was defined as the diagnosis 30 days or more after the onset of COVID-19 infection or the index date. Hazard ratios (HRs) and corresponding 95% confidence intervals (CI) were computed utilizing the Cox regression models after inverse probability weighting.

RESULTS

Compared with the contemporary comparison group, patients with previous COVID-19 infection had higher risks of digestive diseases, including gastrointestinal (GI) dysfunction (HR 1.38 (95% CI 1.26 to 1.51)); peptic ulcer disease (HR 1.23 (1.00 to 1.52)); gastroesophageal reflux disease (GERD) (HR 1.41 (1.30 to 1.53)); gallbladder disease (HR 1.21 (1.06 to 1.38)); severe liver disease (HR 1.35 (1.03 to 1.76)); non-alcoholic liver disease (HR 1.27 (1.09 to 1.47)); and pancreatic disease (HR 1.36 (1.11 to 1.66)). The risks of GERD were increased stepwise with the severity of the acute phase of COVID-19 infection. Even after 1-year follow-up, GERD (HR 1.64 (1.30 to 2.07)) and GI dysfunction (HR 1.35 (1.04 to 1.75)) continued to pose risks to COVID-19 patients. Compared to those with one SARS-CoV-2 infection, reinfected patients were at a higher risk of pancreatic diseases (HR 2.57 (1.23 to 5.38)). The results were consistent when the historical cohort was used as the comparison group.

CONCLUSIONS

Our study provides insights into the association between COVID-19 and the long-term risk of digestive system disorders. COVID-19 patients are at a higher risk of developing digestive diseases. The risks exhibited a stepwise escalation with the severity of COVID-19, were noted in cases of reinfection, and persisted even after 1-year follow-up. This highlights the need to understand the varying risks of digestive outcomes in COVID-19 patients over time, particularly those who experienced reinfection, and develop appropriate follow-up strategies.

Gut microbe-host interactions in post-COVID syndrome: a debilitating or restorative partnership?

Post-COVID syndrome (PCS) patients have reported a wide range of symptoms, including fatigue, shortness of breath, and diarrhea. Particularly, the presence of gastrointestinal symptoms has led to the hypothesis that the gut microbiome is involved in the development and severity of PCS. The objective of this review is to provide an overview of the role of the gut microbiome in PCS by describing the microbial composition and microbial metabolites in COVID-19 and PCS. Moreover, host-microbe interactions via the microbiota-gut-brain (MGB) and the microbiota-gut-lung (MGL) axes are described. Furthermore, we explore the potential of therapeutically targeting the gut microbiome to support the recovery of PCS by reviewing preclinical model systems and clinical studies. Overall, current studies provide evidence that the gut microbiota is affected in PCS; however, diversity in symptoms and highly individual microbiota compositions suggest the need for personalized medicine. Gut-targeted therapies, including treatments with pre- and probiotics, have the potential to improve the quality of life of affected individuals.

Induction of significant neutralizing antibodies against SARS-CoV-2 by a highly attenuated pangolin coronavirus variant with a 104nt deletion at the 3'-UTR

SARS-CoV-2 related coronaviruses (SARS-CoV-2r) from Guangdong and Guangxi pangolins have been implicated in the emergence of SARS-CoV-2 and future pandemics. We previously reported the culture of a SARS-CoV-2r GX_P2V from Guangxi pangolins. Here we report the GX_P2V isolate rapidly adapted to Vero cells by acquiring two genomic mutations: an alanine to valine substitution in the nucleoprotein and a 104-nucleotide deletion in the hypervariable region (HVR) of the 3'-terminus untranslated region (3'-UTR). We further report the characterization of the GX_P2V variant (renamed GX_P2V(short_3UTR)) in in vitro and in vivo infection models. In cultured Vero, BGM and Calu-3 cells, GX_P2V(short_3UTR) had similar robust replication kinetics, and consistently produced minimum cell damage. GX_P2V(short_3UTR) infected golden hamsters and BALB/c mice but was highly attenuated. Golden hamsters infected intranasally had a short duration of productive infection in pulmonary, not extrapulmonary, tissues. These productive infections induced neutralizing antibodies against pseudoviruses of GX_P2V and SARS-CoV-2. Collectively, our data show that the GX_P2V(short_3UTR) is highly attenuated in in vitro and in vivo infection models. Attenuation of the variant is likely partially due to the 104-nt deletion in the HVR in the 3'-UTR. This study furthers our understanding of pangolin coronaviruses pathogenesis and provides novel insights for the design of live attenuated vaccines against SARS-CoV-2.

COVID-19 Pandemic and IBS. Results of the All-Russian Observational Non-interventional Program to Study the Effectiveness of the Drug Kolofort® in Real Clinical Practice in Patients with Irritable Bowel Syndrome After a New Coronavirus Infection (VESNA)

Aim: to study the effectiveness and safety of using the drug Kolofort® in outpatients with irritable bowel syndrome (IBS) after a new coronavirus infection.

Materials and methods. An observational non-interventional program was conducted in patients with exacerbation of IBS symptoms after a new coronavirus infection. One hundred forty-one patients took part in the study. The final efficacy analysis included data from 127 study participants. All patients complained of increased/appearing gastrointestinal symptoms that appeared within 1–6 months after the infection (all patients had a history of COVID-19 infection). To assess the presence and severity of symptoms of the disease, the “7 × 7” questionnaire was used before the start of treatment and three months after the start of treatment.

Results. At the stage of inclusion in the program, the average total score on the “7 × 7” questionnaire was 17.36, which corresponded to a moderately severe disorder. During the treatment period, the average total score decreased to 6.14, which corresponded to borderline disorder. In addition, significant improvement was observed for each symptom separately. After three months of therapy, doctors rated the overall impression of the treatment on a 5-point Likert scale from “very effective” to “ineffective”. The average score was 4.24. In addition, no serious adverse events were identified while taking the drug.

Conclusion. In real clinical practice, the drug Kolofort® demonstrated high clinical efficacy in the treatment of patients with IBS after COVID-19 infection.

Gastrointestinal Manifestations and Outcomes of COVID-19: A Comprehensive Systematic Review and Meta-analysis

Introduction Pulmonary symptoms are the most prominent manifestations of Coronavirus disease 2019 (COVID-19). However, gastrointestinal (GI) symptoms have been reported widely as well. Literature describing the relation of these symptoms with outcomes of COVID-19 patients is limited in terms of sample size, geographic diversity, and the spectrum of GI symptoms included. We aim to evaluate the association of GI symptoms with outcomes of hospitalized COVID-19 patients. Methods A systematic review and meta-analysis of observational studies assessing GI symptoms and outcomes in COVID-19 patients were undertaken using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist. Details on outcomes included ICU vs. non-ICU admission, severe vs. non-severe disease, invasive mechanical ventilation (IMV) vs. no-IMV use, oxygen saturation <90% vs. >90%, in-hospital mortality vs. discharged alive and survivors. We obtained the odds ratio (OR), 95% confidence interval (95%CI), and forest plots. Sensitivity analysis was used to analyze publication bias and heterogeneity. Results In 35 studies with 7931 confirmed COVID-19 patients, we found that anorexia (pooled OR:2.05; 95%CI: 1.36-3.09, p=0.0006) and abdominal pain (OR 2.80; 95%CI: 1.41-5.54, p=0.003) were associated with a higher risk of poor outcomes and no such association was found for diarrhea (OR 1.04; 95%CI: 0.85-1.26, p=0.71), nausea (OR 0.73; 95%CI: 0.38-1.39, p=0.34) and vomiting (OR 1.24; 95%CI 0.86-1.79, p=0.25). Conclusion The meta-analysis concludes that anorexia and abdominal pain are associated with poor outcomes in hospitalized COVID-19 patients, while diarrhea, nausea, and vomiting have no association. Future research should focus on whether detecting GI invasion in conjunction with fecal polymerase chain reaction (PCR) testing can aid in the early triage of high-risk individuals and improve outcomes.

