eng Science and Education Publishing American Journal of Medical Case Reports 2374-216X 2020-10-27 9 1 24 31 10.12691/ajmcr-9-1-8 AJMCR2021918 article Abhilash Haridas abhilashsaras@gmail.com 1 Payal Mukker 2 Department of Gastroenterology, Sree Gokulam Medical College & Sree Gokulam GG Hospital, Trivandrum, India Department of Medicine, Sree Gokulam Medical College & Gokulam Covid Care Center (GCC), Trivandrum, India Gastrointestinal (GI) symptoms are not uncommon in COVID-19 infection. The varied symptomatology and severity of GI symptoms are related to the difference in host viral interaction. We have reviewed the GI manifestations of these patients and noted that three subgroups exist.A group with self-limited GI disease, a group with predominant GI manifestations and group with severe GI disease. A review of the immune response in the different groups with GI manifestations has been done and illustrated by a cat and mouse game theory. In self-limited GI disease, there is early active innate immunity with type I interferon response and followed by an efficient adaptive immune response causing viral clearance. In patients with predominant GI symptoms, viral factors override innate immune mechanisms and cause delayed and weak innate antiviral response. The subsequential adaptive response is a "mishit" response with mucosal injury and GI symptoms. In the later part of this infection, a resurgent adaptive immunity induction can occur, causing persistent fecal shedding followed by viral clearance. In severe disease, there is heightened dysregulation of the adaptive immune response leading to cytokine storm and severe complications like pyroptosis, endothelitis, and hemophagocytic lymphohistiocytosis. http://pubs.sciepub.com/ajmcr/9/1/8/ajmcr-9-1-8.pdf COVID-19 SARS CoV-2 gastrointestinal symptoms innate immunity adaptive immunity cytokine storm