Summary: Gastrointestinal symptoms, when accompanied by fever or a history of exposure to COVID-19, may signal coronavirus infection in children.
Source: Frontiers
Key finding: A study published in Frontiers in Pediatrics recommends that children who present with vomiting, diarrhea, or other gastrointestinal complaints—especially when they also have a fever or a known exposure to the coronavirus—should be evaluated for COVID-19.
Researchers report that some children first showed digestive symptoms rather than classic respiratory signs. This pattern suggests a possible role for the digestive tract in SARS-CoV-2 infection, since the ACE2 receptor targeted by the virus is present not only in lung cells but also in intestinal cells.
Lead author Dr. Wenbin Li of the Department of Pediatrics at Tongji Hospital in Wuhan emphasizes that most pediatric COVID-19 cases are mild, and severe cases are often associated with underlying health issues. He warns that early diagnosis can be missed when symptoms are non-respiratory or when children are treated for other conditions.
“In areas affected by the virus, clinicians should suspect COVID-19 in children who have digestive tract symptoms—especially if fever or a history of exposure is present,” Dr. Li notes. Early suspicion can prompt timely testing, isolation, and treatment, helping to limit transmission.
This case series describes five children who arrived at the emergency department for conditions that initially appeared unrelated to COVID-19—examples include kidney stones and head trauma—but were found to have pneumonia by chest CT and later tested positive for SARS-CoV-2. In four of these five patients, gastrointestinal symptoms were the first noticeable manifestation of the illness.
The investigators connect these digestive symptoms to the biological distribution of ACE2 receptors. Because ACE2 is expressed in both certain lung and intestinal cells, infection could occur not only via respiratory droplets but also through the digestive tract, including contact or fecal-oral transmission. This observation aligns with reports of gastrointestinal manifestations in adult patients as well.
Although diagnostic tests can occasionally yield false positive or false negative results, Dr. Li states the five cases reported in this series were confirmed SARS-CoV-2 infections. He also stresses the need for larger studies to determine how often children present primarily with non-respiratory symptoms and to better characterize their clinical course.
Study details and clinical summary
The case series covers five pediatric patients admitted to Wuhan Children’s Hospital between January 23 and February 20, 2020. All five had positive nucleic acid detection for SARS-CoV-2. The patients ranged from two months to 5.6 years old; four were male and one was female, and all lived in Wuhan. One child had a clear exposure history, one had a suspected exposure, and three had no known exposure.
Three children required emergency treatment for their primary conditions—intussusception, perforated appendicitis with local peritonitis, and traumatic subdural hemorrhage with convulsions—while the other two presented with acute gastroenteritis (one of these also had hydronephrosis and a kidney stone). During illness, four of the five developed fever; one child had neither fever nor cough.
Laboratory results varied: two patients had leukopenia and one had lymphopenia. In the two severe COVID-19 cases, inflammatory markers such as CRP, procalcitonin, serum ferritin, IL-6, and IL-10 were substantially elevated, while T lymphocyte subsets (CD3+, CD4+, CD8+) and natural killer cells (CD16+CD56+) were decreased. These severe cases also showed impaired liver, kidney, and cardiac function, along with electrolyte disturbances including hypoproteinemia, hyponatremia, and hypocalcemia; one patient had abnormal coagulation tests.
All patients were tested for common respiratory and enteric pathogens; except for one child who also had rotavirus, tests for influenza, parainfluenza, respiratory syncytial virus, adenovirus, enterovirus, mycoplasma, Chlamydia, and Legionella were negative. Chest CT imaging for every patient revealed peripheral or subpleural patches or ground-glass opacities, and in some cases large consolidations, consistent with viral pneumonia.
These five cases represent an initial report of pediatric COVID-19 cases in which non-respiratory symptoms were the first clinical signs. The authors call for broader studies to assess frequency, clinical features, and outcomes of similar presentations in children.
About this research
Source: Frontiers in Pediatrics. Original research: “Clinical Characteristics of 5 COVID-19 Cases With Non-respiratory Symptoms as the First Manifestation in Children” by Wenbin Li et al. (open access).
Note: Recognizing gastrointestinal presentations of COVID-19 in children—particularly when combined with fever or known exposure—may improve early detection, isolation, and clinical management, and could help reduce further spread of the virus.
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