Disorders of gut-brain interaction in post-acute COVID-19 syndrome

The novel coronavirus SARS-CoV-2 is responsible for the devastating pandemic which has caused more than 5 million deaths across the world until today. Apart from causing acute respiratory illness and multiorgan dysfunction, there can be long-term multiorgan sequalae after recovery, which is termed 'long COVID-19' or 'post-acute COVID-19 syndrome'. Little is known about long-term gastrointestinal (GI) consequences, occurrence of post-infection functional gastrointestinal disorders and impact the virus may have on overall intestinal health. In this review, we put forth the various mechanisms which may lead to this entity and possible ways to diagnose and manage this disorder. Hence, making physicians aware of this spectrum of disease is of utmost importance in the present pandemic and this review will help clinicians understand and suspect the occurrence of functional GI disease post recovery from COVID-19 and manage it accordingly, avoiding unnecessary misconceptions and delay in treatment.

Long-term Gastrointestinal Sequelae Following COVID-19: A Prospective Follow-up Cohort Study

BACKGROUND & AIMS

Coronavirus disease 2019 (COVID-19) is associated with long-term gastrointestinal sequelae; however, prospective longitudinal data are sparse. We prospectively studied the frequency, spectrum, and risk factors of post infection functional gastrointestinal disorders/disorders of gut-brain interaction (PI-FGID/DGBI) after COVID-19.

METHODS

Three hundred twenty cases with COVID-19 and 2 control groups, group A, 320 healthy spouses/family controls, and group B, 280 healthy COVID serology-negative controls, were prospectively followed up at 1, 3, and 6 months by using validated Rome IV criteria to evaluate the frequency of PI-FGID/DGBI.

RESULTS

Of 320 cases, at 1 month 36 (11.3%) developed FGID symptoms. Persistent symptoms were noted in 27 (8.4%) at 3 months and in 21 (6.6%) at 6 months. At 3 months, 8 (2.5%) had irritable bowel syndrome, 7 (2.2%) had functional diarrhea, 6 (1.9%) had functional dyspepsia, 3 (0.9%) had functional constipation, 2 (0.6%) had functional dyspepsia-IBS overlap, and 1 (0.3%) had functional abdominal bloating/distention. Among symptomatic individuals at 3 months, 8 (29.6%) were positive for isolated carbohydrate malabsorption, 1 (3.7%) was positive for post infection malabsorption syndrome, and 1 (3.7%) was positive for intestinal methanogen overgrowth. None of the healthy controls developed FGID up to 6 months of follow-up (P < .01). Predictive factors at 3 and 6 months were severity of infection (P < .01) and presence of gastrointestinal symptoms at the time of infection (P < .01).

CONCLUSIONS

COVID-19 led to significantly higher number of new onset PI-FGID/DGBI compared with healthy controls at 3 and 6 months of follow-up. If further investigated, some patients can be diagnosed with underlying malabsorption.

Extrapulmonary COVID-19 Presents As Spontaneous Small Bowel Perforation

SARS-CoV2 is a well-recognized pathogen with a myriad of presenting symptoms. Well-documented pulmonary, neurological, gastrointestinal, and hematologic complications have occurred during the global COVID-19 pandemic. While gastrointestinal symptoms are the most commonly reported extrapulmonary symptom of COVID-19, the incidence of primary perforation has not been widely reported. In this case report, we describe a spontaneous small bowel perforation in a patient who was incidentally found to be COVID-19 positive. This peculiar case underlies the continued evolution of SARS-CoV2 understanding and potential unknown complications of the virus.

Sewage surveillance system using urological wastewater: Key to COVID-19 monitoring?

Since December 2019, the emergence of a new Severe Acute Respiratory Syndrome- coronavirus (SARS-CoV-2) has led to a global coronavirus pandemic disease (COVID-19), with devastating consequences for all healthcare worldwide, including urological care. COVID-19 has led to concern among urological healthcare workers about viral presence, detection and routes of transmission during routine clinical practice. The potential presence of (active) virus in bodily fluids of COVID-19 patients remains a continuing topic of debate. Therefore, we highlight viral detection methods and review the presence of SARS-CoV-2 in urine, feces, and semen. Finally, we discuss how excretion of virus particles through urological bodily fluids might be pivotal to epidemiologic monitoring and control of the disease.

Multi-organ system involvement in coronavirus disease 2019 (COVID-19): A mega review

Since the pandemic of the coronavirus disease 2019 (COVID-19) infection, many people have been affected in different ways. The majority of infected people experience mild to moderate symptoms and recover without the need for hospitalization. However, in some affected people, it may lead to catastrophic disease. The severity of COVID-19 infection is widely influenced by co-morbidities, immune system functions, and extra-pulmonary organ injuries. Since the emergence of COVID-19, multi-organ involvement has been documented. In order to implement preventative and protective measures, full attention to potential organ injuries is required. Most existing articles and review papers are focused on a specific organ system, and their numbers are growing. In this review paper, attempts were made to collect review papers and articles published on seven organ system involvements in COVID-19 infection published till 15 July and highlight conclusions and managements of all affected organs. We tried to add to the medical knowledge on COVID-19, pointing out its multi-organ system impact. Finally, we tried to facilitate access to organized information and optimum conclusion by representing review tables for each organ system. Besides, this review article can clarify and magnify the empty research space easily for future investigations.

In COVID-19 Patients, the Identified Gastrointestinal Symptoms in Tertiary Care Center of India

Aim

Materials and methods

Results

Conclusion

How to cite this article

Adenomesenteritis following SARS-CoV-2 Vaccination in Children: A Case Report and Review of The Literature

At present, the vaccine authorized in children aged 5 years and older is the BNT162b2 messenger RNA COVID-19 vaccine. Unlike adults, there is limited data available in the pediatric age describing adverse events after vaccine. We report a case of adenomesenteritis in a young girl following the first dose of vaccine.

Global research production pertaining to gastrointestinal involvement in COVID-19: A bibliometric and visualised study

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a global pandemic that can cause diarrhoea, nausea/vomiting, and abdominal pain, among other gastrointestinal (GI) symptoms.

AIM

To perform a bibliometric analysis of the global research production pertaining to GI involvement in COVID-19.

METHODS

The Scopus database was used to search the global literature on GI involvement in COVID-19 during 2020. A bibliometric review of these publications was also performed using VOSviewer.

RESULTS

Scopus had published 95615 documents on COVID-19 in all areas of research at the time of data collection. In total, 1267 publications on the topic of GI and COVID-19 were identified. Research articles (n = 606; 47.83%), letters (293; 23.13%), and reviews (186; 14.68%) were the most popular types of documents. The most productive countries and institutions in this field were the United States and Huazhong University of Science and Technology. The most cited paper was Xiao et al, which was published in Gastroenterology as a brief communication, with 798 citations. This paper provides evidence for GI infection of COVID-19 and its possible faecal-oral transmission route. In the term cluster analysis, there were two frontiers in this field: GI manifestations among COVID-19 patients and the implications of COVID-19 for the gastroenterologist.

CONCLUSION

GI manifestations among COVID-19 patients and implications of COVID-19 for gastroenterologists were of interest, especially in the early stages of the pandemic.

