Initial presentation

Signs/Symptoms and high risk features

Data from the CDC estimates that 69.7% of patients with COVID-19 present with fever, cough, or dyspnea. The most common individual symptoms are as follows:  

Reported symptoms among persons with laboratory-confirmed COVID-19 — United States, January 22–May 30, 2020. Data based on  373, 833 (28.3%) of confirmed cases 

Reported symptoms among persons with laboratory-confirmed COVID-19 — United States, January 22–May 30, 2020. Data based on  373, 833 (28.3%) of confirmed cases 

Sources:

Stokes EK. Coronavirus Disease 2019 Case Surveillance—United States, January 22–May 30, 2020. MMWR. Morbidity and Mortality Weekly Report. 2020;69.

Last Updated 3 months ago

Natural history of disease

Progression of symptomatic COVID-19 ranges from mild to critical. The largest cohort of patients in China with COVID demonstrated 

  • The majority, 81%, of patients displayed mild symptoms up to mild pneumonia
  • 14% of patients displayed severe symptoms (i.e. dyspnea, hypoxia)
  • 5% of patients displayed critical symptoms (i.e. respiratory failure, shock)
  • Overall case fatality rate is 2.3%, all of which were reported in severe or critical cases

A study of 5700 patients in New York Area calculated the average length of hospital stay 4.1 days.

Critical and Severe Illness

Among patients that developed severe and critical Infection, the median time from onset to 

  • Dyspnea ranged from an estimated median of 5 to 8 days
  • Acute respiratory distress syndrome (ARDS) ranged from 8 to 12 days
    • Typically manifested shortly after onset of dyspnea
    • 20 to 41 percent developed ARDS with COVID-19 confirmed pneumonia
  • Admission to ICU ranged from 10 to 12 days

Complications

  • Acute kidney Injury (AKI)
  • Liver dysfunction with elevated liver enzymes
  • Cardiac injury including arrhythmia, cardiomyopathy, pericarditis, and sudden cardiac death
  • Thromboembolic complications such as stroke and pulmonary embolism
  • Sepsis, shock, and multi-organ failure
  • Less common secondary bacterial pneumonia and encephalitis.

Mortality

Estimates on COVID-19 mortality range broadly and depend on a multitude of factors. As stated above, a large cohort study from China estimated the mortality to be 2.3%. 

An observational study that examined almost 9000 patients in 11 countries that died or were discharged calculated the case fatality rate to be 5.8%. The majority of these patients were from North America. 

List of References 

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020 Feb 15;395(10223):497-506.

Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. New England Journal of Medicine. 2020 May 1.

Novel CP. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua liu xing bing xue za zhi= Zhonghua liuxingbingxue zazhi. 2020 Feb 17;41(2):145.

Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID-19–associated acute hemorrhagic necrotizing encephalopathy: CT and MRI features. Radiology. 2020 Mar 31:201187.

Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, Barnaby DP, Becker LB, Chelico JD, Cohen SL, Cookingham J. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA.

Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. Jama. 2020 Mar 17;323(11):1061-9.

Wu C, Chen X, Cai Y, Zhou X, Xu S, Huang H, Zhang L, Zhou X, Du C, Zhang Y, Song J. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA internal medicine. 2020 Mar 13.

Yang X, Yu Y, Xu J, Shu H, Liu H, Wu Y, Zhang L, Yu Z, Fang M, Yu T, Wang Y. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine. 2020 Feb 24.

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, Guan L. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 2020 Mar 11.

Last Updated 4 months ago

Early symptoms of novel coronavirus infection may be nonspecific, and initial differential should be broad and include non-infectious (vasculitis, dermatomyositis, organizing pneumonia) as well as infectious agents:

  • Seasonal Influenza
  • Common cold (adenovirus, rhinovirus, RSV, etc.)
  • Community acquired bacterial pneumonia (s. pneumoniae, h. influenzae, moraxella catarrhalis, staphylococcus aureus, group A streptococci, aerobic gram-negative bacteria)
  • Atypical pneumonia such as Chlamydial pneumonia or Mycoplasma pneumonia
  • Congestive heart failure

Detection of another respiratory pathogen does not rule out COVID-19.

