SARS-CoV-2–Positive Sputum and Feces After Conversion of Pharyngeal Samples in Patients With COVID-19FREE

The deaths associated with CoVid-19 are exactly as we have previously defined and warned about [1].

The inflammatory reaction precipitated by viruses - worsening coronary artery disease (CAD), cancer, and other chronic inflammatory diseases - was originally laid out in the mid-1990s, published in a Cardiology Textbook in 1999 [2] and later detailed on 20/20 [3] in 2004.

The inflammatory changes, which occur within tissue can and must be measured to determine the severity of CoVid-19 pneumonia (CVP). FMTVDM must also be used if we are to measure the success or failure of proposed treatments for CVP [4-6] - directing individual patient treatment; saving time, money, resources and lives.

You need only ask yourself if guessing is good enough [7] or should we be measuring treatment outcomes?

Simply ask yourself, what would you want if the patient with CVP on a ventilator in a hospital were your friend or someone you loved?

References:

1. Fleming RM, Fleming MR, Chaudhuri TK. Hope and knowledge, after all, is very contagious – more contagious than this virus. 18 March 2020. BMJ 2020;368:m1087. https://www.bmj.com/content/368/bmj.m1087/rr
2. Fleming RM. Chapter 64. The Pathogenesis of Vascular Disease. Textbook of Angiology. John C. Chang Editor, Springer-Verlag New York, NY. 1999, pp. 787-798. doi:10.1007/978-1-4612-1190-7_64.
3. “Hidden Heart Disease. Could a simple, inexpensive test save your life?” 20/20 - ABC Network with Barbara Walters and Dr. Timothy Johnson 16 April 2004. https://www.youtube.com/watch?v=Hvb_Ced7KyA&t=22s
4. The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) using same state single or sequential quantification comparisons. Patent Number 9566037. Issued 02/14/2017.
5. Mahase Elisabeth. Covid-19: what treatments are being investigated? BMJ 2020; 368:m1252
6. Sayburn Anna. Covid-19: trials of four potential treatments to generate “robust data” of what works BMJ 2020; 368 :m1206
7. Fleming RM, Fleming MR, Dooley WC, Chaudhuri TK. Invited Editorial. The Importance of Differentiating Between Qualitative, Semi-Quantitative and Quantitative Imaging – Close Only Counts in Horseshoes. Eur J Nucl Med Mol Imaging. 2020;47(4):753-755. DOI:10.1007/s00259-019-04668-y. Published online 17 January 2020 https://link.springer.com/article/10.1007/s00259-019- 04668-y https://rdcu.be/b22Dd

Disclosures: FMTVDM issued to first author.

Good to peruse this erudite study. The infectivity of sputum is of concern if the infection is air-borne like tuberculosis, and infectivity of stool is of concern only if the COVID-19 virus is not destroyed by gastric juices. Could authors shed light on these important issues.

Disclosures: Nil

To the Editor:

Dr. Chen and colleagues¹ published on the detection of SARS-CoV-2 in the sputum or feces up to 39 and 13 days, respectively, after pharyngeal swabs became negative.  This finding adds to growing evidence of prolonged viral shedding beyond the recommended isolation period for patients. To better understand fecal-oral and fecal-respiratory routes of transmission and to improve infection control strategies, we believe it’s time to time to advocate for Stool testing in hospitalized COVID-19 patients.

Existing data report increased prevalence of GI symptoms up to 12% of COVID-19 patients, with viral shedding observed in 40.5% of all patients² . In a systematic review by Cheung et al., fecal viral shedding was reported in 70.3% of patients after respiratory specimens became negative³.  Xiao et al. were able to isolate the SARS-CoV-2 virus from feces on two viral-RNA-positive patients, and the authors were able to show that the isolated virus was infectious to susceptible cells and could be neutralized by antibodies when the sample is exposed to the patient’s serum⁴.  This result may suggest evidence of fecal-oral transmission or fecal-respiratory transmission through aerosolized feces.  Furthermore, on April 9, 2020 Food and Drug Administration (FDA) released a safety alert on the potential risk of transmission of SARS-CoV-2 by fecal microbiota for transplantation (FMT)⁵.

Up-to-date isolation guidelines may be inadequate to mitigate the spread of infection in both clinical and community settings and thus we want to emphasize the following points:

1. Despite the increased prevalence of GI symptoms and evolving evidence that prolonged viral shedding, to date, there is no FDA  validated emergency use authorization (EUA) stool testing.
2.  Since the updated data on the increasing prevalence of GI symptoms, there has been no updated guideline from the Center for Disease Control (CDC), WHO or Gastroenterology societies on contact isolation for those patients with GI manifestations. 