Review on acute pancreatitis attributed to COVID-19 infection

The coronavirus disease 2019 (COVID-19) is known to cause gastrointestinal symptoms. Recent studies have revealed COVID-19-attributed acute pancreatitis (AP). However, clinical characteristics of COVID-19-attributed AP remain unclear. We performed a narrative review to elucidate relation between COVID-19 and AP using the PubMed database. Some basic and pathological reports revealed expression of angiotensin-converting enzyme 2 and transmembrane protease serine 2, key proteins that aid in the entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into the pancreas. The experimental and pathological evaluation suggested that SARS-CoV-2 infects human endocrine and exocrine pancreas cells, and thus, SARS-CoV-2 may have a direct involvement in pancreatic disorders. Additionally, systemic inflammation, especially in children, may cause AP. Levels of immune mediators associated with AP, including interleukin (IL)-1β, IL-10, interferon-γ, monocyte chemotactic protein 1, and tumor necrosis factor-α are higher in the plasma of patients with COVID-19, that suggests an indirect involvement of the pancreas. In real-world settings, some clinical features of AP complicate COVID-19, such as a high complication rate of pancreatic necrosis, severe AP, and high mortality. However, clinical features of COVID-19-attributed AP remain uncertain due to insufficient research on etiologies of AP. Therefore, high-quality clinical studies and case reports that specify methods for differential diagnoses of other etiologies of AP are needed.

Lethal hemorrhagic necrotizing pancreatitis in a child with congenital immunodeficiency and COVID-19

Purpose

Various manifestations of coronavirus (SARS-CoV-2) have been reported since the pandemic began. Some articles have reported acute pancreatitis in adult patients due to COVID-19 infection. To our knowledge this is the first report of acute hemorrhagic necrotizing pancreatitis in children associated with SARS-CoV-2 infection.

Case presentation

A 7-year-old girl with congenital immunodeficiency was referred to the intensive care (ICU) unit with acute respiratory distress syndrome. She required mechanical ventilation (MV) due to pulmonary involvement of COVID-19 (chest CT with lower lung ground-glass opacities). SARS-CoV-2 infection was laboratory confirmed. Following a 49-day stay in the ICU, due to the clinical and radiological signs of acute abdomen and to the rapid deterioration in the clinical status, an indication to proceed an urgent surgerical intervention was made. Intra-operatively an adhesiolysis with blunt dissection of the of gastrocolic ligament was performed, then followed by debridement of the necrotic pancreas (more than 1⁄2 of the pancreas was damaged). Continuous lavage and drainage were placed. During the post-operative period, patient required aggressive MV and insulin therapy for persistent hyperglycemia. The CT scans reported a necrosis of the pancreas and we observed amylase and lipase elevation in the peritoneal lavage sample. Despite active intensive therapy, the patient's condition did not improve and she died 38 days after laparotomy as a result of multi-organ failure.

Conclusion

The mechanism for the development of acute haemorrhagic necrotizing pancreatitis in the COVID-19 positive patients is unclear; perhaps it is due to a direct cytopathic effect from the COVID-19 virus, or due to the ACE2 expression in pancreas.

Gastric Perforation as a Complication of COVID-19 Infection: A Case Report

Pulmonary symptoms are the primary manifestation of the COVID-19 disease, which originated in Wuhan in China in December 2019. However, it is now established to show widespread extrapulmonary manifestations, including gastrointestinal involvement. Abdominal pain, diarrhea, nausea, and vomiting are considered the most common gastrointestinal symptoms. Gastric perforation in association with COVID-19 is rarely reported in the literature. Here, we report a case of a 71-year-old male COVID-19-infected patient, medically free, who presented to the emergency department complaining of severe abdominal pain for a one-week duration. He was diagnosed with a case of perforated viscus and septic shock. The patient was shifted to the operating room for exploratory laparotomy. We aim in this report to highlight this fatal complication of COVID-19 infection in order to improve patients' outcomes.

Clinical and Molecular Relationships between COVID-19 and Feline Infectious Peritonitis (FIP)

The emergence of severe acute respiratory syndrome 2 (SARS-CoV-2) has led the medical and scientific community to address questions surrounding the pathogenesis and clinical presentation of COVID-19; however, relevant clinical models outside of humans are still lacking. In felines, a ubiquitous coronavirus, described as feline coronavirus (FCoV), can present as feline infectious peritonitis (FIP)-a leading cause of mortality in young cats that is characterized as a severe, systemic inflammation. The diverse extrapulmonary signs of FIP and rapidly progressive disease course, coupled with a closely related etiologic agent, present a degree of overlap with COVID-19. This paper will explore the molecular and clinical relationships between FIP and COVID-19. While key differences between the two syndromes exist, these similarities support further examination of feline coronaviruses as a naturally occurring clinical model for coronavirus disease in humans.

Effects of Ultramicronized Palmitoylethanolamide (um-PEA) in COVID-19 Early Stages: A Case–Control Study

Ultramicronized palmitoylethanolamide (um-PEA), a compound with antioxidant, anti-inflammatory and neuroprotective properties, appears to be a potential adjuvant treatment for early stages of Coronavirus disease 2019 (COVID-19). In our study, we enrolled 90 patients with confirmed diagnosis of COVID-19 that were randomized into two groups, homogeneous for age, gender and BMI. The first group received oral supplementation based on um-PEA at a dose of 1800 mg/day for a total of 28 days; the second group was the control group (R.S. 73.20). At baseline (T0) and after 28 days of um-PEA treatment (T1), we monitored: routine laboratory parameters, inflammatory and oxidative stress (OS) biomarkers, lymphocytes subpopulation and COVID-19 serological response. At T1, the um-PEA-treated group presented a significant reduction in inflammation compared to the control group (CRP p = 0.007; IL-6 p = 0.0001; neutrophils to lymphocytes ratio p = 0.044). At T1, the controls showed a significant increase in OS compared to the treated group (FORT p = 0.05). At T1, the um-PEA group exhibited a significant decrease in D-dimer levels (p = 0.0001) and higher levels of IgG against SARS-CoV-2 (p = 0.0001) compared to the controls. Our data demonstrated, in a randomized clinical trial, the beneficial effects of um-PEA in both asymptomatic and mild-symptomatic patients related to reductions in inflammatory state, OS and coagulative cascade alterations.

The Impact of Information Sources on COVID-19-Related Knowledge, Attitudes, and Practices (KAP) among University Students: A Nationwide Cross-Sectional Study

COVID-19 is an emerging respiratory disease caused by a novel coronavirus accompanied by a tsunami of misinformation and fake news. This can weaken the public health responses by affecting the COVID-19-related knowledge, attitudes, and practices (KAP) of the public. Therefore, this cross-sectional study was designed during the early stage of the pandemic to evaluate the KAP of Palestinian university students and their commonly used information sources. We found that the most trusted information source among students was the World Health Organization (WHO), followed by the Palestinian Ministry of Health (MoH) briefings and healthcare workers, whereas social media was the most frequently used source of information. The participants exhibited a high level of COVID-19-related knowledge, having an average score of 8.65 (range: 0–10). In total, 76% avoided going to crowded places, and only 33% wore a mask while being outdoors. The vast majority (93%) checked the accuracy of COVID-19-related information before publishing it, 56% used the WHO and MoH briefings for fact-checking, and only 8% relied on healthcare workers. This was particularly the case for those who lived in refugee camps. This study provides an insight into the information sources used by Palestinian university students, the sources they trust, and the information formats they prefer. These results may help public health authorities to locate the information sources through which university students should be targeted. Efforts should be made to recommend healthcare workers as credible information sources. In this way, they will be able to prevent the spread of misleading information and provide high-quality information, especially within unconventional settings such as refugee camps.

