Clinical Characteristics，Severity of Illness and Its Influencing Factors in COVID-19 Patients with Diarrhea as the Initial Symptom

doi:10.12114/j.issn.1007-9572.2021.00.435

Abstract

Abstract: Background　There are gastrointestinal symptoms in some patients with COVID-19，but there are few reports about the clinical characteristics and prognosis in COVID-19 patients with diarrhea as the initial symptom.Objective　To analyze the clinical characteristics，severity of illness and its influencing factors in COVID-19 patients with diarrhea as the initial symptom.Methods　A total of 207 COVID-19 patients with positive RNA test results of nasopharyngeal swabs were taken over by Peking University Medical Team for Hubei from 2020-01-28 to 2020-02-28，who were hospitalized in isolated wards in Tongji Hospital Zhongfa New Town Branch Affiliated to Tongji Medical College，Huazhong University of Science and Technology，17 cases with diarrhea as the initial symptom charged by Medical Team of Peking University Third Hospital were selected as observation group，34 cases without diarrhea as the initial symptom were selected as control group.General information，clinical symptoms，blood routine test results，liver function index，blood lipid indices，creatinine，coagulation function indicators，inflammatory indicators，PCT，myocardial injury indicators，chest CT findings，clinical classification，maximum body temperature，therapeutic protocols，incidence of complications，survival status，duration from onset to treatment and hospital stays were compared between the two groups；univariate and multivariate Logistic regression analysis were used to analyze the influencing factors of severity of illness in patients with COVID-19.Results　Incidence of expectoration，D-dimer，abnormal rate of PCT and proportion of patients with severe and critical clinical classification types in observation group were significantly lower than control group，incidence of debilitation and albumin in observation group were significantly higher than control group，prothrombin time and hospital stays in observation group were significantly shorter than control group（P<0.05）.Multivariate Logistic regression analysis results showed that，albumin〔OR=0.739，95%CI（0.569，0.960）〕was the protective factor of severity of illness in patients with COVID-19，but PCT〔OR=7.349，95%CI（1.213，44.513）〕was the risk factor（P<0.05）.Conclusion　In COVID-19 patients with diarrhea as the initial symptom，the respiratory symptom and severity of illness are relatively mild，incidence of debilitation is relatively high，clinical classification is mainly common type，and hospital stays is relatively short；albumin is the protective factor of severity of illness in patients with COVID-19，but PCT is the risk factor.

Key words: Pneumonia, viral；Coronavirus disease 2019；SARS-CoV-2；Disease attribute；Diarrhea；Risk factors；Retrospective studies

摘要： 背景　部分新型冠状病毒肺炎（COVID-19）患者存在胃肠道症状，但目前关于以腹泻为首发症状的COVID-19患者临床特征及预后的研究报道较少见。目的　分析以腹泻为首发症状的COVID-19患者的临床特征、病情严重程度及其影响因素。方法　北京大学援鄂医疗队于2020-01-28至2020-02-28共接管华中科技大学同济医学院附属同济医院中法新城院区隔离病房中鼻咽拭子样本2019新型冠状病毒（SARS-CoV-2）RNA检测结果为阳性的COVID-19患者207例，选取其中由北京大学第三医院医疗分队接管的以腹泻为首发症状者17例作为观察组，未以腹泻为首发症状者34例作为对照组。比较两组患者一般资料、临床症状、血常规检查结果、肝功能指标、血脂指标、肌酐、凝血功能指标、炎性指标、降钙素原、心肌损伤指标、胸部CT检查结果、临床分型、最高体温、治疗情况、并发症发生情况、生存情况、发病至治疗时间、住院时间；COVID-19患者病情严重程度的影响因素分析采用单因素及多因素Logistic分析。结果　观察组患者咳痰发生率、D-二聚体、降钙素原异常率、临床分型为重型及危重型者所占比例低于对照组，乏力发生率、白蛋白高于对照组，凝血酶原时间、住院时间短于对照组（P<0.05）。多因素Logistic回归分析结果显示，白蛋白〔OR=0.739，95%CI（0.569，0.960）〕是COVID-19患者病情严重程度的保护因素，而降钙素原〔OR=7.349，95%CI（1.213，44.513）〕是危险因素（P<0.05）。结论　以腹泻为首发症状的COVID-19患者呼吸道症状及病情严重程度较轻、乏力发生率较高、临床分型以普通型为主、同等治疗情况下住院时间较短；白蛋白是COVID-19患者病情严重程度的保护因素，而降钙素原是危险因素，临床应注意加强对白蛋白及降钙素原的监测。

