Digestive Symptoms in COVID-19 Patients With Mild Disease Severity: Clinical Presentation, Stool Viral RNA Testing, and Outcomes

Abstract

Objectives: Coronavirus disease 2019 (COVID-19) most commonly presents with respiratory symptoms, including cough, shortness of breath, and sore throat. However, digestive symptoms also occur in patients with COVID-19 and are often described in outpatients with less severe disease. In this study, we sought to describe the clinical characteristics of COVID-19 patients with digestive symptoms and mild disease severity.

Methods: We identified COVID-19 patients with mild disease and one or more digestive symptoms (diarrhea, nausea, and vomiting), with or without respiratory symptoms, and compared them with a group presenting solely with respiratory symptoms. We followed up patients clinically until they tested negative for COVID-19 on at least 2 sequential respiratory tract specimens collected ≥24 hours apart. We then compared the clinical features between those with digestive symptoms and those with respiratory symptoms.

Results: There were 206 patients with low severity COVID-19, including 48 presenting with a digestive symptom alone, 69 with both digestive and respiratory symptoms, and 89 with respiratory symptoms alone. Between the 2 groups with digestive symptoms, 67 presented with diarrhea, of whom 19.4% experienced diarrhea as the first symptom in their illness course. The diarrhea lasted from 1 to 14 days, with an average duration of 5.4 ± 3.1 days and a frequency of 4.3 ± 2.2 bowel movements per day. Concurrent fever was found in 62.4% of patients with a digestive symptom. Patients with digestive symptoms presented for care later than those with respiratory symptoms (16.0 ± 7.7 vs 11.6 ± 5.1 days, P < 0.001). Nevertheless, patients with digestive symptoms had a longer duration between symptom onset and viral clearance (P < 0.001) and were more likely to be fecal virus positive (73.3% vs 14.3%, P = 0.033) than those with respiratory symptoms.

Discussion: We describe a unique subgroup of COVID-19 patients with mild disease severity marked by the presence of digestive symptoms. These patients are more likely to test positive for viral RNA in stool, to have a longer delay before viral clearance, and to experience delayed diagnosis compared with patients with only respiratory symptoms.

Figure 1.

Disposition of study patients. There were 131 patients with digestive symptoms, each matched to one control patient who presented with respiratory symptoms only. Of these 262 patients, full historical and clinical data were available for 223 patients, of whom 206 had cleared the virus and were discharged from quarantine at the time this study was conducted, including 48 with digestive symptoms only, 69 with both digestive and respiratory symptoms, and 89 with respiratory symptoms only.

Figure 2.

Illness duration (in days), including days before admission, total time in hospital before evidence of viral clearance, and total duration between symptom onset and viral clearance. Panel A provides data across the full study cohort. Panel B compares data between those with vs without diarrhea, demonstrating a longer disease course in those with diarrhea. Panel C focuses on those with digestive symptoms only and compares those with vs without diarrhea on presentation (no differences noted). Panel D repeats the same analyses in those presenting with Digestive + Respiratory symptoms, also showing no difference in the illness durations stratified by diarrhea. Panel E focuses only on those with digestive symptoms only and compares those with vs without fever on presentation (no differences noted). Panel F repeats the same analyses in those presenting with Digestive + Respiratory symptoms, also showing no difference in illness durations stratified by fever.