Global Prevalence of COVID-19-Associated Mucormycosis (CAM): Living Systematic Review and Meta-Analysis

Mucormycosis, a secondary fungal infection, gained much attention in the ongoing COVID-19 pandemic. This deadly infection has a high all-cause mortality rate and imposes a significant economic, epidemiological, and humanistic burden on the patients and healthcare system. Evidence from the published epidemiological studies showed the varying prevalence of COVID-19-associated mucormycosis (CAM). This study aims to compute the pooled prevalence of CAM and other associated clinical outcomes. MEDLINE, Embase, Cochrane COVID-19 Study Register, and WHO COVID-19 databases were scanned to retrieve the relevant articles until August 2021. All studies reporting the prevalence of mucormycosis among COVID-19 patients were eligible for inclusion. Two investigators independently screened the articles against the selection criteria, extracted the data, and performed the quality assessment using the JBI tool. The pooled prevalence of CAM was the primary outcome, and the pooled prevalence of diabetes, steroid exposure, and the mortality rate were the secondary outcomes of interest. Comprehensive Meta-Analysis software version 2 was used for performing the meta-analysis. This meta-analysis comprised six studies with a pooled sample size of 52,916 COVID-19 patients with a mean age of 62.12 ± 9.69 years. The mean duration of mucormycosis onset was 14.59 ± 6.88 days after the COVID-19 diagnosis. The pooled prevalence of CAM (seven cases per 1000 patients) was 50 times higher than the highest recorded background of mucormycosis (0.14 cases per 1000 patients). A high mortality rate was found among CAM patients with a pooled prevalence rate of 29.6% (95% CI: 17.2-45.9%). Optimal glycemic control and the judicious use of steroids should be the approach for tackling rising CAM cases.

COVID-19-Associated Mucormycosis (CAM): Case-Series and Global Analysis of Mortality Risk Factors

BACKGROUND

Since the novel coronavirus disease (COVID-19) outbreak, the cases of COVID-19 co-infections have been increasingly reported worldwide. Mucormycosis, an opportunistic fungal infection caused by members of the Mucorales order, had been frequently isolated in severely and critically ill COVID-19 patients.

METHODS

Initially, the anamnestic, clinical, and paraclinical features of seven COVID-19-associated mucormycosis (CAM) cases from Egypt were thoroughly reported. Subsequently, an extensive review of the literature was carried out to describe the characteristics of CAM cases globally, aiming to explore the potential risk factors of mortality in CAM patients.

RESULTS

Out of the seven reported patients in the case series, five (71.4%) were males, six (85.7%) had diabetes mellitus, and three (42.9%) had cardiovascular disease. All patients exhibited various forms of facial deformities under the computed tomography scanning, and two of them tested positive for Mucorales using the polymerase chain reaction (PCR) testing. Liposomal amphotericin B (LAmB) was prescribed to all cases, and none of them died until the end of the follow-up. On reviewing the literature, 191 cases were reported worldwide, of which 74.4% were males, 83.2% were from low-middle income countries, and 51.4% were aged 55 years old or below. Diabetes mellitus (79.1%), chronic hypertension (30%), and renal disease/failure (13.6%) were the most common medical comorbidities, while steroids (64.5%) were the most frequently prescribed medication for COVID-19, followed by Remdesivir (18.2%), antibiotics (12.7%), and Tocilizumab (5.5%).

CONCLUSIONS

As the majority of the included studies were observational studies, the obtained evidence needs to be interpreted carefully. Diabetes, steroids, and Remdesivir were not associated with increased mortality risk, thus confirming that steroids used to manage severe and critical COVID-19 patients should not be discontinued. Lung involvement, bilateral manifestation, and Rhizopus isolation were associated with increased mortality risk, thus confirming that proactive screening is imperative, especially for critically ill patients. Finally, surgical management and antimycotic medications, e.g., amphotericin B and posaconazole, were associated with decreased mortality risk, thus confirming their effectiveness.

SARS-CoV-2 Infection as a Cause of Acute Pancreatitis in a Child-A Case Report

The novel coronavirus disease (COVID-19) was detected for the first time in China in December 2019. Soon after it was declared a pandemic. Main symptoms include fever, dyspnea, cough, muscle pain, headache, anosmia and ageusia, however a growing body of evidence shows that other organs can be affected. Gastrointestinal manifestations have been observed in a considerable number of patients and include abdominal pain, diarrhea and vomiting. The involvement of liver as well as pancreas has been also described, however there are only a few cases of acute pancreatitis reported in patients with COVID-19. Therefore, we present a case of 6-year-old child with mild acute pancreatitis and COVID-19 pneumonia.

Is the Gut Microbiome a Target for Adjuvant Treatment of COVID-19?

High expression of the transmembrane protein angiotensin I converting enzyme 2 (ACE2), more than 100-times higher as in the lung, and transmembrane serine protease 2 (TMPRSS2) in the gastrointestinal tract leads to infection with SARS-CoV-2. According to meta-analysis data, 9.8–20% of COVID-19 patients experience gastrointestinal symptoms, where diarrhoea is the most frequent, and about 50% shed viruses with high titre through their faeces, where a first faecal transmission was reported. Furthermore, gut inflammation, intestinal damage, and weakening of the gut mucosal integrity that leads to increased permeability has been shown in different studies for COVID-19 patients. This can lead to increased inflammation and bacteraemia. Low mucosal integrity combined with low intestinal damage is a good predictor for disease progression and submission to the intensive care unit (ICU). Several pilot studies have shown that the gut microbiome of COVID-19 patients is changed, microbial richness and diversity were lower, and opportunistic pathogens that can cause bacteraemia were enriched compared to a healthy control group. In a large proportion of these patients, dysbiosis was not resolved at discharge from the hospital and one study showed dysbiosis is still present after 3 months post COVID-19. Consequently, there might be a link between dysbiosis of the gut microbiome in COVID-19 patients and chronic COVID-19 syndrome (CCS). Various clinical trials are investigating the benefit of probiotics for acute COVID-19 patients, the majority of which have not reported results yet. However, two clinical trials have shown that a certain combination of probiotics is beneficial and safe for acute COVID-19 patients. Mortality was 11% for the probiotic treatment group, and 22% for the control group. Furthermore, for the probiotic group, symptoms cleared faster, and an 8-fold decreased risk of developing a respiratory failure was calculated. In conclusion, evidence is arising that inflammation, increased permeability, and microbiome dysbiosis in the gut occur in COVID-19 patients and thus provide new targets for adjuvant treatments of acute and chronic COVID-19. More research in this area is needed.

Legionella Coinfection in a Patient With COVID-19 Pneumonia

Bacterial superinfection is a well-reported complication of viral pneumonia leading to significantly increased morbidity and mortality. Such superinfections have been reported in patients with pathogenic coronaviruses including severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS), but there are scant reports pertaining to superinfection in the context of coronavirus disease 2019 (COVID-19). We report a case of a middle-aged man who presented with worsening shortness of breath in the context of COVID-19 complicated by superimposed Legionella pneumophilia pneumonia. This case serves to highlight the possibility of bacterial superinfections and to be aware of such possibilities when patients are not responding to standard courses of treatment for COVID-19 as quick clinical deterioration is likely to develop.

Large intestinal perforation secondary to COVID-19: A case report

Introduction

COVID-19 infection is generally characterized by the presence of respiratory symptoms. However, a small percentage of these patients also have gastrointestinal symptoms and complications that are associated with high morbidity and mortality.

Presentation of case

A 50-year-old male patient with COVID-19 infection was being treated for COVID-19 and pneumonia in the ICU. He presented with gastrointestinal symptoms, and the computed tomography (CT) scan revealed a hollow viscus perforation. Ultimately, the patient was taken to surgery, where a spontaneous perforation was found in the right colon. The defect was sutured with separate stitches. There were no complications postoperatively.

Discussion

Although respiratory symptoms are the most common presentation of COVID-19, about 18% of these patients may present with gastrointestinal symptoms. However, an even smaller percentage of critically ill patients may develop serious gastrointestinal complications such as perforation of the large intestine. This unusual complication requires immediate diagnosis and surgical management.

Conclusion

At the time of the COVID-19 pandemic, physicians must recognize COVID-19 in patients presenting gastrointestinal symptoms. A high degree of clinical suspicion enables timely diagnosis and management, thereby preventing major complications.

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Bowel perforation is an uncommon complication of COVID-19. It has been rarely reported in the literature.

