Afifian, M.

Ahmadpour, S.

Aminnejad, R.

Ghadir, M.R.

Hormati, A.

Khodadust, F.

Saeidi, M.

eprints Iran University of Medical Sciences

Gastroenterología y Hepatología 44 (2021) 31--34www.elsevier.es/gastroenterologiaGastroenterología  y HepatologíaSCIENTIFIC LETTERDysentery  as a rare GI  symptom found  in  COVID-19patientsLa  disentería  como  síntoma  digestivo  poco  frecuente  que se  encuentra  enlos  pacientes  con  COVID-19Coronavirus  Disease  2019  (COVID-19)  caused  by  SARS-CoV-2first  started  in Wuhan,  China,  and soon  turned  to  a  pan-demic  and  still  continue  to  spread  across  the  world.1,2 Withan  increasing  number  of  COVID-19  cases  outside  of  China,Table  1  Serial  laboratory  results  of  43-year-old  woman  with  presentation  of dysentery  due  to  the  infection  with  SARS-CoV-2.Blood  biochemistry  Serology,  endocrinology  and  tumor  marker  ESR  1 h,mm/h21a 0--20Test,  unit  Result  ReferencerangeTest,  unit Result  ReferencerangeFBS,  mg/dL  109 70--99Diabetic:>126CRP,  mg/L  8.4a Up  to  6 WBC,  ×103̂/uL7  4.1--10.5Creatinine,mg/dL1.54a 0.7--1.4  Ferritin,ng/mL95.8  20--250  Neutrophil,×103̂  /uL5.70  2--7.7Directbilirubin,mg/dL0.36a 0--0.3 AFP  (Clia),IU/mL3.22  0--4 Lymphocyte,×103̂  /uL3.61  1--2.7Monocyte,×103̂ /uL1.04  0.3--0.7SGOT (AST),U/L30  11--37  CEA  (Clia),IU/mL2.02  Up  to  4.7  Eosinophil,×103̂  /uL0.32  0.2--0.6SGPT (ALT),U/L28  13--40  Hematology  Basophil,×103̂  /uL0.03  0.01--0.3Iron (Fe),g/dL89  40--120  RBC,  106̂/L  4.31  4.5--5.9TIBC, g/dL  419 230--440  Test,  Unit  Result  ReferencerangeHb,  g/dL  13.80  13.5--17.5Hb A1c,  %  6.2  Nondiabetic:4--6Diabetic:>6.5LDH  400  Up  to  300  Platelet,103̂/L92.6  80--100Abbreviation: FBS: Fasting Blood Sugar; AST: Aspartate Amino Transferase; ALT: Alanine Transferase; TIBC: Total Iron-Binding Capacity;Hb A1c: Glycosylated Hemoglobin; CRP: C-Reactive Protein; AFP: Alpha-Fetoprotein; CEA: Embryonic Carcinoma Antigen; LDH: LactateDehydrogenase; WBC: White Blood Cell; RBC: Red Blood Cell; Hb:  Hemoglobin.a Higher in comparison to the reference value.our  clinics  in  Shahid  Beheshti  Hospital,  Qom  city,  was  facedwith  a  large  number  of  patients  who  were  suspected  ofbeing  infected  with  the SARS-CoV-2.  Following  the outbreakof  COVID-19,  the prevalence  of gastrointestinal  (GI) tracthttps://doi.org/10.1016/j.gastrohep.2020.06.0050210-5705/© 2020 Elsevier España, S.L.U. All rights reserved.SCIENTIFIC  LETTERsymptoms  significantly  goes  up. This  incidence  in COVID-19patients  is  well  documented  in literatures.3 After  February20,  2020,  the  day  that  Iran  reported  as  the start of COVID-19outbreak,  the number  of patients  referred  to  our  GI  clinicwas  unusually  increased.  The  most  important  complaint  ofpatients  was  the  incidence  of some  unusual  GI  symptomsresistant  to  medication.4One  of  the questions  that  need to  be  answered  promptlyis  that  whether  the  incidence  of  rare  GI  symptoms  is  pos-sible  in  confirmed  COVID  pneumonia  patients.  The  answerto  this  question  may  help physicians  take  better  diagnosticand  therapeutic  approaches  for  patients  with  this  symptom.Currently,  we have  reported  the  clinical  data  in  details  aswell  as  the  result  of  chest  CT of  a  COVID-19  patient  withdysentery.A  43-year-old  woman  was  referred  to  our  gastroenterol-ogy  clinic,  complaining  from  dysentery  for  one  week.  Shedid  not  mention  any  cough,  dyspnea  or  respiratory  disor-ders.  Her  past  medical  history  was  unremarkable  and  sheignored  smoking,  drinking  or  using  any  drugs  and  medica-tions.  Respiratory  rate:  18  per  minute  and body  temperaturefrom  oral  root:  37.5--38 ◦C.  In order  to  accurately  evaluatethe  patient,  laboratory  test  was  performed.  The  results  aresummarized  in  (Table  1).  