关键词: 肺炎, 病毒性；新型冠状病毒肺炎；新型冠状病毒；疾病特征；腹泻；危险因素；回顾性研究

ZU Ming,SHI Yanyan,NING Jing, et al. Clinical Characteristics，Severity of Illness and Its Influencing Factors in COVID-19 Patients with Diarrhea as the Initial Symptom　[J]. Chinese General Practice, 2021, 24(15): 1874-1882. DOI: 10.12114/j.issn.1007-9572.2021.00.435.
俎明,石岩岩,宁静等. 以腹泻为首发症状的新型冠状病毒肺炎患者临床特征和病情严重程度及其影响因素研究[J]. 中国全科医学, 2021, 24(15): 1874-1882. DOI: 10.12114/j.issn.1007-9572.2021.00.435.

References

［1］HUI D S，AZHAR E I，MADANI T A，et al．The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health——the latest 2019 novel coronavirus outbreak in Wuhan，China［J］．Int J Infect Dis，2020，91：264-266．DOI：10.1016/j.ijid.2020.01.009.
［2］CHEN Y，LIU Q，GUO D.Emerging coronaviruses：genome structure，replication，and pathogenesis［J］．J Med Virol，2020，92（4）：418-423．DOI：10.1002/jmv.25681.
［3］ZHU N，ZHANG D，WANG W，et al．A novel coronavirus from patients with pneumonia in China，2019［J］．N Engl J Med，2020，382（8）：727-733．DOI：10.1056/NEJMoa2001017.
［4］CHAN J F W，KOK K H，ZHU Z，et al．Genomic characterization of the 2019 novel human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting Wuhan［J］．Emerg Microbes Infect，2020，9（1）：221-236．DOI：10.1080/22221751.2020.1719902.
［5］ZHOU P，YANG X L，WANG X G，et al．A pneumonia outbreak associated with a new coronavirus of probable bat origin［J］．Nature，2020，579（7798）：270-273．DOI：10.1038/s41586-020-2012-7.
［6］LEUNG W K，TO K F，CHAN P K S，et al．Enteric involvement of severe acute respiratory syndrome-associated coronavirus infection［J］．Gastroenterology，2003，125（4）：1011-1017．DOI：10.1016/s0016-5085（03）01215-0.
［7］ZHANG H，KANG Z，GONG H，et al．Digestive system is a potential route of COVID-19：an analysis of single-cell coexpression pattern of key proteins in viral entry process［J］．Gut，2020，69（6）：1010-1018．DOI：10.1136/gutjnl-2020-320953.
［8］XIAO F，TANG M，ZHENG X，et al．Evidence for gastrointestinal infection of SARS-CoV-2［J］．Gastroenterology，2020，158（6）：1831-1833.e3．DOI：10.1053/j.gastro.2020.02.055.
［9］HUANG C，WANG Y，LI X，et al．Clinical features of patients infected with 2019 novel coronavirus in Wuhan，China［J］．Lancet，2020，395（10223）：497-506．DOI：10.1016/S0140-6736（20）30183-5.
［10］AN P，CHEN H，JIANG X，et al．Clinical features of 2019 novel coronavirus pneumonia presented gastrointestinal symptoms but without fever onset［J/OL］．Social Science Electronic Publishing（2020-02-02）［2020-04-26］．https：//ssrn.com/abstract=3532530．DOI：10.2139/ssrn.3532530.
［11］国家卫生健康委办公厅.新型冠状病毒肺炎诊疗方案（试行第七版）》［EB/OL］．（2020-03-03）［2020-04-26］．http：//www.gov.cn/zhengce/zhengceku/2020-03/04/content_5486705.htm.
［12］THYGESEN K，ALPERT J S，JAFFE A S，et al．Fourth universal definition of myocardial infarction（2018）［J］．Circulation，2018，138（20）：e618-651．DOI：10.1161/CIR.0000000000000617.
［13］ZHANG L，BAI T，JIN Y，et al．Digestive involvement of the coronavirus disease 2019：need attention on the 'gut-type' in the novel coronaviral infection［J/OL］．Social Science Electronic Publishing（2020-03-01）［2020-04-26］．https：//ssrn.com/abstract=3559590．DOI：10.2139/ssrn.3559590.
［14］ZHANG L，BAI T，JIN Y，et al．Diarrhea in patients with coronavirus disease 2019：clinical characteristics，outcomes and implications［J/OL］．SSRN Electronic Journal（2020-03-20）［2020-04-26］．https：//ssrn.com/abstract=3566201．DOI：10.2139/ssrn.3566201.