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Patients with severe COVID-19 have an increased risk of gastrointestinal complications, including bowel perforation.

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Bowel perforation secondary to COVID-19 in critically ill patients has a nonspecific presentation; thus, it only confers a high degree of suspicion.

Gastrointestinal Manifestation of COVID-19 in Hospitalized Patients

INTRODUCTION

During the initial phase of the pandemic, gastrointestinal (GI) symptoms were less frequent but during the later stages, GI manifestations have become more frequent. This study aims to explore the prevalence of GI symptoms in COVID-19 patients, and also focuses on the frequency of these symptoms.

METHODS

This longitudinal study was conducted in a COVID-19 unit of a tertiary care hospital, Pakistan. Data of patients hospitalized with COVID-19 infection between June 2021 and July 2021 was included in the study. A total of 412 participants were enrolled in the study via consecutive convenient non-probability sampling. Participants' symptoms and demographics were noted in a self-structured questionnaire. The collected data were analyzed using Statistical Package for Social Sciences (SPSS), version 23.0 (IBM Corp., Armonk, NY).

RESULTS

A total of 261 (63.3%) participants had a minimum of one GI symptom. The most common symptom was anorexia (43.9%), followed by diarrhea (24.7%) and nausea/vomiting (17.9%).

CONCLUSION

 Our study indicates high frequency of COVID-19 patients reporting GI symptoms. Anorexia, diarrhea, nausea, and vomiting were commonly reported symptoms. Therefore, COVID 19 testing should be considered with patients presenting with GI symptoms.

Diarrhoea and preadmission antibiotic exposure in COVID-19: a retrospective cohort study of 1153 hospitalised patients

OBJECTIVE

The aims of this study were to describe community antibiotic prescribing patterns in individuals hospitalised with COVID-19, and to determine the association between experiencing diarrhoea, stratified by preadmission exposure to antibiotics, and mortality risk in this cohort.

DESIGN/METHODS

Retrospective study of the index presentations of 1153 adult patients with COVID-19, admitted between 1 March 2020 and 29 June 2020 in a South London NHS Trust. Data on patients' medical history (presence of diarrhoea, antibiotic use in the previous 14 days, comorbidities); demographics (age, ethnicity, and body mass index); and blood test results were extracted. Time to event modelling was used to determine the risk of mortality for patients with diarrhoea and/or exposure to antibiotics.

RESULTS

19.2% of the cohort reported diarrhoea on presentation; these patients tended to be younger, and were less likely to have recent exposure to antibiotics (unadjusted OR 0.64, 95% CI 0.42 to 0.97). 19.1% of the cohort had a course of antibiotics in the 2 weeks preceding admission; this was associated with dementia (unadjusted OR 2.92, 95% CI 1.14 to 7.49). After adjusting for confounders, neither diarrhoea nor recent antibiotic exposure was associated with increased mortality risk. However, the absence of diarrhoea in the presence of recent antibiotic exposure was associated with a 30% increased risk of mortality.

CONCLUSION

Community antibiotic use in patients with COVID-19, prior to hospitalisation, is relatively common, and absence of diarrhoea in antibiotic-exposed patients may be associated with increased risk of mortality. However, it is unclear whether this represents a causal physiological relationship or residual confounding.

The Impact of Angiotensin-Converting Enzyme 2 (ACE2) Expression Levels in Patients with Comorbidities on COVID-19 Severity: A Comprehensive Review

Angiotensin-Converting Enzyme 2 (ACE2) has been proved to be the main host cell receptor for the binding of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for the COVID-19 pandemic. The SARS-CoV-2 spike (S) protein binds to ACE2 to initiate the process of replication. This enzyme is widely present in human organ tissues, such as the heart and lung. The pathophysiology of ACE2 in SARS-CoV-2 infection is complex and may be associated with several factors and conditions that are more severe in COVID-19 patients, such as age, male gender, and comorbidities, namely, cardiovascular diseases, chronic respiratory diseases, obesity, and diabetes. Here we present a comprehensive review that aims to correlate the levels of expression of the ACE2 in patients with comorbidities and with a poor outcome in COVID-19 disease. Significantly higher levels of expression of ACE2 were observed in myocardial and lung tissues in heart failure and COPD patients, respectively. An age-dependent increase in SARS2-CoV-2 receptors in the respiratory epithelium may be also responsible for the increased severity of COVID-19 lung disease in elderly people. Although the role of ACE2 is highlighted regarding the damage that can arise upon the SARS-CoV-2 invasion, there was no association observed between renin-angiotensin-aldosterone system (RAAS) inhibitors and the severity of COVID-19.

Mortality is not increased in SARS-CoV-2 infected persons with hepatitis C virus infection

BACKGROUND

Impact of SARS-CoV-2 infection upon hospitalization, intensive care unit (ICU) admissions and mortality in persons with hepatitis C virus (HCV) infection is unknown.

METHODS

We used the Electronically Retrieved Cohort of HCV infected Veterans (ERCHIVES) database to determine the impact of HCV infection upon the rates of acute care hospitalization, ICU admission and all-cause mortality. We identified Veterans with chronic HCV infection and propensity score matched controls without HCV in ERCHIVES. We excluded those with HIV or hepatitis B virus coinfection.

RESULTS

We identified 975 HCV+ and 975 propensity score matched HCV- persons with SARS-CoV-2 infection. Mean FIB-4 score (±SD) was higher in those with HCV (1.9 ± 2.1 vs 1.2 ± 0.9; P < .0001) and a larger proportion of those with HCV had cirrhosis (8.1% vs 1.4%; P < .0001). A larger proportion of HCV+ were hospitalized compared to HCV- (24.0% vs 18.3%; P = .002); however, those requiring ICU care and mortality were also similar in both groups (6.6% vs 6.5%; P = .9). Among those with FIB-4 score of 1.45-3.25, hospitalization rate/1000-person-years was 41.4 among HCV+ and 20.2 among HCV-, while among those with a FIB-4 > 3.25, the rate- was 9.4 and 0.6 (P < .0001). There was no difference in all-cause mortality by age, gender, FIB-4 score, number of comorbidities or treatment with remdesivir and/or systemic corticosteroids.

CONCLUSIONS

HCV+ persons with SARS-CoV-2 infection are more likely to be admitted to a hospital. The hospitalization rate also increased with higher FIB-4 score. However, admission to an ICU and mortality are not different between those with and without HCV infection.

Unlikely SARS-CoV-2 Transmission During Vaginal Delivery

Pregnant women display a higher risk of progression to disease and higher viral loads during infections due to their more permissive, tolerogenic immune system. However, only few studies have focused on SARS-CoV-2 intrapartum vertical transmission via vaginal secretions or faeces. The aim of this study was to investigate the presence of the virus in vaginal, rectal and blood specimens from pregnant women characterized by different COVID-19 disease severity. We enrolled 56 SARS-CoV-2-positive pregnant women, of which 46 (82%) were in the third trimester of pregnancy, 6 (10%) in the second and 4 (7%) in the first. QPCR was performed to detect the virus in vaginal and rectal swabs and in plasma samples. SARS-CoV-2 was detected in 27% of rectal swabs of pregnant women in the third trimester, while no virus particles were detected in vaginal swabs of the same patients. Furthermore, only 4% plasma samples tested positive to SARS-CoV-2. No virus was detected in newborn’s nasopharyngeal swabs. Despite the low number of subjects enrolled, our data suggest that, while theoretically possible, intrapartum vaginal or orofecal SARS-CoV-2 transmission seems to be unlikely.

