HOW EXTRAPULMONARY SYMPTOMS INVOLVING THE GASTROINTESTINAL TRACT AND ELEVATIONS IN TRANSAMINASE LEVELS CAN BE INDICATIVE OF AN EARLY PHASE OF COVID-19: A CASE STUDY.

Correspondence to: Ricketta H. Clark, DNP, FNP-BC, The University of Tennessee Health Science Center, College of Nursing, 920 Madison Ave, Memphis, TN 38163 (rclark25@uthsc.edu). Coronavirus disease-2019 (COVID-19) is a viral infection that has become an international public health crisis. With this virus, the targeted organ is the lungs. However, extrapulmonary manifestations of the illness can also occur. In the early phases of the disease process, gastrointestinal symptoms have been observed and can be seen before respiratory symptoms become present (Lee, Huo, & Huang, 2020). Angiotensinconverting enzyme 2 (ACE2) is found in organs throughout the body including the heart, lungs, kidney, and liver (Yuki, Fujiogi, & Koutsogiannaki, 2020; Zaim, Chong, Sankaranarayanan, & Harky, 2020). ACE2 can also be found in the upper portion of the esophagus, ileum, and colon (Luo, Zhang, & Xu, 2020). The spiked proteins of coronavirus attack ACE2, which serves as a gateway that provides access to the interior of the human cell where it then replicates, kills the cell, and spreads (Zhang, Shi, & Wang, 2020). Reports of gastrointestinal complaints are common in primary care and account for 10% of the disease processes primary care providers treat (Gikas & Triantafillidis, 2014). In the gastroenterology setting, the complaint of diarrhea is also a common occurrence. Because COVID-19 is a novel virus, the usual presenting symptoms of respiratory and gastrointestinal symptoms could be mistaken for the typical etiology thus leading to misdiagnosis. Individuals who have COVID-19 are most contagious when they are asymptomatic and early in the disease process (He et al., 2020; Nebehay, 2020; Seay, 2020). Failure to consider COVID-19 in the setting of an acute onset of gastrointestinal symptoms in a healthcare culture of the