［15］LIU J，TAO L，LIU X，et al．GI symptoms and fever increase the risk of severe illness and death in patients with COVID-19［J］．Gut，2020，70（2）：442-444．DOI：10.1136/gutjnl-2020-321751.
［16］DIETRICH C G，HüBNER D，MARX G，et al．Primary presentation of COVID-19 solely with gastrointestinal symptoms：a problem for the containment of the disease［J］．Eur J Gastroenterol Hepatol，2020，32（11）：1475-1478．DOI：10.1097/MEG.0000000000001922.
［17］AMARAL L T W，BRITO V M，BERALDO G L，et al．Abdominal symptoms as initial manifestation of COVID-19：a case series［J］．Einstein（Sao Paulo），2020，18：eRC5831．DOI：10.31744/einstein_journal/2020RC5831.
［18］WU C Y，YU X P，MA A H Y，et al．Coronavirus disease 19 with gastrointestinal symptoms as initial manifestations：a case report［J］．J Int Med Res，2020，48（9）：300060520952256．DOI：10.1177/0300060520952256.
［19］LUO S，DENG Z，ZHANG X，et al．Clinical characteristics and outcomes of 2019 novel coronavirus disease patients presenting with initial gastrointestinal symptoms in Wuhan，China：a retrospective cohort study［J］．J Gastroenterol Hepatol，2020．DOI：10.1111/jgh.15199.Online ahead of print.
［20］COVINGTON E W，ROBERTS M Z，DONG J.Procalcitonin monitoring as a guide for antimicrobial therapy：a review of current literature［J］．Pharmacotherapy，2018，38（5）：569-581．DOI：10.1002/phar.2112.
［21］SCHETTINO M，PELLEGRINI L，PICASCIA D，et al．Clinical characteristics of COVID-19 patients with gastrointestinal symptoms in Northern Italy：a single-center cohort study［J］．Am J Gastroenterol，2020．DOI：10.14309/ajg.0000000000000965.Online ahead of print.
［22］ZHANG Y，ZHENG L，LIU L，et al．Liver impairment in COVID-19 patients：a retrospective analysis of 115 cases from a single center in Wuhan city，China［J］．Liver Int，2020，40（9）：2095-2103．DOI：10.1111/liv.14455.
［23］MO P，XING Y，XIAO Y，et al．Clinical characteristics of refractory COVID-19 pneumonia in Wuhan，China［J］．Clin Infect Dis，2020．DOI：10.1093/cid/ciaa270.Online ahead of print.
［24］CHEN T，DAI Z，MO P，et al．Clinical characteristics and outcomes of older patients with coronavirus disease 2019（COVID-19）in Wuhan，China：a single-centered，retrospective study［J］．J Gerontol A Biol Sci Med Sci，2020，75（9）：1788-1795．DOI：10.1093/gerona/glaa089.
［25］QIU H，WU J，HONG L，et al．Clinical and epidemiological features of 36 children with coronavirus disease 2019（COVID-19）in Zhejiang，China：an observational cohort study［J］．Lancet Infect Dis，2020，20（6）：689-696．DOI：10.1016/S1473-3099（20）30198-5.
［26］HOFFMANN M，KLEINE-WEBER H，SCHROEDER S，et al．SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor［J］．Cell，2020，181（2）：271-280.e8．DOI：10.1016/j.cell.2020.02.052.
［27］刘茜，王荣帅，屈国强，等．新型冠状病毒肺炎死亡尸体系统解剖大体观察报告［J］．法医学杂志，2020，36（1）：1-3．DOI：10.12116/j.issn.1004-5619.2020.01.005.
［28］WU Y，GUO C，TANG L，et al．Prolonged presence of SARS-CoV-2 viral RNA in faecal samples［J］．Lancet Gastroenterol Hepatol，2020，5（5）：434-435．DOI：10.1016/S2468-1253（20）30083-2.
［29］YU P，ZHU J，ZHANG Z，et al．A familial cluster of infection associated with the 2019 novel coronavirus indicating potential person-to-person transmission during the incubation period［J］．J Infect Dis，2020，221（11）．DOI：10.1093/infdis/jiaa077.Online ahead of print.