COVID-19 and gastroenteric manifestations

Coronavirus disease 2019 (COVID-19), caused by the infection of a novel coronavirus [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)], has become a pandemic. The infection has resulted in about one hundred million COVID-19 cases and millions of deaths. Although SARS-CoV-2 mainly spreads through the air and impairs the function of the respiratory system, it also attacks the gastrointestinal epithelial cells through the same receptor, angiotensin converting enzyme 2 receptor, which results in gastroenteric symptoms and potential fecal-oral transmission. Besides the infection of SARS-CoV-2, the treatments of COVID-19 also contribute to the gastroenteric manifestations due to the adverse drug reactions of anti-COVID-19 drugs. In this review, we update the clinical features, basic studies, and clinical practices of COVID-19-associated gastroenteric manifestations.

Sudden onset of olfactory and gustatory dysfunctions in coronavirus disease 2019 (COVID-19) is momentous marker

Coronavirus disease 2019 (COVID-19) presenting as global pandemic left no boundaries untouched worldwide. There are conglomerates of clinical and pathological presentation depending on population and geographic distribution. However amidst of such variable presentations, the sudden onset of olfactory and gustatory dysfunctions, if present, remains the most consistent and reliable symptoms of severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection. Olfactory and gustatory dysfunctions can be present either isolated or as a part of the spectrum of common symptoms such as fever, cough, dyspnea, and fatigue in COVID-19. The pathophysiology of olfactory and gustatory loss is thought to be due to the neural and cytopathic effect of SARS CoV-2 on nasal and tongue mucosa and olfactory neuroepithelium. This review intends to provide a concise description of recent evidence for structure, pathophysiology, prognosis, and treatment for smell and taste dysfunction in SARS CoV-2-infected patients, subjected to further studies and research. Vigilant screening of anosmia and ageusia could probably be an important tool in the fight against the COVID-19 pandemic.

Clinical characteristics, gastrointestinal manifestations and outcomes of COVID-19 patients in Iran; does the location matters?

BACKGROUND

Coronavirus disease 2019 (COVID-19) started in Asia, and Iran was one of its first epicenters.

AIM

To study the gastrointestinal (GI) symptoms and comorbidities associated with this pandemic in four different regions of Iran.

METHODS

We analyzed data from severe acute respiratory syndrome coronavirus 2 positive patients evaluated at four hospitals of Iran (n = 91), including South (Shiraz), Southeast (Dezful), Rasht (North), and Northwest (Mashhad) between April and September 2020. Demographics, comorbidities and clinical findings including GI symptoms were collected. Statistical descriptive analysis and correlation analyses of symptoms, comorbidities, and mortality were performed.

RESULTS

The average age of COVID-19 patients was 51.1 years, and 56% were male. Mortality rate was 17%. Cough with 84.6%, shortness of breath with 71.4%, fever with 52.7%, and loss of appetite with 43.9% were the main symptoms. Overall cardiac disease was the most common comorbidity with an average of 28.5% followed by hypertension (28.5%) and diabetes (25.2%). The highest comorbidity in North (Rasht) was diabetes (30%) and in South (Dezful) hypertension (37%). Shiraz leads cardiac disease with 43.4%. The most reported GI symptoms included nausea, diarrhea, vomiting, and abdominal pain, with 42.8%, 31.8%, 26.8%, and 12% prevalence, respectively. In addition, albumin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were elevated in 26.3%.

CONCLUSION

Our results show hypertension and diabetes as the most common comorbidities, but their distribution was different in COVID-19 patients in the four studied regions of Iran. Nausea, diarrhea, and elevated liver enzymes were the most common GI symptoms. There was also a high mortality rate that was associated with high infection rates in Iran at the beginning of the pandemic.

A pilot study of viral load in stools of patients with COVID-19 and diarrhea

It is known that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be detected in the stools of patients with the coronavirus disease 2019 (COVID-19) and that the virus can be transmitted by oral-fecal route. However, there are few reports on the viral load in stools. This pilot study aimed to evaluate the clinical characteristics and viral load of SARS-CoV-2 in the stools of 13 patients with confirmed COVID-19 using as control the pepper mild mottle virus, which was proposed as a potential indicator of human fecal contamination of environmental water. SARS-CoV-2 RNA was detected in stool samples from four patients (31%), among whom three presented diarrhea symptoms. One patient experiencing long-term diarrhea (22 days) had high levels of viral RNA in the stools (8.28 log10 copies/g). However, we could not isolate the SARS-CoV-2 in the stool of any patients, using VeroE6/TMPRESS2 cells for four weeks. Our results suggest that SARS-CoV-2 RNA may be detected in the stools of patients with the diarrhea symptoms. Further studies evaluating the relationship between SARS-CoV-2 viral load in stools and diarrhea symptoms in larger patient cohorts and upon adjusting for other causative factors and virus infectivity are still needed.

Gastrointestinal perforation secondary to COVID-19: Case reports and literature review

INTRODUCTION

Corona virus disease-2019 (COVID-19) presents primarily with respiratory symptoms. However, extra respiratory manifestations are being frequently recognized including gastrointestinal involvement. The most common gastrointestinal symptoms are nausea, vomiting, diarrhoea and abdominal pain. Gastrointestinal perforation in association with COVID-19 is rarely reported in the literature.

PATIENT CONCERNS AND DIAGNOSIS

In this series, we are reporting 3 cases with different presentations of gastrointestinal perforation in the setting of COVID-19. Two patients were admitted with critical COVID-19 pneumonia, both required intensive care, intubation and mechanical ventilation. The first one was an elderly gentleman who had difficult weaning from mechanical ventilation and required tracheostomy. During his stay in intensive care unit, he developed Candidemia without clear source. After transfer to the ward, he developed lower gastrointestinal bleeding and found by imaging to have sealed perforated cecal mass with radiological signs of peritonitis. The second one was an obese young gentleman who was found incidentally to have air under diaphragm. Computed tomography showed severe pneumoperitoneum with cecal and gastric wall perforation. The third case was an elderly gentleman who presented with severe COVID-19 pneumonia along with symptoms and signs of acute abdomen who was confirmed by imaging to have sigmoid diverticulitis with perforation and abscess collection.

INTERVENTIONS

The first 2 cases were treated conservatively. The third one was treated surgically.

OUTCOME

Our cases had a variable hospital course but fortunately all were discharged in a good clinical condition.

CONCLUSION

Our aim from this series is to highlight this fatal complication to clinicians in order to enrich our understanding of this pandemic and as a result improve patients' outcome.

Ultramicronized Palmitoylethanolamide (um-PEA): A New Possible Adjuvant Treatment in COVID-19 patients

The Coronavirus Disease-19 (COVID-19) pandemic has caused more than 100,000,000 cases of coronavirus infection in the world in just a year, of which there were 2 million deaths. Its clinical picture is characterized by pulmonary involvement that culminates, in the most severe cases, in acute respiratory distress syndrome (ARDS). However, COVID-19 affects other organs and systems, including cardiovascular, urinary, gastrointestinal, and nervous systems. Currently, unique-drug therapy is not supported by international guidelines. In this context, it is important to resort to adjuvant therapies in combination with traditional pharmacological treatments. Among natural bioactive compounds, palmitoylethanolamide (PEA) seems to have potentially beneficial effects. In fact, the Food and Drug Administration (FDA) authorized an ongoing clinical trial with ultramicronized (um)-PEA as an add-on therapy in the treatment of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. In support of this hypothesis, in vitro and in vivo studies have highlighted the immunomodulatory, anti-inflammatory, neuroprotective and pain-relieving effects of PEA, especially in its um form. The purpose of this review is to highlight the potential use of um-PEA as an adjuvant treatment in SARS-CoV-2 infection.

