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:

Overview

According to a recent study by Pan et al, 48.5% presented with digestive symptoms as their chief complaint. Anorexia was the most common (83.8%) of digestive symptoms associated with SARS-Cov2 infection. With COVID-19 primarily being a respiratory disease, surprisingly around 3% cases had just the digestive symptoms but no respiratory symptoms.

==Historical Perspective

• On 30th December 2019, three bronchoalveolar lavage samples 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.
• Nanopore sequencing and bioinformatic analyses indicated that the virus had features typical of the coronavirus family and belonged to the Betacoronavirus 2B lineage.
• Initially in reports till Feb 20, 2020, the patients known to have NCOV were reported to age between 30–69 years.
• In the initial reports from WHO, COVID-19 was shown to be transmitted via droplets and fomites during close unprotected contact between an infector and infectee. Airborne was not reported for COVID-19. Fecal shedding was reported to be demonstrated from some patients, with viable virus identified in a limited number of case reports. However, the fecal-oral route did not appear to be a driver of COVID-19 transmission.
• On March 12, 2020, WHO declared the COVID-19 outbreak a pandemic.
• Initially COVID-19 was primarily known as a respiratory disease. In the initial phase of the pandemic, the screening criteria for COVID‐19 did not include symptoms of abdominal pain.
• On Feb 3rd, 2020, a study published by Wang D et al. first described abdominal pain as one of the less common symptoms of COVID-19.
• With the increasing evidence and ongoing research, anorexia associated with COVID-19 is now reported to be a common symptom in patients with COVID-19, and the viral infection is suspected in a patient presenting with anorexia along with other gastrointestinal symptoms. Research is underway to develop a better understanding of the etiology, risk factors, and treatment of anorexia associated with COVID-19.
• Anorexia was described as one of the common symptoms at the onset of illness and it was also reported to be more common in ICU patients.

Classification

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

Pathophysiology

• The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
• On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• Hepatic manifestations can lead to anorexia.

Differentiating anorexia associated with COVID-19 from other Diseases

• Anorexia associated with COVID-19 must be differentiated from other diseases that cause anorexia such as:
• Hepatitis: Acute hepatitis especially autoimmune hepatitis shared common symptoms such as fatigue, abdominal pain, nausea, vomiting, diarrhea, skin rash. Some hepatic infections may involve pleuritis and pleural effusion thus chest pain.
• Crohn's disease: The disease may have remissions and relapses and present with symptoms shared by COVID-19 infection as well specially during a relapse. Other symptoms of Crohn's disease include abdominal pain, diarrhea that may or may not be bloody, fever and rash. A history of Crohn's disease can help the clinician decide on the differential diagnosis but it is equally important to access for possible COVID-19 infection. Patient should be counselled about the similarities in two diseases.
• Ulcerative colitis: A relapse can have symptoms similar to COVID-19 such as: abdominal pain,diarrhea, rash. A history of ulcerative colitis is important it is equally important to access for possible COVID-19 infection. Patient should be counselled about the similarities in two diseases.
• Chronic underlying disease-associated anorexia: Cancer patients have anorexia and are an increased risk of COVID-19 infection itself. High suspicion is required and the patient should be tested for COVID-19 infection if required.
• Remdesivir: The drug used itself in COVID-19 patients has a side effect of anorexia associated with nausea and vomiting.

Epidemiology and Demographics

• Based upon the meta-analysis including 78 studies the weighted pooled prevalence of loss of appetite associated with COVID-19 is approximately 22.3% ( 11.2%-34.6%)

Race

• China being the source of most of the demographic data on clinical features of COVID-19 and fewer studies on the demographics in other races, enabled the scientists to compare the incidence of anorexia in Chinese population and rest of the world. Data showed that loss of appetite was similar in both subgroups non-Chinese and Chinese. There is limited data to comment on the racial predilection of the symptom in other races.

Risk Factors

• The most important risk factor in the development of anorexia associated with COVID-19 is the infection COVID-19 itself.

Natural History, Complications and Prognosis

• The appearance of anorexia has no fixed pattern of appearance in the COVID-19 clinical course. But the symptom is usually associated with nausea and vomiting.
• Anorexia at illness onset was reported in 4 studies WPP 28.9% (11.5%-48.1%).
• Data from 3 studies reported anorexia in OVID-19 patients at admission with a weighted pooled prevalence of 16.3%.
• Prognosis: In a meta-analysis by Mao R. et al. the odds ratio for severe disease in patients with anorexia as one of the gastrointestinal symptoms were 2.83.

Diagnosis

Diagnostic Study of Choice

• COVID-19 nausea and vomiting can be diagnosed based on the history of the same and other gastrointestinal symptoms like anorexia, diarrhea and a positive stool test for SARS-CoV-2
• There are no established criteria for the diagnosis of nausea and vomiting in COVID-19.

History and Symptoms

• Important associated gastrointestinal symptoms with anorexia are nausea or vomiting, diarrhea.

Physical Examination

Patients with [disease name] usually appear Physical examination of patients with [disease name]

Treatment

Medical Therapy

• The mainstay of treatment is COVID-19 infection treatment.
• Rehydration, fluid repletion, are essential.

Primary Prevention

• There have been rigorous efforts in order to develop a vaccine for novel coronavirus and several vaccines are in the later phases of trials.
• Measure to prevent COVID-19 infection itself include:
  • Frequent handwashing with soap and water for at least 20 seconds or using a alcohol based hand sanitizer with at least 60% alcohol.
  • Staying at least 6 feet (about 2 arms’ length) from other people 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.
• For the prevention of transmission through gastrointestinal tract (presence of viral RNA in the stool raise suspicion for fecal-oral transmission)
  • Use of personal protective equipment (PPE) by the personnel handling the fecal matter.
  • Screening of fecal microbiota transplant donors for COVID-19 is also recommended.

References

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