Common Atypical Presentations of Covid-19, By Nana Dadzie Ghansah

Clinical Presentations Coronavirus Global Pandemic National Public Health Emergency SARS-CoV-2

As COVID-19 broke out, several of the authoritative bodies like the WHO and the CDC as well as clinicians from China listed three common presenting symptoms: fever, cough, and shortness of breath.
However, as the disease has continued to spread worldwide, reports are rampant of atypical presentations.

Diarrhea seems one of the more common atypical presenting signs. Guan in their paper in the NEJM that looked at 1009 Chinese patients found an incidence of 3.8%. In a paper to be published soon, Lei Pan and his group found that 35% of the 204 patients they studied presented with both respiratory symptoms and diarrhea. Six of them just had diarrhea.
Loss of appetite is another symptom that has been noted.

Loss of taste and/or smell can be another set of atypical presenting signs. Giacomelli and his team in Milan may have been the first ones to publish about this loss even though there had been reports from China and South Korea. Out of the 59 patients they studied, 20 (33.9%) reported at least one taste or smell disorder and 11 (18.6%) both. 12 of them had the loss before hospitalization and the loss of taste seemed to happen first.

Conjunctivitis (pink eye) may be another. In a small report posted on the JAMA network, Ping Wu et al found 12 out of 38 patients had COVID-19 induced conjunctivitis.

Although rare, neurological symptoms being the presenting signs have been reported – confusion, malaise, seizures, memory loss, headaches, dizziness, and even strokes. Ling Mao and his group published a paper on medRxiv in February about this. There have been case reports in the US from Boca Raton, Detroit, and Connecticut. The CDC warns to look for “new confusion or inability to rouse” as a sign. These neurological symptoms may be due to a possible infection of the brain by the virus.

A sore throat is another atypical symptom Guan highlighted in his NEJM paper.

Then are the body aches (myalgia), feeling of extreme fatigue and chills (rigor)

For clinicians, a rather ominous presentation to look for in patients is what Xie et al (Intensive Care Med, March 2020) call “silent hypoxemia”. These are patients with hypoxemia (very low oxygen saturation on pulse oximetry) but no visible signs of respiratory distress. They can suddenly go into respiratory failure.

The aim of this post is not to induce rampant hypochondriasis but to increase awareness about the disease and how it presents. If I have missed any atypical symptom(s) you may be aware of and a study or studies to back it (them), please let me know…and no anecdotes.

Stay safe, y’all!

Nana Dadzie Ghansah is an anesthesiologist who lives and works in Lexington, Kentucky

Feature photo: Modified image of Coronavirus by Jae Rue from Pixabay & CDC infographic page


A physician providing primary medical care to patients across the lifespan