Sources:

Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation and Treatment Coronavirus (COVID-19) [Updated 2020 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/. 

Ding Q, Lu P, Fan Y, Xia Y, Liu M. The clinical characteristics of pneumonia patients co-infected with 2019 novel coronavirus and influenza virus in Wuhan, China. Journal of medical virology. 2020.

Jain, S. et al (2015). Community-acquired pneumonia requiring hospitalization among U.S. adults. New England Journal of Medicine 373, 415-427. DOI: 10.1056/NEJMoa1500245. 

Jin, Y., Cai, L., Cheng, Z. et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Military Med Res 7, 4 (2020). https://doi.org/10.1186/s40779-020-0233-6. 

Last Updated 5 months ago

Physical exam of a patient with early or mild infection with SARS-CoV-2 may be indistinguishable from other URI and features are generally nonspecific, however consider the following:

Vitals: Temperature, HR, RR, BP, SpO2, peak flow. 

General: Assess for acute distress, general demeanor, affect. 

HEENT: Assess for facial pallor, discoloration of skin and lips. Examine nares, assess for rhinorrhea. Examine oropharynx, assess for Mallampati score. 

Pulmonary: Assess work of breathing. Auscultate anterior and posterior lung fields. 

CV: Auscultate aortic, pulmonic, tricuspid, mitral valve areas. Define PMI. Auscultate carotids, assess for JVD. 

Abdomen: Auscultate for bowel sounds, palpate for localized tenderness. 

Extremities: Assess for edema. 

 

Sources:

Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation and Treatment Coronavirus (COVID-19) [Updated 2020 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/. 

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

Greenhalgh Trisha, Koh Gerald Choon Huat, Car Josip. Covid-19: a remote assessment in primary care BMJ 2020; 368 :m1182. 

Last Updated 5 months ago

 Age is an independent risk factor associated with increased mortality. Overall, the CDC estimated that 80% of COVID related deaths are among patients 65 and older.  A multi-national observational study on nearly 9000 patients determined the mortality rate of COVID-19 patients older than 65 to be 10.0% and 4.9% for patient 65 and younger.  

The CDC estimated the percentage of hospitalization, ICU Admission, and case-fatalities among 1,320,488 persons with COVID-19 from the following age groups: 

Reported Hospitalizations (Including ICU)*, ICU admissions, and case-fatality percentages* among laboratory- confirmed COVID-19 Cases, by age group- United States, January 22, 2020 -May 30, 2020

Mortality rates from a case series in New York estimates the following case fatalities among SARS-CoV2 patients  

A case series on 5700 patients in the Northwell Health System with SARS-CoV2

Sources:

Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, Cereda D, Coluccello A, Foti G, Fumagalli R, Iotti G. Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA. 2020 Apr 6.

Huang, C. et al (2020). Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet 395(10223), 497-506. doi: https://doi.org/10.1016/S0140-6736(20)30183-5. 

Mehra MR, Desai SS, Kuy S, Henry TD, Patel AN. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. New England Journal of Medicine. 2020 May 1.

Older Adults [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2020Jun30]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html

Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, Barnaby DP, Becker LB, Chelico JD, Cohen SL, Cookingham J. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA.

Ruan, Q. et al (2020). Clinical predictors of mortality due to COVID-19 based on analysis of data of 150 patients from Wuhan, China. Intensive Care Medicine. doi: 10.1007/s00134-020-05991-x.

Stokes EK. Coronavirus Disease 2019 Case Surveillance—United States, January 22–May 30, 2020. MMWR. Morbidity and Mortality Weekly Report. 2020;69.

