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Initially, there were only a few coronavirus symptoms to look out for: dry cough, fever, body aches and chest tightness. As the virus has spread, doctors have learned that COVID-19 doesn’t always present the same way. Unfortunately, researchers are running up against barriers to fully understanding this disease. Melissa Hawkins, an epidemiologist at American University, says COVID-19’s rapid spread has made it difficult for doctors to know exactly what to expect. Unlike with other, non-pandemic illnesses, healthcare providers are treating, documenting and researching symptoms all at the same time. “Medicine is both an art and a science,” she says, “and with COVID-19, we’re learning as we go.”
Experts are also hindered by incomplete reporting about how the novel coronavirus affects people. Since most coronavirus patients don’t show up at the hospital, we’re missing huge chunks of data about COVID-19 symptoms that doctors don’t have yet.
Still, with the number of US cases and testing increasing, Hawkins says healthcare providers and researchers are beginning to see some trends. So far, there seems to be a range of symptoms, both respiratory and non-respiratory, and each symptom can range in severity from person to person. Some COVID-19 cases are like mild colds, and others are more like pneumonia. Some infected people never have symptoms at all.
One of the biggest clues about how the virus presents has to do with where it starts and ends up. The virus usually enters the body through the upper respiratory tract, via a person’s eyes, nose or mouth. If the virus stays in the upper respiratory tract, people are more likely to experience milder symptoms, akin to a cold or a mild case of the flu.
But if the virus moves into the lungs, patients might have more severe, pneumonia-like symptoms. Hawkins says the virus also sometimes spreads to other organs and systems in the body, which can lead to a number of less common symptoms, from abdominal pain and diarrhea to neurological problems like disorientation.
Here’s a list of COVID-19 symptoms doctors either know about or are beginning to see in their patients.
As with any infection, many COVID-19 patients report a fever, which the CDC defines as a temperature of 100.4 degrees Fahrenheit or higher in both children and adults. Hawkins says fever occurs in about 90 percent of reported cases. How high the fever gets varies person to person, but according to Hawkins, the COVID-19 fever tends to be higher in the afternoon and evening, and it may come with chills and sweating at night.
COVID-19 often presents with a dry, persistent cough as an early symptom. The cough is similar to a cough someone might have with influenza: It’s not a tickle, it’s not productive (meaning you don’t cough up mucus) and it’s not usually accompanied with a sore throat. The dry cough may lead to shortness of breath in severe cases later on.
Hawkins says severe tiredness or fatigue is one of the earliest signs of COVID-19, seen in about 70 percent of reported cases, often present after the dry cough starts. The level of fatigue people experience can vary based on how severe the illness is. Patients with mild cases may just feel a bit tired; patients with moderate cases may be so tired they stay in bed; and patients with severe cases may be so tired they can’t finish a sentence, which Hawkins says could also happen due to windedness from lung-related symptoms.
Aches and pains
Many infections, including COVID-19, cause muscle aches. A recent study from NYU researchers found that deep muscle aches, known as myalgia, early on in the illness may be a predictor of more severe, lung-related illness later on. But according to the study, these muscle aches are severe, and they don’t occur alone. They’re accompanied by an increase in hemoglobin levels and an enzyme called ALT, which can signal liver inflammation.
Runny nose may appear due to an upper respiratory tract infection, but it’s a less common symptom — less than 5 percent of people with COVID-19 experience it, according to a report by the World Health Organization. Hawkins says given the season, runny nose may be more likely to be a sign of allergies or the common cold.
Some people with upper respiratory tract infections due to COVID-19 might have a sore throat, but Hawkins says it’s important to distinguish it from strep throat, which usually causes stabbing pain, especially while swallowing. Someone with a sore throat is more likely to have allergies or a cold.
Shortness of breath
As the infection moves lower into the lungs, patients may feel shortness of breath, which may or may not be accompanied by a cough. This is far more common in severe cases, Hawkins says. According to the World Health Organization, around 1 in 6 people with COVID-19 will develop difficulty breathing.
The shortness of breath people experience, Hawkins says, is a different feeling from chest tightness when you’re anxious, which usually resolves when you calm down. “It’s like you can’t get enough oxygen in your lungs,” she says. “You’d get winded when you get up and walk to another part of the house.”
Loss of taste or smell
Reports of loss of taste or smell were purely anecdotal until mid-April, when researchers established that these are “profoundly common” symptoms in patients with mild infections.
Liu says in some reports she’s seen, 40 percent or more of COVID-19 patients have presented with loss of taste or smell. This symptom likely has to do with inflammation in the respiratory tract. The nerve that mediates sense of smell is high up in the nose, so when there is inflammation near that nerve, a person could lose both their sense of smell or taste. Sometimes these symptoms drag on after other respiratory symptoms go away.
