The presentation of COVID-19 varies, but the most commonly reported signs and symptoms are:1-7,19
- Shortness of breath or difficulty breathing
- Chills (+/– shaking)
- Sore throat
- Sputum production
Atypical presentations have also been reported. Some of the less common signs and symptoms are:2,3,8-13,20
- Anosmia or ageusia
- Ocular manifestations (including conjunctival hyperemia, chemosis, epiphora, or increased secretions)
- 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
- Centers for Disease Control and Prevention. Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). CDC website.
- 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
- 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
- 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
- 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
- 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.
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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.
- He X, Lau EH, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nature Med 2020; 26:672-675.
- 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.
- 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.
- 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.
- Findings from investigation and analysis of re-positive cases. Division of Risk assessment and International cooperation. KCDC. Published online May 2020.
- Oran DP, Topol EJ. Prevalence of Asymptomatic SARS-CoV-2 Infection. Annals of Internal Medicine. doi: 10.7326/M20-3012.
- 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.