Clinical presentation (Part 5)

What are the signs and symptoms of an infected person?

What is known?

• The majority of COVID-19 cases are mild (81%, N = 44,000 cases).¹
• Initial symptoms include fever (87.9% overall, but only 43.8% present with fever initially² ), cough(67.7%²), fatigue, shortness of breath, headache, reduced lymphocyte count.^3-5 Headache⁶ and diarrhea are uncommonly seen. ^5,7
• Complications include acute respiratory distress (ARDS observed in17-29% of hospitalized patients,^8,9 which causes death in 4-15% of cases^8,5,10), pneumonia,¹¹ cardiac injury, secondary infection, kidney failure, arrhythmia, sepsis, and shock. ^2,5,10,12
• Around 15% of hospitalized patients have been classified as severe,^1,2 and nearly 5% were admitted to the ICU. ^1,2
• Most deaths are caused by respiratory failure or respiratory failure combined with myocardial damage.¹³
• The case fatality rate (CFR) is dependent on comorbidities; cardiovascular disease, hypertension, diabetes, and respiratory conditions heighten the CFR.^1,12
• The CFR increases with age; individuals >60 years of age are at higher risk of death,^1,12 and over 60% of confirmed fatalities have been male. ¹
• Children of all ages can be affected by COVID-19,¹⁴ though generally present with milder symptoms. ¹⁵ Severe symptoms in children; however, are possible. ¹⁶
• In the US, 34% of all hospitalizations have been in individuals below 44 years of age.¹⁷ Based on one patient, a productive immune response is generated and sustained for at least 7 days. ¹⁸

What do we need to know?

• How long does it take for infected individuals to recover outside of a healthcare setting?
• Does reduction in CFR through time indicate better treatment, less overcrowding, or both?

References

1. The Novel Coronavirus Pneumonia Emergency Response Epidemiology, T., The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. China CDC Weekly 2020, 2, 1-10.
2. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of 2019 novel coronavirus infection in China. medRxiv 2020, 2020.02.06.20020974.
3. CDC, Symptoms. https://www.cdc.gov/coronavirus/2019-ncov/about/symptoms.html.
4. Changzheng LJL. Experts in the medical treatment team: Wuhans unexplained viral pneumonia patients can be controlled more. https://www.cn-healthcare.com/article/20200110/content-528579.html.
5. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet 
6. Chang D, Lin M, Wei L, Xie L, Zhu G, Dela Cruz CS, et al. Epidemiologic and Clinical Characteristics of Novel Coronavirus Infections Involving 13 Patients Outside Wuhan, China. JAMA 
7. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. New England Journal of Medicine 
8. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 
9. 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 
10. Pan F, Ye T, Sun P, Gui S, Liang B, Li L, et al. Time Course of Lung Changes On Chest CT During Recovery From 2019 Novel Coronavirus (COVID-19) Pneumonia. Radiology 0 (0), 200370.
11. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet.
12. The Novel Coronavirus Pneumonia Emergency Response Epidemiology, T., The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. China CDC Weekly 2020, 2, 1-10.
13. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Medicine 
14. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics 2020, e20200702.
15. Chen C, Cao M, Peng L, Guo X, Yang F, Wu W, et al. Coronavirus Disease-19 Among Children Outside Wuhan, China. SSRN 
16. Liu W, Zhang Q, Chen J, Xiang R, Song H, Shu S, et al. Detection of Covid-19 in Children in Early January 2020 in Wuhan, China. New England Journal of Medicine 
17. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. . MMWR 
18. Thevarajan I, Nguyen THO, Koutsakos M, Druce J, Caly L, van de Sandt CE, et al. Breadth of concomitant immune responses prior to patient recovery: a case report of non-severe COVID-19. Nature Medicine

(Source: DHS Science and Technology, Master Question List for COVID-19 (caused by SARS-CoV-2), Weekly Report, 18 March 2020)

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA