The clinical features of COVID-19 patients with positive viral RNA stool test results and possibility of fecal-oral transmission : A Systematic Review

Selina Natalia(1), Felicia Imanuella Thorion(2), Luky Adlino(3), Clifford Eltin John(4), Andree Kurniawan(5), Nata Pratama Hardjo Lugito(6),

(1) Faculty of Medicine, Pelita Harapan University, Tangerang
(2) Faculty of Medicine, Pelita Harapan University, Tangerang
(3) Faculty of Medicine, Pelita Harapan University, Tangerang
(4) Faculty of Medicine, Pelita Harapan University, Tangerang
(5) Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Boulevard Jendral Sudirman street, Karawaci, Tangerang
(6) Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Boulevard Jendral Sudirman street, Karawaci, Tangerang
Corresponding Author


Objective : Coronavirus disease 2019 (COVID-19) has been declared as an international public health emergency by the World Health Organization (WHO), with outbreaks in over 200 countries and causing over 390,000 deaths globally. ACE-2 receptors are highly expressed in the upper and lower gastrointestinal system, providing a prerequisite for SARS-CoV-2 infection in the gastrointestinal tract. In addition, over half of the COVID-19 patients have viral nucleic acid detected in their feces and almost one-quarter of the cases, the stool samples test positive even when respiratory samples are negative. The aim of this systematic review is to summarize literature and to evaluate the clinical characteristics of patients with positive viral RNA stool test for COVID-19 and if there is a possibility of fecal-oral transmission of SARS-CoV-2 virus.

Method : This systematic review has been registered in PROSPERO (CRD42020183049). A systematic search of the literature for observational study and randomized control trial was conducted in PubMed central and Google Scholar through May 5th, 2020. Three reviewers independently searched and selected. The risk of bias was evaluated using Newcastle-Ottawa Quality assessment tool.

Results : 340 articles were screened, then from which eight articles were selected. Of eight articles that were included in this study, we sought for three main categories of the clinical manifestation; gastrointestinal, respiratory, and others. Each study was reviewed systematically to gain demographic data and evidence regarding the possibility of fecal oral transmission in SARS-CoV-2. Two studies reported prolongation of positive stool test results after the respiratory specimen conversion to negative which support the theory of fecal oral transmission.

Conclusion : In conclusion, diarrhea, cough, and fever are the most common clinical manifestations in COVID-19 patients with positive RNA stool test results. Fecal oral transmission may be possible due to the ACE-2 receptors in the lining of the gastrointestinal tract. RNA stool test should be used as addition in discharging COVID-19 patients.


Gastroenterology; COVID-19, SARS-CoV-2, viral RNA stool test, clinical characteristics, fecal-oral transmission.


Li Q, Guan X,WuP, et al. Early Transmission Dynamics in Wuhan,China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med 2020;382:1199–207.

Bajema KL, Oster AM, McGovern OL, et al. Persons evaluated for 2019 novel coronavirus - United States, January 2020. MMWR Morb Mortal Wkly Rep 2020;69:166–70.

Chen L, Liu W, Zhang Q. RNA based mNGS approach identifies a novel human coronavirus from two individual pneumonia cases in 2019 Wuhan outbreak. Emerg Microbes Infect 2020;9:313–9.

Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497–506.

Gu J, Han B, Wang J. COVID-19:Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology 2020.

Pan L, Mu M, Yang P, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: A descriptive, cross-sectional, multicenter study. Am J Gastroenterol March 2020.

Zhou P, Yang X, Wang X, Hu B, Zhang L, Zhang W et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579(7798):270-273.

Harmer D, Gilbert M, Borman R, Clark K. Quantitative mRNA expression profiling of ACE 2, a novel homologue of angiotensin converting enzyme. FEBS Letters. 2002;532(1-2):107-110.

Yan R, Zhang Y, Li Y, Xia L, Zhou Q. Structure of dimeric full-length human ACE2 in complex with B0AT1. 2020.

Xiao F, Tang M, Zheng X, et al. Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology 2020.

