ACEP COVID-19 Field Guide

Author: Mark Hauswald, MS, MD, FACEP, Emeritus Professor of Emergency Medicine, Past Associate Dean for Clinical Affairs and Patient Safety, Past Director of Global Health Projects, University of New Mexico Health Sciences Center

The presentation of COVID-19 varies, but the most reported signs and symptoms are^1-8:

• Fever;
• Cough;
• Shortness of breath or difficulty breathing;
• Fatigue;
• Anorexia;
• Chills (with or without shaking);
• Headache;
• Sore throat;
• Sputum production; and
• Myalgia.

Atypical presentations have also been reported. Some of the less common signs and symptoms are^2,3,9-15:

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

Dermatologic manifestations

Dermatologic manifestations can 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%. The association between disease severity and timing of skin symptoms in COVID-19 patients is unclear.

The clinical presentation of skin symptoms appears varied. However, in a study of 171 people with laboratory-confirmed COVID-19 (ranging from mild to severe disease), the most common skin manifestations reported were¹⁶:

• Maculopapular rash (22%);
• Discolored lesions of the fingers and toes (18%); and
• Hives (16%).

Among all study participants with COVID-19 and any skin manifestations, approximately 60% reported fever or cough.

Evaluating skin manifestations in COVID-19 patients remains challenging because symptoms can resemble a variety of other disease conditions. Additionally, COVID-19 treatments can also cause certain skin side effects. Images of cutaneous findings are available in the American Academy of Dermatology article “COVID Toes, Rashes: How the Coronavirus Can Affect Your Skin.”

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 8.1.¹⁷

Table 8.1 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 United States from February 12 to April 2, 2020. Credit: ACEP.

* Cases were included in the denominator if they had a known symptom status for fever, cough, shortness of breath, nausea or vomiting, and diarrhea. Total number of patients by age group: younger than 18 years (N = 2,572); 18 to 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 developed symptoms (asymptomatic) and in patients who were not yet symptomatic (pre-symptomatic).^14,18-22 Because asymptomatic people are not routinely tested, the prevalence of asymptomatic infection and detection of pre-symptomatic infection is not well understood.^23-29 One study found that as many as 13% of RT-PCR–confirmed cases of SARS-CoV-2 infection in children were asymptomatic.¹⁵ Patients may have abnormalities on chest imaging before the onset of symptoms. Some data suggest that pre-symptomatic infection tended to be detected in younger individuals and was less likely to be associated with viral pneumonia.^14,18

References

1. COVID-19 clinical care considerations. CDC. Updated August 4, 2023.
2. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Apr 30;382:1708-1720. 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 Feb 15;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. Lancet. 2020 Feb 15;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. JAMA. 2020 Feb 7;323(11):1061-1069. 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. Am J Gastroenterol. 2020 May;115(5):766-773. doi: 10.14309/ajg.0000000000000620
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. BMJ. 2020 Feb 219;368:m606. doi:10.1136/bmj.m606
8. Richardson S, Hirsch JS, Narasimhan M, Crawford J, McGinn T, Davidson KW; the Northwell COVID-19 Research Consortium.
9. 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. JAMA Intern Med. 2020 Jul 1;180(7):934-943. doi:10.1001/jamainternmed.2020.0994
10. 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. Lancet Respir Med. 2020 May;8(5):475-481. doi:10.1016/S2213-2600(20)30079-5
11. 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. Lancet. 2020 Mar 28;395(10229):1054-1062. doi:10.1016/S0140-6736(20)30566-3
12. Giacomelli A, Pezzati L, Conti F, et al. Self-reported olfactory and taste disorders in SARS-CoV-2 patients: a cross-sectional study. Clin Infect Dis. 2020 Jul 28;71(15):889-890. doi:10.1093/cid/ciaa330
13. Wu P, Duan F, Luo C, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province, China. JAMA Ophthalmol. 2020 May 1;138(5):575-578. doi:10.1001/jamaophthalmol.2020.1291
14. Hu Z, Song C, Xu C, et al. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020 May;63(5):706-711. doi:10.1007/s11427-020-1661-4
15. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among children in China. Pediatrics. 2020 Jun;145(6):e20200702. doi: 10.1542/peds.2020-0702
16. Freeman EE, McMahon DE, Lipoff JB, et al. The spectrum of COVID-19–associated dermatologic manifestations: an international registry of 716 patients from 31 countries. J Am Acad Dermatol. 2020 Oct;83(4):1118-1129. doi: 10.1016/j.jaad.2020.06.1016
17. CDC COVID-19 Response Team. Coronavirus disease 2019 in children — United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69(14):422-426. doi: 10.15585/mmwr.mm6914e4
18. NWang Y, Liu Y, Liu L, Wang X, Luo N, Ling L. Clinical outcomes in 55 patients with severe acute respiratory syndrome coronavirus 2 who were asymptomatic at hospital admission in Shenzhen, China. J Infect Dis. 2020 May 11;221(11):1770-1774. doi:10.1093/infdis/jiaa119
19. Pan X, Chen D, Xia Y, et al. Asymptomatic cases in a family cluster with SARS-CoV-2 infection. Lancet Infect Dis. 2020 Apr;20(4):410-411. doi:10.1016/S1473-3099(20)30114-6
20. Bai Y, Yao L, Wei T, et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA. 2020 Apr 14;323(14):1406-1407. doi:10.1001/jama.2020.2565
21. Kimball A, Hatfield KM, Arons M, et al; CDC COVID-19 Investigation Team. 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 Apr 3;69(13):377-381. doi:10.15585/mmwr.mm6913e1
22. 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 Mar 12;25(10):2000180. doi:10.2807/1560-7917.ES.2020.25.10.2000180
23. He X, Lau EH, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nature Med. 2020 Apr 15;26:672-675. doi: 10.1038/s41591-020-0869-5
24. Period of infectivity to inform strategies for de-isolation for COVID-19 patients. National Centre for Infectious Diseases and the Chapter of Infectious Disease Physicians, Academy of Medicine, Singapore. Published May 23, 2020.
25. Cheng HY, Jian SW, Liu DP, Ng TC, Huang WT, Lin HH; Taiwan COVID-19 Outbreak Investigation Team. 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;180(9):1156-1163. doi:10.1001/jamainternmed.2020.2020
26. Wei WE, Li Z, Chiew CJ, Yong SE, Toh MP, Lee VJ. Pre-symptomatic transmission of SARS-CoV-2 - Singapore, January 23-March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020 Apr 10;69(14):411-415. doi: 10.15585/mmwr.mm6914e1
27. Findings from investigation and analysis of re-positive cases. Korea Centers for Disease Control and Prevention. Published May 19, 2020.
28. 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 Dec;9(1):833-836.  
29. Oran DP, Topol EJ. Prevalence of asymptomatic SARS-CoV-2 infection: a narrative review. Ann Intern Med. 2020 Sep 1;173(5):362-367. doi: 10.7326/M20-3012

Additional readings

• Spinato G, Fabbris C, Polesel J, et al. Alterations in smell or taste in mildly symptomatic outpatients with SARS-CoV-2 infection. JAMA. 2020 May 26;323(20):2089-2090. doi: 10.1001/jama.2020.6771
• Burke RM, Killerby ME, Newton S, et al; Case Investigation Form Working Group. Symptom profiles of a convenience sample of patients with COVID-19 — United States, January–April 2020. MMWR Morb Mortal Wkly Rep. 2020 Jul 17;69(28):904-908. doi: 10.15585/mmwr.mm6928a2