Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
Professor & Head,
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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
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Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case Series
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : OR01 - OR04 Full Version

Diarrhoea in COVID-19 with Emphasis on Non Respiratory Presentation: A Case Series

Published: August 1, 2021 | DOI:
Rahul Tyagi, Manu Madan, Saurabh Mittal, Anant Mohan, Pawan Tiwari

1. Senior Resident, Department of Pulmonary Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India. 2. Senior Resident, Department of Pulmonary Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India. 3. Assistant Resident, Department of Pulmonary Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India. 4. Professor, Department of Pulmonary Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India. 5. Assistant Professor, Department of Pulmonary Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India.

Correspondence Address :
Dr. Pawan Tiwari,
Room No. 10, 3rd Floor, Porta Cabin, Department of Pulmonary Critical Care and
Sleep Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India.


Coronavirus Disease 2019 (COVID-19) infection can have myriad presentations ranging from non specific constitutional symptoms to respiratory failure and extrapulmonary manifestations. As COVID-19 is viewed predominantly as an illness of the respiratory tract, extrapulmonary manifestations are often overlooked. The case series is of seven COVID-19 diagnosed patients who presented with diarrhoea, without respiratory symptoms. Clinicodemographic characteristics, hospital course and outcome of these patients are described here. Median age of the patients was 42 years. There were four males and three females. One patient had diabetes mellitus and hypertension, one had hypothyroidism and one had Hodgkin’s lymphoma along with tuberculosis. Five patients had fever while all had diarrhoea as the predominant presenting complaint. Median duration of symptoms was four days before admission. Laboratory abnormalities included anaemia (n=5; 57.1%), lymphopenia (n=3; 42.9%) and elevated inflammatory markers i.e., ferritin and C-reactive protein (n=2; 28.6%). Most patients did not require any specific treatment other than supportive care. All patients were successfully discharged after a median hospital stay of 10 days. Isolated diarrhoea without respiratory symptoms can be presenting complaint of COVID-19 and should be considered by clinicians in current pandemic scenario.


Coronavirus 2019, Gastrointestinal manifestations, Outcomes, Prognosis

An outbreak of pneumonia of unknown cause in Wuhan, China occurred in December 2019. Investigation into the outbreak led to the identification of new virus, Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) (1). This virus primarily spreads through respiratory droplets and the virus has also been detected in blood and stool (2). Common symptoms include systemic symptoms like fever, myalgias or respiratory symptoms like throat pain, cough and breathlessness. Gastrointestinal symptoms have been reported in a minority of patients and may include nausea, vomiting, anorexia and diarrhoea (3),(4).

There is limited literature on gastrointestinal manifestations of COVID-19. Herein, the clinical features, hospital course and outcomes of admitted COVID-19 patients presenting with diarrhoea are reported from analysis of initial cohort.

The patients presented at All India Institute of Medical Sciences-National Cancer Institute, Jhajjhar (National Capital Region). The institute has been conducting an observational study on all the admitted COVID-19 patients from May 2020 to July 2020. Total 800 patients of the cohort were analysed. In a previously reported clinicoepidemiologic characteristic study, there were 144 COVID-19 patients admitted at the study centre, of which 4 (2.8%) had diarrhoea and 3 (2.1%) had nausea or vomiting; however, none of them had isolated gastrointestinal manifestations (4). Subsequently, it was encountered that some patients had isolated diarrhoea as the only manifestation of COVID-19. This case series describes seven patients who presented to hospital with diarrhoea as the predominant manifestation of COVID-19 infection, without any respiratory symptoms. (Table/Fig 1) shows the outline of all described cases.

Case Report

Case 1

A 56-year-old female presented with history of fever and diarrhoea of four days duration, along with myalgias. She was a known case of hypothyroidism was on thyroid hormone replacement therapy and thyroid hormone levels. She had history of contact with a confirmed case of COVID-19 (husband) who was already in quarantine. Her symptoms started with three to four episodes of loose watery stool per day which did not contain any blood or mucous. She also developed fever which was intermittent and associated with chills and rigours. She denied any history of throat pain, cough or breathlessness.

On examination, patient was febrile, while other vitals being stable and systemic examination was non contributory. Her Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) of nasal and pharyngeal swab was positive for COVID-19.

She was managed with oral and intravenous (IV) fluid rehydration and other supportive measures. Her symptoms resolved in four days and she was discharged to home quarantine after 10 days of hospitalisation.

Case 2

A 48-year-old female presented with fever and diarrhoea of five days duration. She was a known case of diabetes mellitus for eight years and hypertension for two years. She was already on medication Telmisartan 40 mg once a day, and tablet Metformin 1 gm twice a day. She had history of contact with a confirmed case of COVID-19 (husband). She had loose watery stools, seven to eight episodes per day without any blood or mucous. She also had intermittent fever with chills and rigours. Her oral intake was poor.