Chen L, Lou J, Bai Y, et al. COVID-19 disease with positive fecal and negative pharyngeal and sputum viral tests. Am J Gastroenterology 2020.

Han, C., Duan, C., Zhang, S., Spiegel, B., Shi, H., Wang, W., Zhang, L., Lin, R., Liu, J., Ding, Z. and Hou, X., 2020. Digestive Symptoms in COVID-19 Patients With Mild Disease Severity. American Journal of Gastroenterology, 115(6), pp.916-923.

Lo I, Lio C, Cheong H, Lei C, Cheong T, Zhong X et al. Evaluation of SARS-CoV-2 RNA shedding in clinical specimens and clinical characteristics of 10 patients with COVID-19 in Macau. International Journal of Biological Sciences. 2020;16(10):1698-1707.

Chen, Y., Chen, L., Deng, Q., Zhang, G., Wu, K., Ni, L., Yang, Y., Liu, B., Wang, W., Wei, C., Yang, J., Ye, G. and Cheng, Z., 2020. The presence of SARS‐CoV‐2 RNA in the feces of COVID‐19 patients. Journal of Medical Virology, 92(7), pp.833-840.

Li, Y., Hu, Y., Yu, Y., Zhang, X., Li, B., Wu, J., Li, J., Wu, Y., Xia, X., Tang, H. and Xu, J., 2020. Positive result of Sars‐Cov‐2 in faeces and sputum from discharged patient with COVID‐19 in Yiwu, China. Journal of Medical Virology.

Xu Y, Li X, Zhu B, Liang H, Fang C, Gong Y et al. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nature Medicine. 2020;26(4):502-505.

Xu M, Liu X, Su C, Zeng Y, Zhang J, Li X et al. A Research on the Results of Viral Nucleic Acid Tests and CT Imaging Variation of Patients with COVID-19. 2020.

Xing Y, Ni W, Wu Q, Li W, Li G, Wang W et al. Prolonged viral shedding in feces of pediatric patients with coronavirus disease 2019. Journal of Microbiology, Immunology and Infection. 2020;53(3):473-480.

Balla M, Merugu G, Patel M, Koduri N, Gayam V, Adapa S et al. COVID-19, Modern Pandemic: A Systematic Review From Front-Line Health Care Providers’ Perspective. Journal of Clinical Medicine Research. 2020;12(4):215-229.

Donà D, Minotti C, Costenaro P, Da Dalt L, Giaquinto C. FECAL-ORAL TRANSMISSION OF SARS-COV-2 IN CHILDREN. Pediatric Infectious Disease Journal. 2020;Publish Ahead of Print.

Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA. 2020;323(11):1061.

Yeo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: is faecal–oral transmission of SARS-CoV-2 possible?. The Lancet Gastroenterology & Hepatology. 2020;5(4):335-337.

Cipriano M, Ruberti E, Giacalone A. Gastrointestinal Infection Could Be New Focus for Coronavirus Diagnosis. Cureus. 2020.

Wang R, Pan M, Zhang X, Han M, Fan X, Zhao F et al. Epidemiological and clinical features of 125 Hospitalized Patients with COVID-19 in Fuyang, Anhui, China. International Journal of Infectious Diseases. 2020;95:421-428.

Ho, A., Sung, J. and Chan-Yeung, M., 2003. An Outbreak of Severe Acute Respiratory Syndrome among Hospital Workers in a Community Hospital in Hong Kong. Annals of Internal Medicine, 139(7), p.564.

Cai J, Xu J, Lin D, Yang z, Xu L, Qu Z et al. A Case Series of children with 2019 novel coronavirus infection: clinical and epidemiological features. Clinical Infectious Diseases. 2020.

Wu Y, Guo C, Tang L, Hong Z, Zhou J, Dong X et al. Prolonged presence of SARS-CoV-2 viral RNA in faecal samples. The Lancet Gastroenterology & Hepatology. 2020;5(5):434-435.

Full Text: PDF

Article Metrics

Abstract View : 417 times
PDF Download : 282 times

DOI: 10.24871/221202142-51


  • There are currently no refbacks.