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Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis.
Gastroenterology. 2020 07; 159(1):81-95.G

Abstract

BACKGROUND & AIMS

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which has been characterized by fever, respiratory, and gastrointestinal symptoms as well as shedding of virus RNA into feces. We performed a systematic review and meta-analysis of published gastrointestinal symptoms and detection of virus in stool and also summarized data from a cohort of patients with COVID-19 in Hong Kong.

METHODS

We collected data from the cohort of patients with COVID-19 in Hong Kong (N = 59; diagnosis from February 2 through February 29, 2020),and searched PubMed, Embase, Cochrane, and 3 Chinese databases through March 11, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We analyzed pooled data on the prevalence of overall and individual gastrointestinal symptoms (loss of appetite, nausea, vomiting, diarrhea, and abdominal pain or discomfort) using a random effects model.

RESULTS

Among the 59 patients with COVID-19 in Hong Kong, 15 patients (25.4%) had gastrointestinal symptoms, and 9 patients (15.3%) had stool that tested positive for virus RNA. Stool viral RNA was detected in 38.5% and 8.7% among those with and without diarrhea, respectively (P = .02). The median fecal viral load was 5.1 log10 copies per milliliter in patients with diarrhea vs 3.9 log10 copies per milliliter in patients without diarrhea (P = .06). In a meta-analysis of 60 studies comprising 4243 patients, the pooled prevalence of all gastrointestinal symptoms was 17.6% (95% confidence interval [CI], 12.3-24.5); 11.8% of patients with nonsevere COVID-19 had gastrointestinal symptoms (95% CI, 4.1-29.1), and 17.1% of patients with severe COVID-19 had gastrointestinal symptoms (95% CI, 6.9-36.7). In the meta-analysis, the pooled prevalence of stool samples that were positive for virus RNA was 48.1% (95% CI, 38.3-57.9); of these samples, 70.3% of those collected after loss of virus from respiratory specimens tested positive for the virus (95% CI, 49.6-85.1).

CONCLUSIONS

In an analysis of data from the Hong Kong cohort of patients with COVID-19 and a meta-analysis of findings from publications, we found that 17.6% of patients with COVID-19 had gastrointestinal symptoms. Virus RNA was detected in stool samples from 48.1% patients, even in stool collected after respiratory samples had negative test results. Health care workers should therefore exercise caution in collecting fecal samples or performing endoscopic procedures in patients with COVID-19, even during patient recovery.

Authors+Show Affiliations

Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong; Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong.Department of Medicine and Geriatrics, Ruttonjee and Tang Shiu Kin Hospital, Hong Kong.Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong.Department of Medicine, United Christian Hospital, Hong Kong.Department of Medicine and Geriatrics, Ruttonjee and Tang Shiu Kin Hospital, Hong Kong.Department of Medicine, Tuen Mun Hospital, Hong Kong.Department of Medicine, Queen Elizabeth Hospital, Hong Kong.Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong.Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong.Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong.Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong.Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong.Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong; Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong; Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong.State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong.Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong. Electronic address: waikleung@hku.hk.

Pub Type(s)

