








key: cord-338689-4u1ezk64
authors: Ata, Fateen; Almasri, Hussam; Sajid, Jamal; Yousaf, Zohaib
title: COVID-19 presenting with diarrhoea and hyponatraemia
date: 2020-06-07
journal: BMJ Case Rep
DOI: 10.1136/bcr-2020-235456
sha: 
doc_id: 338689
cord_uid: 4u1ezk64

COVID-19 is a viral disease with a high infectivity rate. The full spectrum of the disease is not yet understood. This understanding may help in limiting potential exposure. We present a young man with diarrhoea, abdominal pain and hyponatraemia who turned out to be positive for COVID-19.

COVID-19 is a viral disease with a high infectivity rate. The full spectrum of the disease is not yet understood. This understanding may help in limiting potential exposure. We present a young man with diarrhoea, abdominal pain and hyponatraemia who turned out to be positive for COVID-19.

COVID-19 is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Fever is a common presenting symptom, along with cough, dyspnoea, myalgia and fatigue. Severe cases may lead to organ dysfunction and death. 1 As with any infectious disease, one of the challenges with COVID-19 is to understand both the typical and atypical disease presentations. Atypical presentations carry the risk of going undetected for a longer duration, and in turn may lead to the spillover of the disease in a healthcare setting as well as the community.

A 27-year-old Indian man, with known type 2 diabetes, presented with a 5-day history of gradually progressive, moderate severity, generalised abdominal pain. The pain was accompanied by watery diarrhoea five to six times per day. He did not have any fever, sore throat, myalgias, influenzalike symptoms or shortness of breath. A review of systems was remarkable for dry cough of similar duration.

There was no recent history of travel and no sick contacts or animal exposure.

On initial presentation, he was not febrile, tachypnoeic, tachycardiac or hypotensive. Physical examination revealed a patient in distress due to abdominal pain. There was mild generalised abdominal tenderness, but no guarding, rigidity or rebound. The chest examination showed coarse bibasal crackles. The rest of the physical examination was unremarkable.

Initial work-up revealed normocytic anaemia, thrombocytopaenia and non-elevated inflammatory markers. Two repeated samples confirmed asymptomatic hyponatraemia. Liver enzymes, renal function and the endocrine panel were unremarkable. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) was the probable cause of hyponatraemia (table 1) .

On the first day of admission, the patient developed high-grade fever. He was placed under isolation and screened for viral respiratory infections. The patient turned out to be positive for COVID-19.

Given the patient's chief complaint of abdominal pain with diarrhoea, gastroenteritis was the initial working diagnosis. There was no food intake from outside and no sick contacts. Stool analysis for ova and parasites was negative. Also, ELISA immunoassay for Clostridium difficile toxin came out negative. Stool culture was unrevealing. Stool PCR for SARS-CoV-2 was unavailable in the local hospital lab.

Pancreatitis was another differential, but lipase was negative. Atypical pneumonia was another possibility considering the minimal respiratory symptoms and bilateral chest X-ray findings (figure 1). The patient did not produce any sputum for culture, and two sets of blood cultures were negative. Due to hyponatraemia, Legionella pneumonia was considered; however, the urinary antigen was negative.

Viral pneumonia was another diagnostic possibility for which a viral panel was sent, which included SARS-CoV-2 PCR, which eventually came back positive and hence confirmed the diagnosis of the novel coronavirus pneumonia (table 2) .

The patient was initially started on ceftriaxone, azithromycin and oseltamivir as empirical therapy for community-acquired pneumonia. After the tests for COVID-19 PCR from nasal swab came positive, the patient received chloroquine phosphate 250 mg two times per day, darunavir/cobicistat 950 mg daily and ribavirin 1200 mg two times per day for 14 days, based on local guidelines. Ribavirin 1200 mg two times per day was added to his antiviral regimen. The patient remained clinically stable throughout the hospital course until discharge.