The  levels  of  CRP,  LDH  and  ESR1 h  were  higher  than  the normal range  and  were  equal  to8.4,  400  and  21  respectively.  Alkaline  phosphatase,  amylaseserum  and  bilirubin  values  of  the  patient  were in normalrange.  Medication  with  ciprofloxacine,  500  mg and  metro-dinazole,  500 mg was  started  after  the  first  symptoms  ofdysentery,  to  reduce  the volume  of  diarrhea  and  severedehydration.  Due  to  the  persistence  of  diarrhea  and  thelack  of  therapeutic  response  to  medications,  as  well  as  eval-uation  for  the probability  of inflammatory  bowel  disease(IBD)  in  the  patient,  colonoscopy  was  performed  which  wasresulted  in patchy  erythema  (Fig.  1).  Also,  pathological  find-ing  was  associated  with  the infiltration  of  inflammation  cellswhich  made  us  suspect  infectious  (viral)  colitis.  Since theincidence  of  such GI  symptoms  coincided  with  the COVID-Figure  1  Colonoscopy  finding  of  43-year-old  woman  with  presentation  of  dysentery  which  was  resulted  in  patchy  erythema.Figure  2  Chest  CT scans  (transverse  plane)  of  43-year-old  woman  with  presentation  of  dysentery  due  to  the  infection  withSARS-CoV-2.  Chest  CT  resulted  bilateral  peripheral  ground  glass,  crazy  paving  and  small  consolation  opacities.32Gastroenterología  y Hepatología  44  2021  31--3419  outbreak  in Iran,  and also  more  importantly  since  thepatients  reported  to  reside  in  high  risk  areas,  we  suspectedpatients  to be  infected  by  SARS-CoV-2.  Therefore,  for  morevalidation,  laboratory-confirmed  COVID  pneumonia  was  per-formed  by  using SARS-CoV-2  conventional  polymerase  chainreaction  assay  and  sequencing  of the polymerase  chain  reac-tion  (PCR)  amplicons,  which  was  reported  to  be  positive  forthe  patient.  After performing  chest  CT  scan,  we noticed  thebilateral  lung  involvement,  as  revealed  bilateral  peripheralground  glass,  crazy  paving  and small  consolation  opacities(Fig.  2).  Patient  was  isolated  in a negative  pressure  roomfor  one  week  and  underwent  medications  as  mentionedabove.According  to  the  findings  of  Zou  et  al.,  about  the role  ofACE-2  as  the  main  host  cell receptor  for  entrance  of  2019-nCoV  to  cell and with  notice  to  the high  expression  of  ACE-2receptor  in the oral cavity,  as  well  as  in  colon,  intestineand  gallbladder  and  enriching  in epithelial  cells,  we  sup-posed  that  this receptor  may  mediate  some  GI  symptomsof  infected  patients.5 Previously,  epidemiologic  finding  ofLai  et  al.,  demonstrated  that  among  adult  patients,  somecommon  respiratory  symptoms  were  followed  by  diarrhea.3Previously,  we reported  that  infected  patients  with  COVID-19  can present  some unusual  GI  symptoms.4 These  symptomswere  resistant  to  medications  and  in some  cases  without  anymedications,  they  subsided.At  the  age  of  COVID-19  crisis,  in  some  patients,  GI  physi-cians  may  face  rare  GI  symptoms  such as  dysentery,  hepaticinvolvement  or  other  ones  in patients.  Therefore,  it  is  nec-essary  that  all  GI  physicians  should  be  aware  of the possibleoccurrence  of  these  symptoms  as  an  important  prognosisof COVID  pneumonia.  Although,  in this letter  we  only doc-umented  one  case  of  this  issue, at  the age  of  COVID-19,all  rare  GI  symptoms  should  be  exactly  addressed  in newreferred  patients  to  GI  clinic.  Recording  and  investigationof  these  symptoms  may  open  a  new  window  to  help  findingvaluable  information  on  the characterization  of  this  myste-rious  disease.DeclarationsEthics  approvalApproval  was obtained  from  the  ethics  committee  of  QomUniversity  of Medical  Sciences.  