Journal Article
Meta-Analysis
Systematic Review

Language

eng

PubMed ID

32251668

Citation

Cheung, Ka Shing, et al. "Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis." Gastroenterology, vol. 159, no. 1, 2020, pp. 81-95.
Cheung KS, Hung IFN, Chan PPY, et al. Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology. 2020;159(1):81-95.
Cheung, K. S., Hung, I. F. N., Chan, P. P. Y., Lung, K. C., Tso, E., Liu, R., Ng, Y. Y., Chu, M. Y., Chung, T. W. H., Tam, A. R., Yip, C. C. Y., Leung, K. H., Fung, A. Y., Zhang, R. R., Lin, Y., Cheng, H. M., Zhang, A. J. X., To, K. K. W., Chan, K. H., ... Leung, W. K. (2020). Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology, 159(1), 81-95. https://doi.org/10.1053/j.gastro.2020.03.065
Cheung KS, et al. Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology. 2020;159(1):81-95. PubMed PMID: 32251668.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. AU - Cheung,Ka Shing, AU - Hung,Ivan F N, AU - Chan,Pierre P Y, AU - Lung,K C, AU - Tso,Eugene, AU - Liu,Raymond, AU - Ng,Y Y, AU - Chu,Man Y, AU - Chung,Tom W H, AU - Tam,Anthony Raymond, AU - Yip,Cyril C Y, AU - Leung,Kit-Hang, AU - Fung,Agnes Yim-Fong, AU - Zhang,Ricky R, AU - Lin,Yansheng, AU - Cheng,Ho Ming, AU - Zhang,Anna J X, AU - To,Kelvin K W, AU - Chan,Kwok-H, AU - Yuen,Kwok-Y, AU - Leung,Wai K, Y1 - 2020/04/03/ PY - 2020/03/16/received PY - 2020/03/23/revised PY - 2020/03/26/accepted PY - 2020/4/7/pubmed PY - 2020/8/8/medline PY - 2020/4/7/entrez KW - Fecal-to-Oral Transmission KW - PRISMA KW - SARS KW - Viral Persistence SP - 81 EP - 95 JF - Gastroenterology JO - Gastroenterology VL - 159 IS - 1 N2 - BACKGROUND & AIMS: Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which has been characterized by fever, respiratory, and gastrointestinal symptoms as well as shedding of virus RNA into feces. We performed a systematic review and meta-analysis of published gastrointestinal symptoms and detection of virus in stool and also summarized data from a cohort of patients with COVID-19 in Hong Kong. METHODS: We collected data from the cohort of patients with COVID-19 in Hong Kong (N = 59; diagnosis from February 2 through February 29, 2020),and searched PubMed, Embase, Cochrane, and 3 Chinese databases through March 11, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We analyzed pooled data on the prevalence of overall and individual gastrointestinal symptoms (loss of appetite, nausea, vomiting, diarrhea, and abdominal pain or discomfort) using a random effects model. RESULTS: Among the 59 patients with COVID-19 in Hong Kong, 15 patients (25.4%) had gastrointestinal symptoms, and 9 patients (15.3%) had stool that tested positive for virus RNA. Stool viral RNA was detected in 38.5% and 8.7% among those with and without diarrhea, respectively (P = .02). The median fecal viral load was 5.1 log10 copies per milliliter in patients with diarrhea vs 3.9 log10 copies per milliliter in patients without diarrhea (P = .06). In a meta-analysis of 60 studies comprising 4243 patients, the pooled prevalence of all gastrointestinal symptoms was 17.6% (95% confidence interval [CI], 12.3-24.5); 11.8% of patients with nonsevere COVID-19 had gastrointestinal symptoms (95% CI, 4.1-29.1), and 17.1% of patients with severe COVID-19 had gastrointestinal symptoms (95% CI, 6.9-36.7). In the meta-analysis, the pooled prevalence of stool samples that were positive for virus RNA was 48.1% (95% CI, 38.3-57.9); of these samples, 70.3% of those collected after loss of virus from respiratory specimens tested positive for the virus (95% CI, 49.6-85.1). CONCLUSIONS: In an analysis of data from the Hong Kong cohort of patients with COVID-19 and a meta-analysis of findings from publications, we found that 17.6% of patients with COVID-19 had gastrointestinal symptoms. Virus RNA was detected in stool samples from 48.1% patients, even in stool collected after respiratory samples had negative test results. Health care workers should therefore exercise caution in collecting fecal samples or performing endoscopic procedures in patients with COVID-19, even during patient recovery. SN - 1528-0012 UR - https://www.unboundmedicine.com/medline/citation/32251668/Gastrointestinal_Manifestations_of_SARS_CoV_2_Infection_and_Virus_Load_in_Fecal_Samples_From_a_Hong_Kong_Cohort:_Systematic_Review_and_Meta_analysis_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0016-5085(20)30448-0 DB - PRIME DP - Unbound Medicine ER -