Clinical course of COVID-19: What GPs need to know

Evelyn Lewin

1/04/2020 3:32:44 PM

newsGP looks at the presenting symptoms, how the illness progresses clinically, and why patients deteriorate.

Experts warn patients with COVID-19 may appear to improve but can then experience a rapid deterioration later in the illness.

As the number of Australians with COVID-19 continues to climb, more information is being gathered regarding how the infection presents and what type of course it may run.
Presenting complaint
According to the Department of Health, the recognised symptoms of COVID-19 (coronavirus) currently include fever, shortness of breath, and flu-like symptoms such as coughing, sore throat and fatigue.
But Associate Professor Louis Irving, Director of Respiratory and Sleep Medicine at the Royal Melbourne Hospital, believes there are more possible presenting features of COVID-19.
One key feature may be asymptomatic carriage, he said. 
Others may include anosmia, reduced sense of smell or taste, altered taste, gastrointestinal symptoms and cardiac presentations, including new onset myocarditis, pericarditis or atrial fibrillation.
Gastrointestinal symptoms are such a common feature of COVID-19, they comprised the chief complaint in 48.5% of patients, a paper published in The American Journal of Gastroenterology on 20 March found.
That research examined 204 patients with COVID-19. Reported symptoms ranged from anorexia (83% of cases) to diarrhoea (29%), vomiting (0.8%) and abdominal pain (0.4%).
Of note, the paper reported patients without gastrointestinal symptoms were more likely to be cured and discharged than patients with the above symptoms (60% versus 34.3%).
How does the infection progress?
‘The clinical course is highly variable,’ Associate Professor Irving said.
‘Some patients spontaneously improve, and other patients deteriorate. The deterioration can be a few days, even a week later, rather than a stepwise deterioration from the time of presentation.
‘That’s the really tricky bit.’
Just as patients appear to be improving clinically, they can deteriorate rapidly.
‘And I think that’s one of the take-home messages: that the course is not reliable,’ Associate Professor Irving said.
Citing a message he received on social media reportedly written by an emergency physician in New Orleans, Associate Professor Irving said the writer claims to have seen ‘several hundred’ COVID-19 patients and writes down a possible course of the illness.
Associate Professor Irving said this is likely to be an accurate representation of the clinical course of COVID-19:

  • Day 2–11 post-exposure (on average, day 5) – the patient develops onset of flu-like symptoms. These commonly include fever, headache, dry cough and myalgia (mainly back pain), nausea without emesis, abdominal discomfort with some diarrhoea, anorexia, anosmia and fatigue.
  • Day 5 – The patient is likely to develop increasing shortness of breath due to bilateral viral pneumonia.
  • Day 10 – A cytokine storm may occur in those with severe manifestations of SARS-CoV-2, leading to acute lung injury (previously known as acute respiratory disease syndrome [ARDS]) and multi-organ failure.
According to the above source, 81% of patients experience mild symptoms, 14% have a severe disease requiring hospitalisation, and 5% of patients become ‘critical’.
Recent research supports these numbers.
The case series involving 138 patients in Wuhan, China, was published in JAMA Network on 7 February. It found the median time from first symptom to dyspnoea was five days, to hospital admission seven days, and to acute lung injury eight days.
Of the patients studied, 26% required admission to an intensive care unit (ICU), and 4.3% died.
According to research in The Lancet, patients with COVID-19 who tend to fare worse include those who are older, and those who have underlying comorbidities such as hypertension and cardiovascular disease.
Associate Professor Irving said it is currently unclear whether patients who undergo that rapid deterioration are those who had a more severe illness to begin with, or whether people with mild illness are as likely to go downhill.
‘I’d make the recommendation that all patients should be encouraged to report any worsening, even if they initially appear to be getting better,’ he said.
‘It has to be worded in a way that doesn’t scare the daylights out of them, but they shouldn’t be complacent.’
The reason patients with COVID-19 tend to have a late deterioration in their illness may relate to a sudden worsening of the lung disease itself, or as an immune reaction to a cytokine storm, Associate Professor Irving said.
Most patients who do not survive COVID-19 succumb to severe lung injury, Associate Professor Irving said.
‘What that means is the capillary bed and the alveolar spaces are damaged and inflamed. Their lungs become stiff and don’t exchange gas and they die a hypoxic death,’ he explained.
‘But it could be other pathologies, [such as] ongoing viral infection and even secondary pneumonia that’s not showing up, and obviously worsening of other comorbidities.’
However, Associate Professor Irving is keen to note the vast majority of patients with COVID-19 recover from the illness. He said there is obviously no data yet on long-term effects following COVID-19, but that the likely prognosis can be extrapolated based on similar respiratory illnesses.
Young, otherwise healthy patients who experience mild illness and recover are more likely to develop secondary bacterial infection in the three months following COVID-19.
Meanwhile, older patients are at increased risk of myocardial infarction for two years following this illness.
The minority of people who develop an acute lung injury and survive, or those who develop secondary bacterial pneumonia, may end up with permanent pulmonary fibrosis.
‘But the average person who gets a respiratory virus and recovers is likely to have no long-term sequelae,’ Associate Professor Irving said.
The RACGP has more information on coronavirus available on its website.
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Dr Gurvinder Singh Saini   2/04/2020 7:18:51 AM

I wonder what is the data on
1. post-infection immunity;
2. possibility of being silent carrier but still infective;
3. whether aerosol could be mode of transmission;
4. any correlation between initial inoculum load and outcome.