On admission, she had mild tachycardia with other vitals being normal (Pulse Rate (PR)- 120/min, blood pressure- 110/64 mmHg, SpO2 (Saturated Oxygen)-97% on room air). Systemic examination did not reveal anything else. Her RT-PCR of nasal and pharyngeal swab was positive for COVID-19.

She was managed with IV fluids while antihypertensive medications were stopped. Insulin was given as per sliding scale for blood sugar control while in view risk of severe disease, patient was given tab. Hydroxychloroquine (HCQ) according to standard protocol (400 mg twice daily, on day 1 followed by 400 mg once a day, for next four days). She made a complete recovery over next five days with complete resolution of symptoms and was discharged on 12th day of admission.

Case 3

A 41-year-old male presented with history of diarrhoea of four days duration. He also complaint of nausea on and off. He had no known co-morbidities. He had history of contact with a confirmed case of COVID-19 (wife) who was already in quarantine. His symptoms started with four to five episode of loose watery stool per day which did not contain any blood or mucous. He denied any history of fever, throat pain, cough or breathlessness. Patient was vitally stable. His RT-PCR of nasal and pharyngeal swab was positive for COVID-19.

He was managed with oral rehydration solution and made complete recovery in four days and was discharged in 10 days.

Case 4

A 42-year-old male presented with history of fever and diarrhoea of three days duration. He had no known co-morbidities. He had history of contact with a confirmed case of COVID-19. His symptoms started with three to four episode of loose watery stool per day which did not contain any blood or mucous. He gave history of intermittent fever not associated with chills for six days. Patient was vitally stable with normal systemic examination. His RT-PCR of nasal and pharyngeal swab was positive for COVID-19.

He was managed with oral rehydration solution and made complete recovery in three days and was discharged in 10 days.

Case 5

A 36-year-old male presented with history of fever for three days along with diarrhoea for two days. He also had headache for last two days. He had no known co-morbidities. He had history of contact with a confirmed case of COVID-19 (flatmate) who was already in quarantine. He had seven episodes of diarrhoea over 24 hours. Stools did not contain any blood or mucous. There was no history of breathlessness. Patient was vitally stable and systemic examination was non-contributory. His RT-PCR of nasal and pharyngeal swab was positive for COVID-19.

He was managed with oral rehydration and made complete recovery in three days and was discharged in 10 days.

Case 6

A 26-year-old female presented with history of fever, nausea and diarrhoea of two days duration. She had no known co-morbidities. She was a health care worker and was working at a designated COVID-19 hospital. Her symptoms started with intermittent fever with chills and loose watery stool of two days duration. She had five episodes over 24 hours. Stools did not contain any blood or mucous. Patient was vitally stable and systemic examination was non-contributory. Her RT-PCR of nasal and pharyngeal swab was positive for COVID-19.

She was managed with oral rehydration and she made complete recovery in four days. She was discharged in 10 days.

Case 7

A 57-year-old male presented with loss of appetite, diarrhoea and easy fatiguability of seven days duration. He was a known case of Hodgkin’s lymphoma (in remission) and Lymph node tuberculosis in continuation phase of Antitubercular Therapy (ATT). He underwent testing for COVID-19 in view of him being symptomatic and having risk to severe disease. He had loose watery stools to 8 to 10 episodes per day without any blood or mucous. He had poor oral intake and easy fatiguability also.

On admission, had tachycardia (heart rate 124 beats per minute), and dry tongue; other vitals were normal (blood pressure-100/62 mmHg, oxygen saturation 96% on room air). Other systemic examination was normal. His RT-PCR of nasal and pharyngeal swab was positive for COVID-19.

He was managed with IV fluids, ATT and HCQ. He made a complete recovery over next seven days with complete resolution of symptoms and was discharged on 11th day of admission.


Diarrhoea is not a common symptom of COVID-19 infection, and its frequency has been documented to range from 2-50%, with a pooled prevalence of around 12% (6). SARS-CoV-2 uses host Angiotensin Converting Enzyme 2 (ACE2) receptor for entry. ACE 2 receptor is expressed in human intestine in proximal and distal enterocytes and can control inflammation and diarrhoea (7). Xiao F et al., performed oesophageal, gastric, duodenal, and rectal biopsies in patient with COVID-19 induced Acute Respiratory Distress Syndrome (ARDS) having features of gastrointestinal bleeding. Authors did not find any mucosal damage during endoscopy, but histological examination revealed high percentage of ACE2 protein in the glandular cells of all examined segments, except for oesophagus (8). Median symptom duration was four days in the present series, which was similar to a study in published literature (6).

