ACEP COVID-19 Field Guide

The presentation of COVID-19 varies, but the most commonly reported signs and symptoms are:^1-7,19

• Fever 
• Cough 
• Shortness of breath or difficulty breathing
• Fatigue 
• Anorexia 
• Chills (+/– shaking)
• Headache
• Sore throat
• Sputum production 
• Myalgias 

Atypical presentations have also been reported. Some of the less common signs and symptoms are:^2,3,8-13,20

• Confusion
• Rhinorrhea 
• Hemoptysis
• Vomiting
• Diarrhea 
• Nausea
• Anosmia or ageusia
• Ocular manifestations (including conjunctival hyperemia, chemosis, epiphora, or increased secretions)

Dermatologic Manifestations

• Dermatologic manifestations may be associated with COVID-19 and although the frequency remains unknown, reports have ranged from 0.2%, early in the pandemic, to as high as 20.4%. 
• Association with disease severity and timing of skin symptoms among COVID-19 patients is unclear. 
• The clinical presentation appears varied, though in a study of 171 persons with laboratory-confirmed COVID-19 (ranging from mild to severe disease), the most common skin manifestations reported were: 
• a maculopapular rash (22%), 
• discolored lesions of the fingers and toes (18%)
• hives (16%). 
• Among all study participants with COVID-19 and any skin manifestations, approximately 60% reported fever and/or cough.

Evaluating skin manifestations in COVID-19 patients remains challenging as symptoms can resemble a variety of other disease conditions. Additionally, COVID-19 treatments also may cause certain skin side-effects. Images of cutaneous findings are available from the American Academy of Dermatology.

According to the CDC’s “Coronavirus Disease 2019 in Children — United States, February 12-April 2, 2020,” signs and symptoms among pediatric and adult patients with laboratory-confirmed COVID-19 include those in Table 6.1.

Table 6.1 Signs and symptoms among 291 pediatric (age <18 years) and 10,944 adult (age 18-64 years) patients* with laboratory-confirmed COVID-19 in the US from February 12, 2020, to April 2, 2020.

* Cases were included in the denominator if they had a known symptom status for fever, cough, shortness of breath, nausea/vomiting, and diarrhea. Total number of patients by age group: <18 years (N = 2,572), 18-64 years (N = 113,985).

^a Includes all cases with one or more of these symptoms.

^b Patients were included if they had information for either measured or subjective fever variables and were considered to have a fever if “yes” was indicated for either variable.

^c Runny nose and abdominal pain were less frequently completed than other symptoms; therefore, percentages with these symptoms are likely underestimates.

Asymptomatic and Pre-Symptomatic Infection 

Several studies have documented SARS-CoV-2 infection in patients who never develop symptoms (asymptomatic) and in patients not yet symptomatic (pre-symptomatic).^13-18 Since asymptomatic persons are not routinely tested, the prevalence of asymptomatic infection and detection of pre-symptomatic infection is not well understood. One study found that as many as 13% of RT-PCR-confirmed cases of SARS-CoV-2 infection in children were asymptomatic.²¹ Patients may have abnormalities on chest imaging before the onset of symptoms.^13,14 Some data suggest that pre-symptomatic infection tended to be detected in younger individuals and was less likely to be associated with viral pneumonia.^13,14

