JAAD ONLINE: NOTES & COMMENTS
Sexual transmission of severe acute
respiratory syndrome coronavirus 2
(SARS-CoV-2): A new possible route of
infection?
To the Editor: The severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) is the virus responsible
for the coronavirus disease (COVID-19), first identi-
fied in Wuhan, China, in December 2019, and that
has now actually spread worldwide. The human-to-
human transmission routes hitherto recognized
include direct transmission, through cough, sneeze,
droplet inhalation, and contact transmission,
comprising contact with oral, nasal, and eye mucous
membranes.
To date, COVID-19 has not been reported to be
sexually transmitted. However, a series of data
raises the possibility that sexual intercourse could
be an additional direct way of infection. This
hypothesis mainly derives from the recent evidence
of a likely fecal-oral transmission.1 The exact
mechanisms by which SARS-CoV-2 interacts with
the gastrointestinal tract is unknown. However,
angiotensin-converting enzyme II (ACE2) seems to
be used by the virus as a receptor to enter cells.
ACE2 messenger RNA is highly expressed in the
gastrointestinal system, and immunofluorescent
data show that the ACE2 protein is abundantly
present in the glandular cells of rectal epithelia.2,3
In addition, SARS-CoV-2 RNA identification and
intracellular staining of viral nucleocapsid protein
in rectal epithelia demonstrated that the virus
infects such epithelial cells.2-4
The recognition of viral RNA from feces indicates
that virions are secreted from the virus-infected
cells.2-4 Moreover, SARS-CoV-2 can also be trans-
mitted through the saliva, and ACE2 has been
detected on the mucosa of oral cavity, which is rich
in epithelial cells.4 Therefore, if saliva and feces are
both capable of carrying the virus and ACE2 is
expressed both in the glandular cells of rectal
epithelia and oral mucosa, how can we be sure that
sexual intercourse does not represent another way of
contagion? We thus hypothesize that practice of
certain sexual behaviors could constitute an addi-
tional way for the contagion, both directly (eg
through oral-anal contacts), or indirectly (eg with
exposure of the rectal mucosa to the saliva for
lubrication during anal sex).
This issue could be particularly noteworthy if
considering that a patient with COVID-19 is actually
considered cured after at least 2 upper respiratory
tract samples negative for SARS-CoV-2 are collected
J AM ACAD DERMATOL
at $24-hour intervals. Nevertheless, it has been
demonstrated that patients can persistently test pos-
itive on rectal swabs even after negative results for
nasopharyngeal testing.5 This means that the gastro-
intestinal tract may continue shedding the virus and
that fecal-oral, or eventually sexual, transmission
may be possible despite the apparent recovery.
Indeed, some authors recommend that real-time
reverse transcription polymerase chain reaction be
routinely performed to test for SARS-CoV-2 from
feces.3
Patients’ sexual habits are often not investigated.
These observations highlight the need for physi-
cians, and dermatologists in particular, to strongly
discourage sexual practices if infected during the
pandemic COVID-19. Indeed, beyond the hypothe-
sized possibility of a direct sexual transmission,
sexual intercourse involves close contact that inev-
itably expose individuals to the risk of contagion.
Refining the questions in epidemiologic surveys and
conducting extensive studies of the mucosal sites
( genitals included) of SARS-CoV-2 shedding may
perhaps confirm our hypothesis, allowing for a
greater understanding about SARS-CoV-2 transmis-
sion routes and effective strategies to control infec-
tion spread.
Angela Patrı, MD, Lucia Gallo, MD, Maria Guarino
and Gabriella Fabbrocini, MD
From the Section of Dermatology, Department of
Clinical Medicine and Surgery, University of
Naples Federico II, Naples, Italy.
Funding sources: None.
Conflicts of interest: None disclosed.
IRB approval status: Not applicable.
Reprints not available from the authors.
Correspondence to: Angela Patrı, MD, Department of
Clinical Medicine and Surgery, Section of
Dermatology and Venereology, University of
Naples Federico II, Via Pansini 5, 80131 Naples,
Italy
E-mail: patriangela.ap@gmail.com
REFERENCES
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controls in dental practice. Int J Oral Sci. 2020;12(1):9.
2. Hindson J. COVID-19: faecal-oral transmission? Nat Rev Gastro-
enterol Hepatol. 2020. https://doi.org/10.1038/s41575-020-
0295-7.
n 2020 e1
e2 Notes & Comments
3. Xiao F, Tang M, Zheng X, et al. Evidence for gastrointestinal
infection of SARS-CoV-2. Gastroenterology. 2020. S0016-
5085(20)30282-1.
4. Xu H, Zhong L, Deng J, et al. High expression of ACE2 receptor
of 2019-nCoV on the epithelial cells of oral mucosa. Int J Oral
Sci. 2020;12(1):8.
J AM ACAD DERMATOL
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5. Xu Y, Li X, Zhu B, et al. Characteristics of pediatric SARS-CoV-2
infection and potential evidence for persistent fecal viral
shedding. Nat Med. 2020. https://doi.org/10.1038/s41591-
020-0817-4.
https://doi.org/10.1016/j.jaad.2020.03.098