The CDC recently added chills to its list of possible COVID-19 signs. In COVID-19 cases, Hawkins says, many people experience chills, which cause them to feel cold and shaky, at the onset — before other symptoms like fever or aches and pains show up. Generally, the chills don’t persist throughout the course of the illness, unless a person becomes significantly sicker.
Dr. Anne Liu, an infectious disease physician at Stanford Health Care, says people may experience mild diarrhea (you might think you have a stomach bug) to severe, appendicitis-like abdominal pain. GI symptoms are more likely to be associated with COVID-19 in areas with a higher concentration of cases. “Someone in New York City presenting with diarrhea will be more likely to have COVID-19 than someone presenting in a place with a lot less coronavirus,” Liu says.
Sometimes people develop GI symptoms like diarrhea early on in the illness, then develop respiratory symptoms later on. Other patients may only have GI symptoms, which can be confusing for both patients and doctors. So far, Liu says, it seems to be more common that the GI symptoms develop into respiratory symptoms.
Doctors still aren’t sure exactly why some people with COVID-19 experience digestive upset. It could be that the virus is replicating in the GI tract, but Liu says that hasn’t been established yet.
According to the WHO, about 5 percent of cases experience nausea. As a symptom, it’s often related to inflammation in the GI tract, which can happen due to a viral infection. Liu says people with COVID-19 may be a little nauseous, or so nauseous that they are vomiting. Like diarrhea, nausea might happen on its own, without a dry cough or difficulty breathing. But doctors don’t yet have enough data to determine how often it occurs with or without respiratory symptoms.
Headaches are also somewhat common in COVID-19, but Hawkins describes them as a “nonspecific symptom,” which means on their own, headaches aren’t a sign of COVID-19. That’s because a number of COVID-19 symptoms can cause headaches, like dehydration from a fever or sinus pressure or congestion from an upper respiratory infection. According to Hawkins, headaches may be more common in mild or moderate adult cases, and among all cases in children.
Conjunctivitis (pink eye)
The virus can enter through any part of your respiratory tract, including the mouth, nose or eyes. If it enters through the eye — like if you touch a surface infected with COVID-19, then rub your eyes, or if an infected person coughs directly toward your eye — pink eye could be the first sign of infection. That’s why healthcare providers wear protective glasses along with a mask. Typically, pink eye causes eye redness, itching and excessive tears; it may also cause eye discharge or crusting.
It’s not uncommon for viruses in general to trigger rashes, and some people are experiencing it with COVID-19. Hawkins says reports in Italy and Thailand also include skin rashes as a symptom. Commonly, the rash is described as itchy, hive-like skin lesions, usually on the trunk. It may look like a cluster of mosquito bites. Some people complain of a burning sensation with the rash.
To keep track of skin-related manifestations in COVID-19 cases, The American Academy of Dermatology created a registry of symptoms. One emerging symptom, dubbed “COVID toes,” shows up as pinkish-reddish lesions on the feet that sometimes turn purple over time. Hawkins says some people experience swelling in their extremities (both hands and feet) that often feels painful to the touch. COVID toes are currently listed as a symptom in more than half of the 300 cases on the AAD’s registry. And as of now, the lesions primarily occur alongside more common COVID-19 symptoms.
So far, experts have a few theories about why this is happening. According to Hawkins, most patients who’ve reported COVID toes are younger — ranging from children to young adults — so it might have to do with the speed and aggression of a younger person’s immune response to the virus. Hawkins says COVID toes could also be due to small blood clots or an inflammatory reaction in the blood vessels.
Less common symptoms
Liu says doctors are also seeing patients who come to the ER thinking they’re having a heart attack due to chest pain symptoms, which is really caused by the novel coronavirus attacking the heart and causing inflammation in the chest. When this happens, people have abnormal EKG and evidence of cardiac inflammation in blood tests and CT scans; they then test positive for COVID-19. Sometimes this happens when people have already had respiratory symptoms, but it may occur in people without any.
While chest pain can occur in people of any age and doesn’t necessarily happen more commonly in people with preexisting conditions, Liu says it’s not as common as respiratory symptoms. Once cardiac inflammation does happen, though, it tends to bode poorly for patient outcomes.
Disorientation or confusion
In some severe cases, Liu says COVID-19 patients present with neurological symptoms like disorientation or confusion, which could serve as a sign that the infection has become more severe. While confusion is itself a less common symptom, some studies show it generally occurs alongside the typical symptoms like cough and fever. Hawkins says people might describe feeling woozy, funny or “off,” perhaps with tingling or numbness in their extremities and a lack of balance.
What causes COVID-19 patients to experience these neurological issues isn’t certain. Hawkins says doctors aren’t sure yet whether the coronavirus actually infects the brain or if the neurological symptoms are an indirect consequence of inflammation or oxygen levels altered by the virus.
In some of the most severe cases, patients are experiencing blood clots in the lungs and other organs and blood vessels, which can lead to complications like stroke. Most of these patients, Hawkins says, are already in the hospital, and sometimes the blood clots aren’t discovered until an autopsy.