References

1. Centers for Disease Control and Prevention. Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). CDC website.
2. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China [published online ahead of print, 2020 Feb 28]. N Engl J Med. 2020;NEJMoa2002032. doi:10.1056/NEJMoa2002032
3. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-513. doi:10.1016/S0140-6736(20)30211-7
4. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China [published correction appears in Lancet. 2020 Jan 30]. Lancet. 2020;395(10223):497-506. doi:10.1016/S0140-6736(20)30183-5 
5. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China [published online ahead of print, 2020 Feb 7]. JAMA. 2020;e201585. doi:10.1001/jama.2020.1585
6. 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 [published online ahead of print]. Am J Gastroenterol. 2020.
7. Xu XW, Wu XX, Jiang XG, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series [published correction appears in BMJ. 2020 Feb 27;368:m792]. BMJ. 2020;368:m606. Published 2020 Feb 19. doi:10.1136/bmj.m606
8. Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China [published online ahead of print, 2020 Mar 13]. JAMA Intern Med. 2020;e200994. doi:10.1001/jamainternmed.2020.0994
9. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study [published online ahead of print, 2020 Feb 24] [published correction appears in Lancet Respir Med. 2020 Feb 28]. Lancet Respir Med. 2020. doi:10.1016/S2213-2600(20)30079-5 
10. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published correction appears in Lancet. 2020 Mar 28;395(10229):1038] Lancet. 2020;395(10229):1054-1062. doi:10.1016/S0140-6736(20)30566-3
11. Giacomelli A, Pezzati L, Conti F, et al. Self-reported olfactory and taste disorders in SARS-CoV-2 patients: a cross-sectional study [published online ahead of print, 2020 Mar 26]. Clin Infect Dis. 2020;ciaa330. doi:10.1093/cid/ciaa330
12. Wu P, Duan F, Luo C, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China [published online ahead of print, 2020 Mar 31]. JAMA Ophthalmol. 2020;e201291. doi:10.1001/jamaophthalmol.2020.1291
13. Hu Z, Song C, Xu C, et al. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China [published online ahead of print, 2020 Mar 4]. Sci China Life Sci. 2020;10.1007/s11427-020-1661-4. doi:10.1007/s11427-020-1661-4 
14. Wang Y, Liu Y, Liu L, Wang X, Luo N, Ling L. Clinical outcome of 55 asymptomatic cases at the time of hospital admission infected with SARS-Coronavirus-2 in Shenzhen, China [published online ahead of print, 2020 Mar 17]. J Infect Dis. 2020;jiaa119. doi:10.1093/infdis/jiaa119
15. Pan X, Chen D, Xia Y, et al. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. Lancet Infect Dis. 2020;20(4):410-411. doi:10.1016/S1473-3099(20)30114-6
16. Bai Y, Yao L, Wei T, et al. Presumed asymptomatic carrier transmission of COVID-19 [published online ahead of print, 2020 Feb 21]. JAMA. 2020;e202565. doi:10.1001/jama.2020.2565
17. Kimball A, Hatfield KM, Arons M, et al. Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility - King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. 2020;69(13):377-381. Published 2020 Apr 3. doi:10.15585/mmwr.mm6913e1
18. Mizumoto K, Kagaya K, Zarebski A, Chowell G. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Euro Surveill. 2020;25(10):2000180. doi:10.2807/1560-7917.ES.2020.25.10.2000180
19. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area [published online ahead of print, 2020 Apr 22]. JAMA. 2020;10.1001/jama.2020.6775. doi:10.1001/jama.2020.6775
20. Spinato G, Fabbris C, Polesel J, et al. Alterations in smell or taste in mildly symptomatic outpatients with SARS-CoV-2 infection [published online ahead of print, 2020 Apr 22]. JAMA. 2020;10.1001/jama.2020.6771. doi:10.1001/jama.2020.6771
21. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics. April 2020, e20200702; doi: 10.1542/peds.2020-0702
22. Yongchen Z, Shen H, Wang X, et al. Different longitudinal patterns of nucleic acid and serology testing results based on disease severity of COVID-19 patients. Emerg Microbes Infect 2020; 0:1–14.
23. He X, Lau EH, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nature Med 2020; 26:672-675.
24. Period of Infectivity to Inform Strategies for De-isolation for COVID-19 Patients. Position Statement from the National Centre for Infectious Diseases and the Chapter of Infectious Disease Physicians, Academy of Medicine, Singapore. Published online 2020 May 23.
25. Cheng HY, Jian SW, Liu DP, et al. Contact tracing assessment of COVID-19 transmission dynamics in Taiwan and risk at different exposure periods before and after symptom onset. JAMA Intern Med. 2020 May 1.
26. Wei WE, Li Z, Chiew CJ, et al. Pre-symptomatic transmission of SARS-CoV-2 - Singapore, January 23 - March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020; 69: 411-415.
27. Findings from investigation and analysis of re-positive cases. Division of Risk assessment and International cooperation. KCDC. Published online May 2020.
28. Oran DP, Topol EJ. Prevalence of Asymptomatic SARS-CoV-2 Infection. Annals of Internal Medicine. doi: 10.7326/M20-3012.
29. Burke RM, Killerby ME, Newton S, et al. Symptom Profiles of a Convenience Sample of Patients with COVID-19 — United States, January–April 2020. MMWR Morb Mortal Wkly Rep 2020;69:904–908.