SARS-CoV-2 Detection in Fecal Sample from a Patient with Typical Findings of COVID-19 Pneumonia on CT but Negative to Multiple SARS-CoV-2 RT-PCR Tests on Oropharyngeal and Nasopharyngeal Swab Samples

Reverse transcriptase polymerase chain reaction (RT-PCR) negative results in the upper respiratory tract represent a major concern for the clinical management of coronavirus disease 2019 (COVID-19) patients. Herein, we report the case of a 43-years-old man with a strong clinical suspicion of COVID-19, who resulted in being negative to multiple severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR tests performed on different oropharyngeal and nasopharyngeal swabs, despite serology having confirmed the presence of SARS-CoV-2 IgM. The patient underwent a chest computed tomography (CT) that showed typical imaging findings of COVID-19 pneumonia. The presence of viral SARS-CoV-2 was confirmed only by performing a SARS-CoV-2 RT-PCR test on stool. Performing of SARS-CoV-2 RT-PCR test on fecal samples can be a rapid and useful approach to confirm COVID-19 diagnosis in cases where there is an apparent discrepancy between COVID-19 clinical symptoms coupled with chest CT and SARS-CoV-2 RT-PCR tests' results on samples from the upper respiratory tract.

COVID-19, nausea, and vomiting

Exclusion of nausea (N) and vomiting (V) from detailed consideration as symptoms of COVID-19 is surprising as N can be an early presenting symptom. We examined the incidence of NV during infection before defining potential mechanisms. We estimate that the overall incidence of nausea (median 10.5%), although variable, is comparable with diarrhea. Poor definition of N, confusion with appetite loss, and reporting of N and/or V as a single entity may contribute to reporting variability and likely underestimation. We propose that emetic mechanisms are activated by mediators released from the intestinal epithelium by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) modulate vagal afferents projecting to the brainstem and after entry into the blood, activate the area postrema (AP) also implicated in anorexia. The receptor for spike protein of SARS-CoV-2, angiotensin 2 converting enzyme (ACE2), and transmembrane protease serine (for viral entry) is expressed in upper gastrointestinal (GI) enterocytes, ACE2 is expressed on enteroendocrine cells (EECs), and SARS-CoV-2 infects enterocytes but not EECs (studies needed with native EECs). The resultant virus-induced release of epithelial mediators due to exocytosis, inflammation, and apoptosis provides the peripheral and central emetic drives. Additionally, data from SARS-CoV-2 show an increase in plasma angiotensin II (consequent on SARS-CoV-2/ACE2 interaction), a centrally (AP) acting emetic, providing a further potential mechanism in COVID-19. Viral invasion of the dorsal brainstem is also a possibility but more likely in delayed onset symptoms. Overall, greater attention must be given to nausea as an early symptom of COVID-19 and for the insights provided into the GI effects of SARS-CoV-2.

COVID-19 and geriatric population: from pathophysiology to clinical perspectives

The COVID-19 pandemic has not only led to a worldwide socio-economic depression, but has also had the highest health impact on the geriatric population. Elderly population, due to various reasons such as low immunity, pre-existing co-morbidities such as hypertension, cardiovascular diseases or diabetes, are obviously predisposed to develop severe infections and exhibit a high mortality rate. This is because of many reasons which include the atypical presentation in the geriatric population which might have led to diagnostic delay. As per the WHO guidelines to perform RT-PCR only on the symptomatic individuals, a very small portion of individuals were tested, leaving a fraction of population undiagnosed. Therefore, there remained a chance that many asymptomatic individuals such caregivers, healthcare professionals, family members were undiagnosed and might have carried this virus to the geriatric patients. Also, many countries were not prepared to handle the burden on their healthcare system which included sudden increased demand of ICU beds, mechanical ventilation etc. As a result, they had to make decision on who to be admitted. Atypical presentation in geriatric population may include afebrile or low-grade fever, absence of cough, malaise, muscle pains, dyspnoea etc. Geriatric population shows a more severe type of pneumonia, significantly higher number of neutrophils and C-reactive protein, less lymphocytes and a higher proportion of multiple lobe involvement. Extreme social suppression during COVID-19 pandemic has increased the risk of mental and physical adverse effects that has made older adults more vulnerable to depression and anxiety.

A Comprehensive Analysis of COVID-19 Impact in Latin America

BACKGROUND

Latin America has now become the epicenter of the global coronavirus disease 2019 (COVID-19) pandemic. In the ongoing COVID -19 pandemic, a profound burden of SARS-COV-2 infection has been reported in Latin America. In the present study, we aim to determine the profiles that are associated with this disease in Latin America. We analyzed symptoms, morbidities and gastrointestinal (GI) manifestations by country.

METHODS

We analyzed data from SARS-CoV-2 positive patients evaluated at healthcare centers and hospitals of 8 Latin American countries including Brazil, Peru, Mexico, Argentina, Colombia, Venezuela, Ecuador, and Bolivia between March 1 and July 30, 2020. These countries consist of a total population that exceeds 519 million. Demographics, comorbidities and clinical symptoms were collected. Statistical descriptive analysis and correlation analyses of symptoms, comorbidities and lethality were performed.

RESULTS

A total of 728,282 patients tested positive for COVID-19 across all the 8 Latin American countries. Of these, 52.6% were female. The average age was 48.4 years. Peru had the oldest cohort with 56.8 years old and highest rate of females (56.8%) while Chile had the youngest cohort (39 years old). Venezuela had the highest male prevalence (56.7%). Most common symptoms were cough with 60.1% (Bolivia had the highest rate 78%), fatigue/tiredness with 52.0%, sore throat with 50.3%, and fever with 44.2%. Bolivia had fever as the top symptom (83.3%). GI symptoms including diarrhea (highest in Mexico with 22.9%), nausea, vomiting, and abdominal pain were not associated with higher mortality.Hypertension was among the top (12.1%) comorbidities followed by diabetes with 8.3% and obesity 4.5%. In multivariable analyses, the leading and significant comorbidities were hypertension (r=0.83, p=0.02), diabetes (r=0.91, p=0.01), and obesity (r=0.86, p=0.03). Asthma (r=0.37, p=0.54) and increasing age (0.13 p=0.81) were not independently associated with higher mortality. Lethality was highest in Mexico (16.6%) and lowest in Venezuela (0.9%) among the analyzed cohorts.

CONCLUSION

Nearly, 10.5%-53% of patients with COVID-19 have GI manifestations. Differential clinical symptoms were associated with COVID-19 in Latin America countries. Metabolic syndrome components were the main comorbidities associated with poor outcome. Country-specific management and prevention plans are needed. Country-specific management and prevention plans can be established from this meta-analysis.

Rates and characteristics of SARS-CoV-2 infection in persons with hepatitis C virus infection

BACKGROUND

Rate of SARS-CoV-2 infection and impact of liver fibrosis stage upon infection rates in persons with hepatitis C virus (HCV) infection are unknown.

METHODS

We retrospectively analysed the Electronically Retrieved Cohort of HCV Infected Veterans (ERCHIVES), a well-established database of HCV-infected Veterans in care. We excluded those with missing FIB-4 score and those with HIV or hepatitis B virus co-infection. We determined the number of persons tested, proportion who tested positive for SARS-CoV-2 and the infection rate by age and liver fibrosis stage.

RESULTS

Among 172,235 persons with HCV, 14,305 (8.3%) were tested for SARS-CoV-2 infection and 892 (6.2%) tested positive. Those with SARS-CoV-2 infection were older, more likely to be Black (55.2% vs 37.8%), obese (body mass index >30 kg/m² 36.2% vs 29.7%) and have diabetes or stroke (P < .0001 for all comparisons). Mean FIB-4 scores and proportion of persons with cirrhosis (based on a FIB-4 > 3.25) were similar in both groups. Incidence rate/1,000 tested persons was much higher among Blacks (88.4; 95% CI 81.1, 96.2) vs Whites (37.5; 95% CI 33.1, 42.4) but similar among those with cirrhosis (FIB-4 > 3.25). The rates were also similar among those who were untreated for HCV vs those treated with or without attaining a sustained virologic response.

CONCLUSIONS

Testing rates among persons with HCV are very low. Persons with infection are more likely to be Black, have a higher body mass index and diabetes or stroke. The degree of liver fibrosis does not appear to have an impact on infection rate.

Guidelines: Discharge Instructions for Covid-19 Patients

INTRODUCTION/OBJECTIVES

Clinicians treating COVID-19 patients face a major challenge in providing an effective relationship with patients who are discharged to return to home in order to optimize patient self-management after discharge. The purpose of these discharge instructions is to assist and provide guidance for physicians, nurses, and other health care personnel involved in discharging COVID-19 patients to home after encounters at hospitals, emergency departments, urgent care settings, and medical offices.

METHODS

A systematic literature-search of studies evaluating both symptoms and signs of COVID-19 was performed in order to establish specific optimal performance criteria in monitoring a patient's status with regard to disease safety. These optimal performance criteria parameters were considered with regard to the severity of morbidity and mortality. Strategies used to develop the discharge instructions included review of a broad spectrum of literature to develop the discharge criteria.

RESULTS

These guidelines are presented for patient education and should achieve the essential goals including: enabling patients to understand their medical situation, preventing complications, supporting patients by providing instructions, helping patients make more effective use of available health services, and managing patient stress by giving patients comfort through the knowledge of specific recommendations including how to respond to situations.

CONCLUSION

The COVID-19 pandemic requires clinicians to efficiently teach their patients self-management strategies and to provide a safe educated response to the patient and the surrounding community environment. The primary goal of the patient education discharge-instructions (PEDI) is to provide self-management strategies for preventing complications and disease transmission.

Epidemiological and clinical features of Croatian children and adolescents with a PCR-confirmed coronavirus disease 2019: differences between the first and second epidemic wave

AIM

To describe epidemiological and clinical features of Croatian children and adolescents with a polymerase chain reaction (PCR)-confirmed coronavirus disease 2019.

METHODS

Data on patients aged ≤19 years with a positive SARS-CoV-2 PCR test recorded in the period March 12-May 12 (first wave) and June 19-July 19, 2020 (second wave) were retrospectively analyzed. The periods were separated by several weeks with no incident cases.

RESULTS

We analyzed data on 289 children and adolescents (6.5% of all cases; incidence rate [IR]=3.54, 95% confidence interval [CI] 3.14-3.97/million person-days), 124 in the first wave (IR=2.27) and 165 in the second wave (IR=6.37): IRR second/first=2.71 (2.13-3.44). During the first wave, the incidence was highest in infants (IR=3.48), while during the second wave it progressively increased to IR = 7.37 in 15-19-year olds. Family members were the key epidemiological contacts (72.6% cases), particularly during the first wave (95.8% vs 56.3%). Overall, 41.3% patients were asymptomatic, 25.3% in the first and 52.6% in the second wave. Age 15-19 years (vs younger) was associated with a higher (RR = 1.26, 1.02-1.54) and infection in the second wave with a lower probability (RR=0.66, 0.53-0.81) of being symptomatic. The most common symptoms were fever, cough, and rhinorrhea. In children aged ≥7 years, headache, anosmia/ageusia, and sore throat were also recorded. Only one child suffered a severe disease. All but 18 (7.8%) children were treated only symptomatically, and all fully recovered.

CONCLUSION

A large proportion of SARS-CoV-2 PCR-positive children/adolescents were asymptomatic. The associated disease was predominantly mild, comparably so in the first and second pandemic wave.

Skin and gastrointestinal symptoms in COVID-19

INTRODUCTION

The first cases of coronavirus disease 2019 (COVID-19) were noted in December 2019 in Wuhan province, China. The World Health Organisation (WHO) announced the pandemic status on March 11, 2020. The manifestations of the disease are as follows: fever, cough, fatigue, anosmia and ageusia, dyspnoea, chest pain, muscle soreness, chills, sore throat, rhinitis, headache, gastrointestinal (GI) symptoms, and dermal lesions.

AIM

To evaluate the relationship between dermal lesions and GI symptoms in a group of COVID-19 patients.

MATERIAL AND METHODS

A group of 441 COVID-19 patients admitted to the Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw between March 15th and June 15th, 2020.

RESULTS

Of 441 patients with confirmed SARS-CoV-2 infection, 255 (58.5%) experienced gastrointestinal (GI) symptoms: lack of appetite was reported in 124 (48.6%) cases, diarrhoea was noted in 109 (42.7%), abdominal pain in 95 (37.3%), vomiting in 37 (14.5%), and nausea in 32 (12.5%) cases. Eight (1.81%) patients had dermal lesions: erythematous macular lesions (2 patients - 25%), erythematous infiltrated lesions (2; 25%), erythematous infiltrated and exfoliative lesions (3; 37.5%), erythematous papular lesions (3; 37.5%), and erythematous oedematous lesions (2; 25%). All of those patients reported gastrointestinal symptoms during the hospitalisation.

CONCLUSIONS

The following study analyses possible causes of dermal lesions and their coexistence with GI symptoms. Several possible theories were taken into account, including the microbiota alterations and issue of drug-related complications.

COVID-19 gastrointestinal manifestations: a systematic review

INTRODUCTION

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has greatly challenged public health worldwide. A growing number of studies have reported gastrointestinal (GI) symptoms. We performed a systematic review of GI symptoms associated with coronavirus disease 2019 (COVID-19) as well as of the serum levels of biomarkers related to liver function and lesion in SARS-CoV-2-infected individuals.

METHODS

We surveyed relevant articles published in English, Spanish, and Portuguese up to July, 2020 in the PubMed, MEDLINE, SciELO, LILACS, and BVS databases. Moreover, we surveyed potentially important articles in journals such as the NEJM, JAMA, BMJ, Gut, and AJG.

RESULTS

This systematic review included 43 studies, including 18,246 patients. Diarrhea was the most common GI symptom, affecting 11.5% of the patients, followed by nausea and vomiting (6.3%) and abdominal pain (2.3%). With regard to clinical severity, 17.5% of the patients were classified as severely ill, whereas 9.8% of them were considered to have a non-severe disease. Some studies showed increased aspartate transaminase and alanine aminotransferase levels in a portion of the 209 analyzed patients and two studies.

CONCLUSIONS

Our results suggest that digestive symptoms are common in COVID-19 patients. In addition, alterations in cytolysis biomarkers could also be observed in a lesser proportion, calling attention to the possibility of hepatic involvement in SARS-CoV-2-infected individuals.

Innate immunity during SARS-CoV-2: evasion strategies and activation trigger hypoxia and vascular damage

Innate immune sensing of viral molecular patterns is essential for development of antiviral responses. Like many viruses, SARS-CoV-2 has evolved strategies to circumvent innate immune detection, including low cytosine-phosphate-guanosine (CpG) levels in the genome, glycosylation to shield essential elements including the receptor-binding domain, RNA shielding and generation of viral proteins that actively impede anti-viral interferon responses. Together these strategies allow widespread infection and increased viral load. Despite the efforts of immune subversion, SARS-CoV-2 infection activates innate immune pathways inducing a robust type I/III interferon response, production of proinflammatory cytokines and recruitment of neutrophils and myeloid cells. This may induce hyperinflammation or, alternatively, effectively recruit adaptive immune responses that help clear the infection and prevent reinfection. The dysregulation of the renin-angiotensin system due to down-regulation of angiotensin-converting enzyme 2, the receptor for SARS-CoV-2, together with the activation of type I/III interferon response, and inflammasome response converge to promote free radical production and oxidative stress. This exacerbates tissue damage in the respiratory system, but also leads to widespread activation of coagulation pathways leading to thrombosis. Here, we review the current knowledge of the role of the innate immune response following SARS-CoV-2 infection, much of which is based on the knowledge from SARS-CoV and other coronaviruses. Understanding how the virus subverts the initial immune response and how an aberrant innate immune response contributes to the respiratory and vascular damage in COVID-19 may help to explain factors that contribute to the variety of clinical manifestations and outcome of SARS-CoV-2 infection.