Dr Nicholas John Brodie Page   2/04/2020 7:31:29 AM

Yes Gurvinder Singh.
These four points are very important.

Dr KJ   2/04/2020 7:45:33 AM
This may start to answer some of your questions.

Dr David Pat Shui Fong   2/04/2020 7:54:16 AM

The linked article from the American Journal of Gastroenterology has been revised. Of the 204 patients admitted to Hubei (a province in China, including the city of Wuhan) with 'pneumonia of unknown cause' and confirmed to have COVID-19, 50.5% had gastrointestinal symptoms. But I don't think the article claims that in these 50.5% that GI symptoms are the *chief* complaint. Actually, in most of those patients, nausea was the only gastrointestinal complaint. The authors write that 18.6% of the total patients had a 'gastointestinal specific' symptom (excluding nausea alone).

The breakdown (on the last page, including patients with nausea):
47% (n = 97) : gastointestinal + respiratory symptoms
41% (n = 84) : respiratory symptoms, no GI symptoms
3% (n = 6) : GI symptoms, no respiratory symptoms
9% (n = 17) : neither respiratory nor GI symptoms

Dr Cho Oo Maung   2/04/2020 9:24:04 AM

I feel like - we are managing this crisis in wrong direction. If it is real Pandemic, a lot of people would die in 3rd world nations where tests is no affordable such as Lao & Myanmar. COVID-19 - a new strain of common cold. Do we normally test for common cold ?

In management, not only concentrate on Virus, but also need to focus on financial survival of the Nations. It should continue doing social distancing , Hand washing and self isolation at home if we have URTI symptoms until symptom free. If I were an authority, I would manage as :

1. All URTI Symptomatic people must isolate at home until 3 days of symptom free.

2. all Asymptomatic people run the Business as usual.
No need border closure. Let the flight fly in the sky with following social distancing rules and disinfecting the cabin with affordable fee for both parties.

Keep the testing criteria the same. Even though, we need to review Cost -Benefit analysis. By testing , how much change in management. If the management is not really change, should we still swabing for this new common cold= COVID -19. It is more Outrage than real Out break compare to Mortality of MVA or Annual Flu. Is it Biological Terror by Media ?

Dr Rosanna Devlet   2/04/2020 9:32:48 AM

Agree with above points

Dr Peter James Strickland   2/04/2020 12:52:05 PM

My immediate instinct clinically with those who are reasonably fit who develop Covid 19, but die quickly, is that they have developed acute viral myocarditis with acute left heart failure, and the "pneumonia" is possibly fluid in the lung from cardiac dysfunction as well a pneumonitis, and secondary to that heart failure. It is important here to have all patients who pass away to have a post-mortem and histopathology of their myocardium to exclude that possibility, as well as lung or other organ examination. This could also apply to the younger patients who die unexpectedly from this Covid 19. Experience tells me that viral myocarditis can be rapid in onset, and probably more likely to cause death quicker than pneumonia in the younger patients.

Dr Lee Anton Drury   2/04/2020 1:15:21 PM

Dr Maung - "all Asymptomatic people run the Business as usual" - I think the Americans started off down this route, and have backtracked sharply.

Dr Justine Mackie   2/04/2020 1:51:22 PM

What are your thoughts on what is the end game?
Coronavirus is going to be bouncing around international communities for years (especially developing countries), and vaccination is a long way off. Once we “flatten the curve”, when could we lift social distancing? I don’t see how we can?
Thanks for you alternative perspective Dr Cho Oo Maung. It’s important to consider the financial and economic livelihoods that are impacted.

Dr Katherine Frances Michelmore   2/04/2020 10:19:43 PM

Thank you for this summary regarding the clinical course of COVID-19, however I feel that an important part of "what GPs need to know" is in fact how to treat patients with confirmed or suspected COVID-19 symptoms. I recognize that there is no established clear guideline, but I have questions such as: Is treating my asthmatic patient with steroids likely to be of benefit with COVID-19? Could steroids increase the potential for development of pneumonia? Should we expand the use of LAMAs and LABAs? Are steroids recommended for patients with COVID-19 who don't have pre -existing asthma or COPD? What is the verdict on ibuprofen? Should all COVID-19 patients get antibiotics if they have a pre-existing respiratory condition?
I am concerned that as we progress with increasing numbers of cases of COVID-19, that more and more of our patients will need to be managed at home and the advice on how to do this is lacking.

Dr K Fonseka   3/04/2020 9:25:55 AM

The above article states "According to the above source, 81% of patients experience mild symptoms, 14% have a severe disease requiring hospitalisation, and 5% of patients become ‘critical’.
This is rather misleading. What we have here is a virus that is highly infective but causes minimal or no symptoms in the majority of the population. Therefore I would hazard a guess that for the each confirmed case that was used in the above calculation 10 other people would have been infected but suffered minor or nil symptoms and not diagnosed.
Only time and a lot more testing will tell.

Dr Louise Frances Ragg   5/04/2020 12:04:01 PM

Dr Katherine Frances Michelmore thankyou for your comment, I totally agree. I feel like we need more practical on the ground training now, to look after these patients, eg. if a pt calls and says they are deteriorating, how do we safely assess them? How do we safely palliate pts dying of Covid-19 in their homes - assuming this will happen before to long in the elderly population? Especially those that have had the foresight to write an advanced care plan: "do not call ambulance, do not take me to hospital..."