Verity R, Okell LC, Dorigatti I, Winskill P, Whittaker C, Imai N, Cuomo-Dannenburg G, Thompson H, Walker PG, Fu H, Dighe A. Estimates of the severity of coronavirus disease 2019: a model-based analysis. The Lancet Infectious Diseases. 2020 Mar 30.

Last Updated 2 months ago

Research indicates increased risk of severe illness and death in patients infected with COVID-19 that have underlying health conditions. This is true at any age, including children.    

Based on research, the CDC classifies the following diseases as having the strongest and most consistent evidence with adverse outcomes:   

  • Serious heart conditions including heart failure, coronary artery disease, or cardiomyopathies
  • Chronic kidney disease
  • COPD
  • Obesity (BMI greater than 30)
  • Sickle cell disease 
  • Solid organ transplant 
  • Type II diabetes 

Data from the CDC's Morbidity and Mortality Weekly Report released on June 19th noted

The following conditions had mixed evidence in terms of contributing to serious illness from COVID-19:

  • Asthma 
  • Cerebrovascular disease 
  • Hypertension 
  • Pregnancy 
  • Smoking 
  • Use of corticosteroids and immunosuppresive medications 

Sources:

Evidence used to update the list of underlying medical conditions that increase a person's risk of severe illness from COVID-19 [Internet]. 2020 [cited 2020Jun30]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/evidence-table.html

Stokes EK. Coronavirus Disease 2019 Case Surveillance—United States, January 22–May 30, 2020. MMWR. Morbidity and Mortality Weekly Report. 2020;69.

Last Updated 3 months ago

Neuropsychiatric

Data from a meta-analysis of 976 SARS-CoV-2 patients noted the prevalence of the following symptoms in ICU patients: 

At discharge, one study noted 15 (33%) of 45 patients with COVID-10 had dysexecutive syndrome. Symptoms of this condition include poor attention, lack of orientation, and disorganized movements in response to command.

Mood Symptoms 

Two preprints in the meta-analysis used rating scales to assess for depressive and anxiety symptoms.

In one preprint from China, 50 patients (35%) of 141 had symptoms of anxiety while 41 (28%) had symptoms of depression. However, these assessments used the Hospital Anxiety and Depression Scale and were not diagnostic. 

In another preprint, 26 Chinese patients with SARS-CoV-2 scored higher on Hamilton Anxiety and Depression scales compared with two groups of controls. However, these scores significantly improved after the first week of hospital stay.  

List of References 

Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kummerlen C, Collange O, Boulay C, Fafi-Kremer S, Ohana M, Anheim M. Neurologic features in severe SARS-CoV-2 infection. New England Journal of Medicine. 2020 Apr 15.

Kong X, Zheng K, Tang M, Kong F, Zhou J, Diao L, Wu S, Jiao P, Su T, Dong Y. Prevalence and Factors Associated with Depression and Anxiety of Hospitalized Patients with COVID-19. medRxiv. 2020 Jan 1.

Kwek SK, Chew WM, Ong KC, Ng AW, Lee LS, Kaw G, Leow MK. Quality of life and psychological status in survivors of severe acute respiratory syndrome at 3 months postdischarge. Journal of psychosomatic research. 2006 May 1;60(5):513-9.

Rogers J, Edward C, Dominic O, Thomas P, Philip M, Paolo FP, Michael Z, Glyn L, Anthony D. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. The Lancet Psychiatry. 2020 Jul 21.

Yang L, Wu D, Hou Y, Wang X, Dai N, Wang G, Yang Q, Zhao W, Lou Z, Ji Y, Ruan L. Analysis of psychological state and clinical psychological intervention model of patients with COVID-19. medRxiv. 2020 Jan 1.

Zhang B, Zhou X, Qiu Y, Feng F, Feng J, Jia Y, Zhu H, Hu K, Liu J, Liu Z, Wang S. Clinical characteristics of 82 death cases with COVID-19. medRxiv. 2020 Jan 1.

Last Updated 4 months ago
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