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Are You Overlooking Extrapulmonary COVID-19?

By Dr. Nwamaka Osakwe

The COVID-19 pandemic caused by SARS-CoV-2 is one of the most significant pandemics to have hit the world. Since its appearance in Wuhan, China, in 2019, the SARS-CoV-2 virus has rapidly spread worldwide, with more than 400 million recorded infections and almost 6 million deaths as of February 2022.

The virus is principally spread through short-range airborne transmission or droplet transmission. The incubation period can be as short as two days and as long as fourteen days.

Respiratory disease is the most recognized presentation of COVID-19, and typical symptoms are fever, myalgia, sore throat, cough, and dyspnoea. But not all patients with COVID-19 are present in this classical manner. As such, health professionals need to have a high index of suspicion to identify patients with atypical clinical features.

In this blog post, you will learn about some of the ways COVID-19 may manifest.

Gastrointestinal symptoms

Patients with COVID-19 may present with gastrointestinal (GI) symptoms. However, it can be challenging for clinicians to differentiate between GI symptoms due to COVID-19 and those caused by other conditions.

Patients may have COVID-19 symptoms alone or in combination with respiratory symptoms. For example, the first reported case of COVID-19 in the United States was a patient who presented with dry cough, nausea, and vomiting but later developed diarrhoea while on admission in the hospital. Sometimes the gastrointestinal symptoms occur before the fever and respiratory disease. 

In general, the frequency of GI symptoms varies in different reports. For example, GI symptoms were found in up to 55% of COVID-19 cases studies in one report. However, in an African study among pediatric COVID-19 cases, the study participants from Tunisia all reported one form of GI symptom or the other. 

The common GI symptoms are abdominal pain, diarrhoea, anorexia, nausea, and vomiting. Patients with GI symptoms also had more headaches, fatigue, and cough. In addition, deranged liver enzymes were found in some COVID-19 cases during workup.

These GI symptoms are believed to result from:

  • The virus directly invading the GI cells.
  • Immune dysregulation because patients with COVID-19 have relatively higher levels of the opportunistic pathogen in the gut.
  • The effect of drugs like cephalosporins and beta-lactam antibiotics used for treatment.

The SARS-CoV-2 RNA has been detected in faecal samples of COVID-19covid patients with and without GI symptoms and those without GI symptoms. Interestingly, faecal samples remained positive for SARS-CoV-2 weeks after respiratory tract samples became negative. The presence of viral RNA in faecal samples makes experts speculate about the possibility of faeco-oral transmission.

Treatment of GI symptoms include:

  • Antivirals
  • Immune modulation with probiotics
  • Consideration for a diet that may be enteral or parenteral. A nasogastric tube can be inserted for feeding
  • Supportive care, including antiemetics for vomiting, antacids for heartburn, and loperamide for diarrhoea.

Neurological symptoms

Neurological symptoms are relatively common; 8 in 10 individuals hospitalized for COVID-19 have at least one neurological symptom. Many people associate the inability to smell or taste with COVID-19. Still, patients may present with other neurological symptoms, including headache, myalgia, stroke, confusion, seizures, and acute psychosis. The lesions may be in the central nervous system (CNS) or peripheral nervous system. 

In a report published by JAMA, 38% of 3053 patients who had COVID-19 reported headaches. Patients have described the headache as bilateral, predominantly frontal, and of varied intensity. Others have described headaches resembling a migraine or a tension-type headache. Patients with primary headaches may come to the hospital with worsening symptoms or headaches that are no longer responsive to typical therapy.

Ischaemic and haemorrhagic strokes have been documented along with cerebral vasculitis and cerebral venous thrombosis.

Other CNS manifestations of COVID-19 include acute psychosis, which can present as delirium and hallucinations; this is usually associated with a high fever. Confusion and seizures can also occur during febrile episodes in patients infected with SARS-CoV-2.

Proposed mechanisms for neurological symptoms include:

  • Hypoxia
  • Thrombosis
  • Systemic immune response to SARS-CoV-2 infection
  • Direct invasion of nervous tissue by the virus

Bell’s palsy and Guillain-Barré syndrome have been described.

Patients with long COVID (symptoms lasting weeks or months after the initial infection with COVID-19 or new symptoms appearing weeks after) may experience recurring fatigue, pain, mood swings, and brain fog that disrupt daily activities. Management of neurological disorders in COVID-19 is similar to management for patients without COVID-19. However, in addition to standard treatment, patients should be isolated and managed as hospitalized or non-hospitalized patients with COVID-19, depending on the circumstances.

Dermatological symptoms

Most skin lesions appear after the onset of systemic features. Therefore, the link between COVID-19 and skin rashes is not surprising since viral infections are associated with rashes.

Patients with COVID-19 may complain of a morbilliform rash over the trunk. Some others present with macules over the fingers and toes termed COVID toes. The rash of COVID toes typically disappears in two to eight weeks. But a few patients experience a longer course, while others develop recurrent disease.

Other skin manifestations include vesicular rash, urticaria, and conjunctivitis.

Experts recommend that clinicians observe most of these skin lesions. Steroids and non-sedating antihistamines may be considered for urticaria, vasculitic rashes, or severe skin presentation.

Cardiac manifestations

COVID-19 can cause acute coronary syndrome, arrhythmia, cardiac arrest, and shock. This occurs more frequently in those with pre-existing cardiac conditions. 

Patients may present with chest pain, palpitations, cough, or breathlessness. Some patients with COVID-19 have reported palpitations without fever or cough on presentation.

Because the SARS Cov-2 virus uses the angiotensin-converting enzyme 2 receptors to enter the cell, the speculation is that angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) may upregulate these receptors and lead to severe disease. However, currently, there is no evidence to support a relationship between using these drugs and disease severity. As such, there is no need to discontinue ACEi or ARB in your patients. 

Bottom line

Our understanding of the clinical manifestations of COVID-19 has evolved. It is essential to recognize that COVID-19 is a multi-system disease. The lung is the most affected organ in patients with COVID-19. In addition to respiratory symptoms, gastrointestinal symptoms are common and maybe the only manifestation in some patients. Some patients develop hypercoagulability, leading to cardiovascular complications including myocardial infarction, stroke, and pulmonary embolism. Neurological manifestations may include headache, dizziness, loss of smell and taste, seizures, and encephalopathy.

As a clinician, you need a high index of suspicion to diagnose atypical cases. 

The scientific knowledge about COVID-19 continues to evolve. Therefore, it is essential to keep abreast with current knowledge and evidence to correctly identify and manage cases and protect patients and staff appropriately from high-risk exposure.

More information

Additional information and resources on COVID-19 are available here and here.

Nwamaka Osakwe, FWACP, MBBS, is an award-winning physician who loves writing about health and wellness. You can reach her here

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