[1]	YANG Jiang, LI Jiansheng, CHEN Yaolong, LIU Huiguo, WANG Jianxin, YU Jiajie, LI Huiru, XIAO Qionghua, XIE Yang, LI Suyun, WANG Minghang. Guideline on Treating Adult Community-acquired Pneumonia with Chinese Patent Medicines (2025 Edition) [J]. Chinese General Practice, 2025, 28(20): 2464-2480.
[2]	LI Ruitong, YUE Yuchuan, GU Xujie, XIONG Lingling. Risk Prediction Models for Refractory Mycoplasma Pneumoniae Pneumonia in Children: a Systematic Review [J]. Chinese General Practice, 2025, 28(09): 1105-1114.
[3]	WU Jun, ZHANG Ling, GU Dongwei, ZHENG Lei, ZHAO Zhuxiang, ZHAO Ziwen. Comparative Study of Pathogenic Bacteria in Patients of Bronchiectasis with and without Chronic Obstructive Pulmonary Disease [J]. Chinese General Practice, 2025, 28(06): 729-736.
[4]	LYU Guangyu, SUN Wanjun, ZHOU Qianqian, CHEN Xianmeng, LIU Xuehan, HU Xiaowen. Clinical Characteristics and Risk Factors of Patients with Pulmonary Infarction Secondary to Intermediate and High-risk Pulmonary Embolism Misdiagnosed as Pneumonia [J]. Chinese General Practice, 2024, 27(32): 3987-3992.
[5]	JIANG Qixia, XIE Haoting, WANG Huajun, LI Xiuyun, ZHU Yuling, WANG Yaling, MIN Yan, WANG Ke. Effectiveness Analysis of Two Incontinence Care Plans Based on Guidelines for Elderly COVID-19 Patients with Incontinence [J]. Chinese General Practice, 2024, 27(18): 2212-2217.
[6]	YANG Shuo, LIU Xinying, WANG Huizhe, LI Huanmin, LI Xinmin. Risk Factors for Severe Mycoplasma Pneumoniae Pneumonia in Children: a Meta-analysis [J]. Chinese General Practice, 2024, 27(14): 1750-1760.
[7]	WANG Minghang, HAN Weihong, BI Lichan, YANG Jiang, LI Jiansheng. Evaluation Study of Traditional Chinese Medicine Syndrome Differentiation Therapy on the Quality of Life and Efficacy Satisfaction in Elderly Community-acquired Pneumonia Patients after Discharge [J]. Chinese General Practice, 2024, 27(08): 1001-1007.
[8]	Expert group of expert consensus on the application of ulinastatin in common clinical critical illness. Expert Consensus on the Application of Ulinastatin in Common Clinical Critical Illness [J]. Chinese General Practice, 2023, 26(26): 3207-3219.
[9]	WANG Shumin, LI Xuejun, ZHANG Yixing, JIANG Zhiyan, XIAO Zhen. Correlation between Mycoplasma Pneumoniae Infection and Coronary Artery Lesions in Mucocutaneous Lymph Node Syndrome: a Meta-analysis [J]. Chinese General Practice, 2023, 26(20): 2532-2539.
[10]	ZHANG Kang, JI Wenshuai, KONG Xinxin, DU Chen, XIE Kai, WANG Haifeng. Predictive Efficacies of SOFA Score, CURB-65 Score and PSI Score for 28-day Mortality in Patients with Severe Pneumonia: a Comparative Study [J]. Chinese General Practice, 2023, 26(18): 2217-2222.
[11]	XUE Jingru, SUN Suzhen. Clinical Characteristics and Risk Factors for Unfavourble Prognosis of Mycoplasma Pneumoniae Encephalitis in Children [J]. Chinese General Practice, 2023, 26(17): 2125-2131.
[12]	ZHANG Caixia, LIU Xinnian, DU Chuan, WANG Xinwei. mNGS and Serum G Test in Distinguishing between Pneumocystis Jirovecii Colonization and Infection: Value Comparison and Correlation Analysis [J]. Chinese General Practice, 2023, 26(11): 1355-1360.
[13]	LAN Hailong, NING Guanyuan, HUANG Xiangmin, XIAO Yeyu. Sequences of SS_TSE and Modified Abdominal T2WI Magnetic Resonance Imaging in the Diagnosis of Neonatal Pneumonia [J]. Chinese General Practice, 2023, 26(03): 308-312.
[14]	Jiang YANG, Xuanlin LI, Jianxin WANG, Yang XIE, Huiguo LIU, Suyun LI, Minghang WANG. Efficacy and Safety of Shufeng Jiedu Capsules in the Adjuvant Treatment of Community-acquired Pneumonia in Adult: a Meta-analysis [J]. Chinese General Practice, 2022, 25(23): 2922-2931.
[15]	Jingjing GUI, Aquan JIN, Yu WAN, Xuan ZHAO, Linjie ZHU, Yidong ZHAO, Jiaqi YAO, Liwen ZHANG, Zhiying HUANG. Value of Thromboelastography for Condition Assessment in Children with Mycoplasma Pneumoniae Pneumonia [J]. Chinese General Practice, 2022, 25(21): 2624-2628.