The patient's abdominal pain and diarrhoea resolved without any specific management. He did not require any ventilatory support during his stay. His SARS-CoV-2 PCR turned negative on repeat testing after 2 weeks and he was discharged home. learning points ► Knowing the atypical presentation of the disease is as important as knowing a typical presentation. ► Anyone with gastrointestinal symptoms with no alternative explanation should be isolated and screened for COVID-19. ► Early screening may impact the spread of the disease. ► We recommend studies to evaluate the effectiveness of stool PCR for severe acute respiratory syndrome coronavirus 2 if initial nasopharyngeal PCR is negative and suspicion remains high.

The novel coronavirus belongs to a group of severe acute respiratory syndrome-related coronaviruses. 2 It originated in Wuhan, Hubei Province, China, in December 2019 and was declared a pandemic by WHO on 11 March 2020. 3 The most common clinical features are fever, dry cough, myalgia, anorexia and dyspnoea. 4 Gastrointestinal symptoms such as diarrhoea, abdominal pain and vomiting have been previously seen with acute viral respiratory infections and reported recently as rare manifestations of COVID-19. [4] [5] [6] The confirmation of a suspected case relies on SARS-CoV-2 RNA detection via PCR.

Watery diarrhoea is present in SARS-CoV-1 infection secondary to virus replication within the intestinal cells. 7 The presence of gastrointestinal symptoms in coronavirus infection (SARS-CoV-1 and SARS-CoV-2) can be linked to the distribution of ACE2 receptor, which is present in lung alveolar type 2 cells, as well as in enterocytes. 8 Acute hyponatraemia is present in atypical pneumonia, especially Legionella. 9 The underlying mechanism is the syndrome of inappropriate antidiuretic hormone (ADH) secretion. 10 There is a rapidly accumulating body of knowledge regarding the epidemiology, pathophysiology, clinical manifestations, infection control and management of COVID-19. Like any other RNA virus, SARS-CoV-2 attacks the host cell, and penetrates and enters the nucleus for replication. The virus has an affinity to ACE2 as binding receptors. 11 This affinity is the probable reason that the lungs are the most commonly affected organs.

The response of the host organ can be from minimal symptoms to organ failure. T cell immune response to the coronaviruses has been studied in the past. 12 Another common disease phenomenon observed and reported is a hypercoagulable state, which can be explained by the expression of ACE2 enzymes by the endothelium. 13 Similarly, the gastrointestinal tract also expresses ACE2, leading to a viral attack of the system. 14 There is ongoing research to understand the pathophysiology of COVID-19 infection.

An important aspect is to understand the atypical presentation of the disease. Timely detection of suspected cases with prompt isolation and screening is one of the factors that may help curb the spread in the community. 15 Our patient had acute hyponatraemia, abdominal pain and diarrhoea with minimal

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

The species severe acute respiratory syndromerelated coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2

WHO Director-General's opening remarks at the media briefing on COVID-19 -11

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China

Clinical and virological factors associated with gastrointestinal symptoms in patients with acute respiratory infection: a two-year prospective study in general practice medicine

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

A novel coronavirus associated with severe acute respiratory syndrome

COVID-19: gastrointestinal manifestations and potential fecaloral transmission

Legionnaires' disease

Hyponatraemia and the inappropriate ADH syndrome in pneumonia

COVID-19 pathophysiology: a review

T cell-mediated immune response to respiratory coronaviruses

Angiotensin converting enzyme-2 confers endothelial protection and attenuates atherosclerosis

The digestive system is a potential route of 2019-nCov infection: a bioinformatics analysis based on single-cell transcriptomes

The International Bank for Reconstruction and Development / The World Bank

Competing interests None declared. patient consent for publication Obtained.provenance and peer review Not commissioned; externally peer reviewed.This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

Fateen Ata http:// orcid. org/ 0000-0001-7121-8574 Hussam Almasri http:// orcid. org/ 0000-0002-9549-8352 Zohaib Yousaf http:// orcid. org/ 0000-0002-4631-9899

