COVID-19-associated anorexia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Javaria Anwer M.D.[2]

Synonyms and Keywords: COVID-19 associated loss of appetite, COVID-19 and hunger, appetite and COVID-19, loss of appetite in COVID, COVID and hunger, SARS-Cov-2 associated anorexia, SARS-Cov-2 associated loss of appetite, SARS CoV2 and hunger, Coronavirus and hunger, appetite and COVID-19.

Overview

COVID-19 is primarily known to be a respiratory disease. Anorexia associated with COVID-19 is the most common digestive symptom among patients with COVID-19. The exact mechanism of loss of appetite associated with the infection is unknown, but the symptom may be due to various causes. Several diseases share loss of appetite symptom, so it is important to suspect COVID-19 and perform RT-PCR to detect the infection or CXR to detect possible lung manifestations. Patients with loss of appetite may present with associated symptoms such as nausea or vomiting and diarrhea. The mainstay of treatment in COVID-19 infection is supportive therapy and antiviral therapy. Hand hygiene and social distancing are important primary prevention tools. Contact tracing is an important tool of secondary prevention.

Historical Perspective

  • COVID-19 was first discovered in Wuhan, China. On 30th December 2019, three bronchoalveolar lavage samples were collected from a patient with pneumonia of unknown etiology – a surveillance definition established following the SARS outbreak of 2002-2003 – in Wuhan Jinyintan Hospital. Real-time PCR (RT-PCR) assays on these samples were positive for pan-Betacoronavirus.[1]
  • Nanopore sequencing and bioinformatic analyses indicated that the virus had features typical of the coronavirus family and belonged to the Betacoronavirus 2B lineage.[1]
  • COVID-19 was primarily known as a respiratory disease. In the initial reports from the World Health Organization (WHO), the mode of transmission of COVID-19 was reported to spread through droplets and fomites during close unprotected contact between an infector and an infectee. Airborne transmission was not reported initially.
  • Fecal shedding was demonstrated from patients, with viable virus identified in a limited number of case reports. However, fecal-oral route did not appear to drive COVID-19 transmission.[1][2]
  • COVID-19 associated anorexia was first described as one of the less common symptoms of COVID-19 in a retrospective, single-center case series by Wang D et al. published on Feb 7th, 2020. The patient data was derived from January 1st-Jan 28th,2020 at Zhongnan Hospital in Wuhan, China.[3]
  • COVID-19 associated anorexia was not only described as one of the common symptoms at the illness onset, it was reported to be more common among ICU patients.[3]
  • On March 11th, 2020, WHO declared the COVID-19 outbreak a pandemic.[4]
  • With the increasing evidence and ongoing research, anorexia associated with COVID-19 is now reported to be a common symptom among patients with COVID-19, and the viral infection is suspected in a patient presenting with anorexia along with other gastrointestinal symptoms.

Classification

There is no established system for the classification of anorexia in COVID-19.

Pathophysiology

Causes

COVID-19 associated anorexia may be classified according to the COVID-19 associated entity causing the symptom:

Differentiating COVID-19 associated anorexia from other Diseases

  • For further information regarding the differential diagnosis, click here.
  • To view the differential diagnosis of COVID-19, click here

Epidemiology and Demographics

  • The pooled prevalence of COVID-19 associated anorexia is 21% according to a systematic review and meta-analysis based on the studies worldwide published between January 1st, 2020, and April 4th, 2020.[18]
  • The pooled prevalence of COVID-19 associated anorexia in Hong Kong is approximately 26.8%. The information is presented in a meta-analysis from the cohort of COVID-19 patients from Hong Kong (N = 59, from February 2 through February 29, 2020). 25% of the patients had GI symptoms associated with COVID-19.[19]
  • According to recent reviews and meta-analyses of COVID-19, patients from different parts of the world (China, Hong Kong) anorexia is the most common (40-84%) digestive symptoms associated with COVID-19.[20][18][19]
  • A retrospective study from Wuhna, China describing 1,141 cases of COVID-19 reported loss of appetite in 98% patients (n=180). Anorexia was the most common presenting symptom among all GI symptoms of COVID-19.[21]

Age

  • There is insufficient data to support an age group that is affected to a greater extent from COVID-19 associated anorexia.

Gender

Men more commonly presented with GI symptoms with anorexia being the most common symptom in Wuhan, China according to a retrospective study involving 1,141 cases of COVID-19.[21]

Race

  • There is no racial predilection for COVID-19 associated anorexia according to a systematic review and meta-analysis of observational studies on 12,797 patients. The meta-analysis compared Chinese race (Chinese group) from all other races (non-Chinese group) as the data from China makes a major part of COVID-19 related literature.[22]

Risk Factors

  • The most potent risk factor for the development of anorexia associated with COVID-19 is the infection COVID-19 itself.
  • Other risk factors involved in the process COVID-19 infected people presenting with anorexia have yet to be understood.

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

  • History of contact with a person suspected or confirmed to have COVID-19 infection is important to suspect COVID-19 in a patient.
  • Anorexia is itself a symptom. Based on a retrospective observational study including 1,141 cases of COVID-19 from Wuhan, China anorexia was the most common gastrointestinal symptom of COVID-19.[21]
  • The most common accompanying symptoms of COVID-19 besides anorexia were nausea, vomiting, and diarrhea.[25]
  • The timing of symptoms and presence of co-morbid conditions helps differentiate the diseases with similar symptoms.

Physical Examination

Physical examination may be remarkable for:

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT scan

  • Abdominal CT scan may be helpful in finding the cause of COVID-19 associated anorexia.
  • Findings on CT scan suggestive of gastrointestinal symptoms (anorexia one of them) associated with COVID-19 infection include peri-intestinal inflammatory reaction.[27]
  • The CT scan findings in COVID-19 can be viewed by clicking here.

MRI

Other Imaging Findings

  • Bedside lung ultrasound may be helpful in the diagnosis of COVID-19 infection.
  • Other Imaging findings in bedside lung ultrasound to detect the signs of respiratory COVID-19 infection even when there are no respiratory symptoms.[27]

Treatment

Medical Therapy

Primary Prevention

  • Effective measures for the primary prevention of COVID-19 include::[45]
    • Frequent hand-washing with soap and water for at least 20 seconds or using a alcohol based hand sanitizer with at least 60% alcohol. Alcohol means ethanol here not methanol/ wood alcohol, as FDA warns against the use of methanol containing hand-wash.[46]
    • Staying at least 6 feet (approximately 2 arms’ length) from other individuals who do not live with you.
    • Covering your mouth and nose with a cloth face cover when around others and covering sneezes and coughs.
    • Cleaning and disinfecting.

Secondary prevention

  • Effective measures for the secondary prevention of COVID-19 include:
    • Use of personal protective equipment (PPE) by the personnel handling the fecal matter or visiting the patient. Protective eyewear (such as goggles or a face shield) used by healthcare personnel should cover the front and sides of the face with no gaps between glasses and the face.[47].
    • Screening of fecal microbiota transplant donors for COVID-19 is also recommended.[48]
    • Contact tracing helps reduce the spread of the disease.[49]
  • Oncologists from Wright State University OH, USA suggest fellow oncologists reconsider the routine use of prophylactic dexamethasone as an antiemetic among [cancer patients who are not infected with [COVID-19]]. As reported in several studies, higher lymphocyte level may be associated with better outcomes in COVID-19, avoiding dexamethasone will help avoid inducing lymphopenia.[50]

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