The  procedures  used  in thisstudy  adhere  to  the tenets  of  the declaration  of Helsinki  (Nu:IR.MUQ.REC.1399.044).Consent  to publishPatients  signed  informed  consent  regarding  publishing  theirdata  and  photographs.Availability  of supporting  dataAll  data  and  materials  are available.Authors’ contributionAhmad  Hormati,  Writing  of  the report  and  therapeutic  physi-cian.  Mohammad  Reza  Ghadir,  Therapeutic  physician.  RezaAminnejad  & Fatemeh  Khodadust,  Review  and  edit of  themanuscript.  Mahboubeh  Afifian,  Collecting  of  the data.  Saj-jad  Ahmadpour,  Writing  of  the report  and  correspondence.FundingNo funding  was  provided  for  this  manuscript.Conflict of interestThe  authors  declare  that  they  have no  conflict  of  interest.AcknowledgmentsThe  authors  would  like to  thank  Sanam  Ahmadpour  for  hercontribution  to the  edit  of  the present  manuscript.Appendix A.  Supplementary dataSupplementary  data  associated  with  this  arti-cle  can  be  found,  in the  online  version,  atdoi:10.1016/j.gastrohep.2020.06.005.References1.  Salzberger B, Glück T, Ehrenstein B. Successful containment ofCOVID-19: the WHO-Report on the COVID-19 outbreak in China.Infection. 2020;48:151--3.2. Cheng ZJ, Shan J.  2019 Novel coronavirus: where we are and whatwe know. Infection. 2020;48:155--63.3. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute res-piratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirusdisease-2019 (COVID-19): the epidemic and the challenges. Int JAntimicrob Agents. 2020;55:105924.4. Hormati A, Shahhamzeh A, Afifian M, Khodadust F, Ahmadpour S.Can COVID-19 present unusual GI symptoms? J  Microbiol ImmunolInfect. 2020, http://dx.doi.org/10.1016/j.jmii.2020.03.020.5. Zou X, Chen K,  Zou J, Han P, Hao  J, Han Z. Single-cellRNA-seq data analysis on the receptor ACE2 expres-sion reveals the potential risk of different human organsvulnerable to 2019-nCoV infection. Front Med. 2020,http://dx.doi.org/10.1007/s11684-020-0754-0.33SCIENTIFIC  LETTERAhmad  Hormati a,b,  Mohammad  Reza  Ghadirb,Mohammad  Saeidi c,  Reza  Aminnejad c,d,Fatemeh  Khodadust e,  Mahboubeh  Afifian f,Sajjad  Ahmadpourb,∗a Gastrointestinal  and Liver  Diseases  Research  Center,  IranUniversity  of Medical  Sciences,  Tehran,  Iranb Gastroenterology  and Hepatology  Diseases  ResearchCenter,  Qom  University  of  Medical  Sciences,  Qom, Iranc Department  of  Anesthesiology  and  Critical  Care,  QomUniversity  of  Medical  Sciences,  Qom,  Irand Department  of  Anesthesiology  and Critical  Care,  ShahidBeheshti  University  of Medical  Sciences,  Tehran,  Irane Department  of  Radiopharmacy,  Faculty  of  Pharmacy,Mazandaran  University  of  Medical  Sciences,  Sari,  Iranf Health  Information  Technology,  Tehran  University  ofMedical  Sciences,  Tehran,  Iran∗ Corresponding  author.E-mail  address:  sajjadahmadpour@yahoo.com(S.  Ahmadpour).34

Dysentery as a rare GI symptom found in COVID-19 patients La disenterÃ­a como sÃ­ntoma digestivo poco frecuente que se encuentra en los pacientes con COVID-19

http://eprints.iums.ac.ir/33322/1/Dysentery%20as%20a%20rare%20GI%20symptom%20found%20in%20COVID-19%20patients%20La%20disenter%C3%83%C2%ADa%20como%20s%C3%83%C2%ADntoma%20digestivo%20poco%20frecuente%20que%20se%20encuentra%20en%20los%20pacientes%20con%20COVID-19%20.pdf

Dysentery as a rare GI symptom found in COVID-19 patients La disenterÃa como sÃntoma digestivo poco frecuente que se encuentra en los pacientes con COVID-19

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eprints Iran University of Medical Sciences

Dysentery as a rare GI symptom found in COVID-19 patients La disenterÃ­a como sÃ­ntoma digestivo poco frecuente que se encuentra en los pacientes con COVID-19

Abstract

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eprints Iran University of Medical Sciences

Dysentery as a rare GI symptom found in COVID-19 patients La disenterÃa como sÃntoma digestivo poco frecuente que se encuentra en los pacientes con COVID-19