The many faces of Covid-19


  • Wellness
  • Tuesday, 23 Jun 2020

Temperature checks are common in many places now as a fever is the most common symptom of Covid-19. — S.S. KANESAN/The Star

Since March 22 (2020), the Health Ministry’s definition of a person under investigation (PUI) for Covid-19 has been an “acute respiratory infection (sudden onset of respiratory infection with at least one of: shortness of breath, cough or sore throat) with or without fever AND travelled to/resided in foreign country within 14 days before the onset of illness OR close contact in 14 days before illness onset with a confirmed case of Covid-19 OR attended an event associated with known Covid-19 outbreak”.

This column is based on published data from the World Health Organization (WHO), China and other countries in Asia, Europe and North America.

It is now known that any person of any age can have mild to severe symptoms, or no symptoms at all (asymptomatic) when they have Covid-19.

The disease is more severe in senior citizens and persons with underlying medical conditions.

Data from the first 72,314 patients diagnosed with Covid-19 in China found that it affected males almost as much as females, but more males died from the disease (63.8% male deaths versus 36.2% female deaths).

More than 80 in 100 patients had mild symptoms; about 14 in 100 patients had severe symptoms; and about five in 100 patients were critical.

The symptoms and signs of Covid-19 have varied across geographical locations, and can be common or uncommon.

Common symptoms

These are symptoms that most Covid-19 patients experience:

Fever

Fever was reported in more than three-quarters of patients in a China study, with a higher frequency in some reports and a higher occurrence after hospitalisation.

Some patients may have chills (feeling cold without an apparent cause) and rigors (sudden feeling of cold with shivering, accompanied by fever).

The fever may be prolonged and intermittent.

Fever in children may be brief and resolves rapidly.

Cough

A cough, which is usually dry (i.e. without production of phlegm or mucus) was reported in about 60 out of 100 patients, with a higher frequency in some reports.

The coughing out of sputum was reported in 23 out of 100 patients in a China study, with a higher frequency in some other studies.

Shortness of breath

Dyspnoea, or shortness of breath, has been estimated by the WHO to occur in 31 to 40 out of 100 patients.

The largest meta-analysis of studies in China reported dyspnoea in 20 out of 100 patients, i.e. one in five patients.

The time from onset of symptoms to the development of dyspnoea is a median (i.e. the middle number in a list of numbers) of five to eight days.

Dyspnoea is less common in children, but is the most common sign in neonates (babies less than four weeks old).

Loss of smell and/or taste

Hyposmia (decreased sense of smell) or anosmia (inability to smell) was reported to occur in 53 out of 100 patients in a literature review.

Ageusia (loss of taste) or dysgeusia (altered taste) was reported in 44 out of 100 patients in the same review.

Altered smell and/or taste appeared to be higher in European studies.

American studies report that altered smell was the initial symptom in about a quarter of patients, and more than 70 in 100 patients reported anosmia prior to diagnosis.

Some countries have included altered smell/taste in their case definitions.

Fatigue

Fatigue (tiredness) was reported in about 34 out of 100 patients in a China study, with a higher frequency in some reports.

Some patients may also report malaise (general feeling of discomfort or illness, the exact cause of which is difficult to identify).

Muscle and joint pain

Myalgia (muscle pain) was reported in about 22 out of 100 patients in a China study, with a higher frequency in some other studies.

Arthralgia (joint pain) has also been reported.

Loss of appetite

Anorexia (loss of appetite) was reported in 23 out of 100 patients in a China study, with a higher frequency in some other studies.

Chest tightness

Chest tightness was reported in 23 out of 100 patients in a China study, with a higher frequency in some other studies.

Uncommon symptoms

Although conjunctivitis or pink eye is a very rare symptom of Covid-19, it can sometimes be the only symptom a patient has. — Wikimedia CommonsAlthough conjunctivitis or pink eye is a very rare symptom of Covid-19, it can sometimes be the only symptom a patient has. — Wikimedia Commons

Less common symptoms include:

Gastrointestinal problems

Gastrointestinal symptoms, i.e. nausea, vomiting, diarrhoea and abdominal pain, were reported in 15 out of 100 patients, with a higher frequency in those who were severely ill.

These symptoms are more frequent outside China.

Dizziness and headache

Twelve in 100 patients experienced dizziness and 11 in 100 patients had headaches in a China study.

Sore throat

Eleven out of 100 patients reported having a sore throat in a China study.

Neurological problems

Neurological symptoms like confusion, delirium, agitation, anxiety, depression and sleep problems, have also been reported in some studies.

Skin problems

Symptoms like rashes and itchiness, were reported in eight out of 100 hospitalised patients in Italy.

The symptoms were varied and occurred in both adults and children.

Runny and blocked nose

Rhinorrhoea (running nose) was reported in seven out of 100 patients in a China study.

Nasal congestion (blocked nose)was reported in four out of 100 patients in another study.

Chest pain

Chest pain was reported in two to five out of 100 patients in a study.

However, this may be a sign of pneumonia (lung infection).

Conjunctivitis

Conjunctivitis was reported in one out of 100 patients in a study, with a higher frequency in other studies.

It appears to occur more often in those with severe illness and may be the only presenting symptom in some patients.

Pregnancy

Certain Covid-19 symptoms, like nausea, vomiting and fatigue, are also normal symptoms of pregnancy. — AFPCertain Covid-19 symptoms, like nausea, vomiting and fatigue, are also normal symptoms of pregnancy. — AFP

Published data on Covid-19 in pregnant women are less than that of the general population.

The current data indicates that the clinical presentation in the pregnant is similar to that of the non-pregnant.

It is vital to remember that symptoms like fever, dyspnoea, fatigue and gastrointestinal symptoms can also occur as either a normal part of pregnancy, or more importantly, a problem with the pregnancy.

Unusual symptoms

Atypical or unusual symptoms and signs are more common in senior citizens and those who are immunocompromised.

These include falls, reduced mobility, fainting, persistent hiccups and an absence of fever.

Co-infections, i.e. simultaneous infections by other bacteria or viruses, have been reported in hospitalised patients with Covid-19, more so in intensive care units (ICUs).

Bacterial co-infections are more common than that of fungi and viruses.

Covid-19 patients with influenza co-infection have been reported to show similar clinical symptoms and signs to patients with Covid-19 only.

Helpful data

As Covid-19 has many faces, a high index of suspicion is necessary.

It would be very helpful for the public and all healthcare professionals if the Health Ministry is forthcoming with data on the clinical features of Covid-19 in Malaysia.

In addition, the following data are relevant:

  • The prevalence or frequency of Covid-19 in Malaysia
  • The total number of asymptomatic cases
  • The total number of asymptomatic cases that converted to symptomatic cases
  • The proportion of asymptomatic imported cases that have been linked to transmission chains that led to clusters of Covid-19.

It should be emphasised that one of the pillars of public trust is transparency of health information.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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