Based on current data, we urge for the expansion of our testing of viral RNA detection to stool samples to understand viral shedding dynamics better. As hospitalists we recognize the limitations of current testing capabilities, feasibility to perform stool testing in all COVID-19 patients.  However, a rigorous approach, such as stool testing in addition to nasopharyngeal swab testing to confirm disease recovery, may have implications, especially in moderate and severe covid-19 patients require hospitalization. Hospitalized patients who require gastrointestinal interventions, intraabdominal surgical procedures, and care transition,  discharging patients to long term or short term health facilities.

REFERENCES:

1. Chen C, Gao G, Xu Y, et al. SARS-CoV-2-Positive Sputum and Feces After Conversion of Pharyngeal Samples in Patients With COVID-19. Annals of internal medicine. 2020;172(12):832-834.
2. Parasa S, Desai M, Thoguluva Chandrasekar V, et al. Prevalence of Gastrointestinal Symptoms and Fecal Viral Shedding in Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis. JAMA Network Open. 2020;3(6):e2011335-e2011335.
3. Cheung KS, Hung IFN, Chan PPY, et al. Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology. 2020.
4. Xiao F, Sun J, Xu Y, et al. Infectious SARS-CoV-2 in Feces of Patient with Severe COVID-19. Emerg Infect Dis. 2020;26(8).
5. Administration USFD. Information Pertaining to Additional Safety Protections Regarding Use of Fecal Microbiota for Transplantation - Screening Donors for COVID-19 and Exposure to SARS-CoV-2 and Testing for SARS-CoV-2. 2020, April 09; https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/safety-alert-regarding-use-fecal-microbiota-transplantation-and-additional-safety-protections.

Disclosures:

NA

Thank you for your comments and continuous interest in our study. In addition to our observation on the positive test of SARS-CoV-2 in feces, authors noticed that the virus was isolated from feces and present as a high prevalence ¹. Thus, it is important to understand the fecal-oral and fecal respiratory routes of transmission.

 Currently, the commonly recognized transmission route of COVID-19 is through droplets by airway breathing and close contact via contaminated hands². Several recent outbreaks provided the contaminant food may also cause the infection, especially the reemergence of SARS-CoV-2 in Beijings Xinfadi Wholesale Market after 56 days silent of the virus³. Sparking concern that salmon could be contaminated with the deadly virus, and whether SARS-CoV-2 could transmitted from fish to humans is unclear. These evidences raised the potential risk of fecal-oral and fecal-respiratory transmitted routes in addition to respiratory route of SARS-CoV-2.

 There is dearth evidence to support the fecal-oral or fecal-respiratory transmission yet. Limited data of epidemic surveillance of SARS-CoV-2 in feces has been illustrated⁴. In our hospital, lack of the human source in clinic, the epidemic surveillance of SARS-CoV-2 in feces is still not carried out. However, there are increasing studies reporting GI manifestations among patients infected with COVID-19 especially among those who turned to be negative in pharyngeal swabs suggesting that the SARS-CoV-2 in not only confined to the lung but also to the other parts of respiratory tract and gastrointestinal system⁵.

 In addition, our recent study demonstrated two SARS-CoV-2 variant types co-infected in one patient, but might lead to different organs, subsequently. The further tropism of SARS-CoV-2 in gastrointestinal tract and respiratory tract should be cared for. These mutants of virus might play important roles for virus to evade the host immunity under different immune selective pressure.

 We agree it is time to conduct more research on exploration of consolidate evidence to support the establishment of other transmission route other than respiratory transmission. Under current situation without consolidate evidence of fecal-oral or fecal-respiratory transmission, stools monitoring is necessary to either for the confirmation of disease recovery or for the determination of the isolation.

 REFERENCES:

1. Parasa S, Desai M, Thoguluva Chandrasekar V, et al. Prevalence of Gastrointestinal Symptoms and Fecal Viral Shedding in Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis. JAMA Network Open. 2020; 3(6):e2011335-e2011335.
2. Zhang R, Li Y, Zhang AL, Wang Y, et al. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proceedings of the National Academy of sciences. 2020; 117(26):202009637.
3. Bhowmick GD, Dhar D, Nath D, et al. Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. npj Clean Water. 2020.
4. Wenjie Tan, Peihua Niu, Xiang Zhao, et al. Reemergent Cases of COVID-19 — Xinfadi Wholesales Market, Beijing Municipality, China, June 11, 2020[J]. China CDC Weekly, 2020, 2(27): 502-504. doi: 10.46234/ccdcw2020.132.
5. Xiao F, Tang M, Zheng X, Li C, Shan H. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology. 2020; 158(6):1831-3.