Treatment described in literature is mainly supportive in absence of any approved specific treatment. Supportive treatment in form of rehydration is recommended. Various drugs that are being studied for a role in COVID-19 include chloroquine, HCQ, lopinavir-ritonavir, remdesivir and immunomodulators (7). As per the institute policy, HCQ was used in patients who were at risk for severe disease (Diabetes, Malignancy, Age >65 years). HCQ was given after Electrocardiogram (ECG) was done and corrected QT interval (QTc) was normal.

In contrast, some studies have shown greater requirement of mechanical ventilation in patient with gastrointestinal symptoms, this series did not report any need for intensive care admission (6),(7). In fact, all patients had symptoms which were mild in severity. Infact, diarrhoea was also mild, most patients did not have signs of dehydration either, except for couple of cases requiring IV fluids. Thus, severity of diarrhoea might also be a factor in determining severity of disease, while its corollary might also hold true; that severe disease tend to have severe diarrhoea while diarrhoea per se might not be a risk factor for severe disease.

Importantly, five of the seven patients had fever (71.4%) and none had any respiratory symptoms, thereby stating the importance of testing in patients who present with diarrhoea at onset, especially from hotspot areas and have had high risk contacts. It highlights is the possibility of orofaecal transmission amongst household contacts, which can be seen from the patients having only gastrointestinal symptoms and no respiratory symptoms, these patients should also be subjected to testing of stool samples for viral Ribonucleic Acid (RNA) (9). While vomiting and diarrhoea are included in the World Health Organisation (WHO) definition of suspect COVID-19, the Indian testing strategy places the onus on discretion of evaluating physician in case of non respiratory symptoms (10),(11). Thus, one should be aware of this non respiratory presentation of COVID-19, to avoid missing the diagnosis.

Another interesting feature highlighted from the patients is presence of anaemia in five of the seven patients (71.4%), which was higher than what is reported in other studies where anaemia has been found in up to 51% patients (12),(13),(14),(15). Lower haemoglobin has been associated with severe disease in few studies while its significance has been questioned in others (13),(14),(15). Various mechanisms have been attributed to anaemia in COVID-19 patients like bone marrow dyserythropoiesis in which patients tend to have high Red-cell Distribution Width {(RDW) greater than 14.5%}, and secondary to interleukins causing hepcidin like mechanism and increasing serum ferritin, while decreasing serum iron (16). In couple of the reported patients, anaemia was present despite serum ferritin levels not being raised and normal RDW, which can be explained secondary to poor nutrition in a developing country. Interesting feature is that despite anaemia, all included patients had mild severity and did not have respiratory complaints. Possible explanation can be that patients had orofaecal transmission and because of anaemia which is not owing to systemic immune reaction, they had a milder and a localised gastrointestinal disease, as it has been postulated that iron deficiency may interfere with viral replication. One of the postulated mechanisms of HCQ is also by acting through iron haemostasis mechanism (17).

The present case series describes initial observation of diarrhoea as presenting complaint of COVID-19. Limitations include a small sample size, and lack of long term follow-up. Also, no microbiologic evaluation of stool samples could be done, due to scarcity of resources. Though this was a part of observational study and data was prospectively collected, it may not correctly estimate the proportion of this presentation in COVID-19 patients. Detailed anaemia work-up was not possible, except for serum ferritin and peripheral smears, in view of short stay and clinical improvement with treatment. Nevertheless, this case series highlights an important consideration for clinicians, in the current pandemic situation, to suspect COVID-19 in patients presenting with predominantly non respiratory symptoms.


COVID-19 is a novel infection, and its clinical presentations, diagnostic markers and treatment are evolving. Although diarrhoea is documented in literature as a symptom of this infection, the emphasis on the same in real world scenario is lacking. It is essential that gastrointestinal symptoms of COVID-19 be studied in further detail and physicians should be sensitised to the presence of these symptoms as a presentation for COVID-19.


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Mohan A, Tiwari P, Bhatnagar S, Patel A, Maurya A, Dar L, et al. Clinico-demographic profile & hospital outcomes of COVID-19 patients admitted at a tertiary care centre in north India. Indian Journal of Medical Research. 2020;152(1):61. [crossref] [PubMed]
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Tables and Figures
[Table / Fig - 1]
DOI and Others


Date of Submission: Jan 16, 2021
Date of Peer Review: Feb 13, 2021
Date of Acceptance: Jul 03, 2021
Date of Publishing: Aug 01, 2021

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Jan 21, 2021
• Manual Googling: Jun 24, 2021
• iThenticate Software: Jul 07, 2021 (4%)

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