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Symptoms of COVID-19: Acute vs persistent. A tally of acute and chronic effects of the virus.

photo by anastasia gepp courtesy of

Acute symptoms of COVID-19

CDC guidelines published July 17, 2020 state that 96 percent of laboratory-confirmed symptomatic cases of COVID-19 have one of these three symptoms: cough (84%), fever (80%), or shortness of breath (38% of patients not hospitalized.) 45 percent have all three.

Additional common acute symptoms: chills (63%), myalgia (muscle pain) (63%), headache (59%), fatigue (62%), rhinorrhea (runny nose) (51%), and sore throat. (Wired symptom guide, July 31, 2020.)

Less-common acute symptoms: congestion, runny nose, conjunctivitis (pink eye), and anosmia (loss of the sense of smell) (22%.) Gastrointestinal (GI) symptoms: nausea, vomiting (13%), diarrhea (38%), and abdominal pain. Skin symptoms: rash and discoloration of fingers or toes (“COVID toes”.)

Confusion was also reported by about 20% of patients (in the CDC article about persistent symptoms, below.) This may include such things as night-time delirium or nightmares, loss of orientation to time and place, and hallucinations. These symptoms were not included in many surveys but have been consistently reported by an unknown number of patients.

More serious symptoms: dyspnea (shortness of breath or difficulty breathing) (82% of hospitalized patients), cyanosis (bluish discoloration starting on lips), angina pectoris (chest pain or pressure), or paresis (weakness) and aphasia (inability to speak.)

In a “convenience sample” of 164 patients with symptoms, the CDC found the following percentages:

Each of the following symptoms was reported by >50% of patients: cough (84%), fever (80%), myalgia (63%), chills (63%), fatigue (62%), headache (59%), and shortness of breath (57%)… …. Approximately half of patients reported one or more GI symptoms; among these, diarrhea was reported most frequently (38%) and vomiting least frequently (13%). Among adult patients, shortness of breath was more commonly reported by hospitalized than by nonhospitalized patients (82% versus 38%). In contrast, new changes in smell and taste and rhinorrhea were reported by a higher percentage of nonhospitalized patients (22% and 51%, respectively) than hospitalized patients (7% and 21%, respectively).

Symptoms lasting more than a week

These are acute symptoms, those that occur within about two weeks (averaging 5 days) after exposure to the virus (SARS-COV-2)– but what about chronic or persistent symptoms? A CDC report dated July 31, 2020 on persistent symptoms and “delayed return to health” found a number of persistent problems.

About 65% of patients reported “returning to their usual state of health” an average of a week after being tested. Younger and previously healthy patients were more likely to recover quickly. Obese patients and those with psychiatric conditions had more than double the odds of a “delayed return to health.”

Cough (43%) and fatigue (35%) were the symptoms least likely to have resolved, but “[a]mong respondents who reported returning to their usual state of health, 34% (59 of 175) still reported one or more of the 17 queried COVID-related symptoms at the time of the interview.” (That is, they thought they were well, but on questioning, a third of them still had one of the symptoms.)

This sentence has been widely paraphrased to point out that COVID-19 is much worse than the flu:

Even among young adults aged 18–34 years with no chronic medical conditions, nearly one in five reported that they had not returned to their usual state of health 14–21 days after testing. In contrast, over 90% of outpatients with influenza recover within approximately 2 weeks of having a positive test result.

Symptoms lasting a month or more

Patients who are seriously ill and admitted to the hospital are in for months of illness and recovery. Being placed on a ventilator brings with it the side effects of being (therapeutically) paralyzed, in a (medically induced) coma, and not moving or being aware for however long is needed to recover one’s lung function.

These patients must go through extensive rehabilitation to regain muscle strength and re-develop mental capacities that are deeply impaired by the drugs needed to adapt the patient to ventilation.

We will leave aside these critically ill patients for a time, however, and concentrate on those who are merely sick enough to stay home and on the couch for a while. What about these patients?

The survey above only evaluated patients for three weeks after they had first been tested. What about really persistent symptoms? This article in talks about the phenomenon:

It is becoming increasingly apparent that many patients who recovered from the acute phase of the SARS-CoV-2 infection have persistent symptoms. This includes clouding of mentation, sleep disturbances, exercise intolerance, and autonomic symptoms. (See Tables 1 and 2 below) Some also complain of temperature dysregulation and lymphadenopathy.

Table 1: (general symptoms that persist)

  • Insomnia or frequent awakenings
  • Inability to concentrate and think clearly
  • Easy fatiguability [sic] despite normal lung function
  • Anorexia [loss of appetite] or increased appetite
  • Temperature dysregulation [being hot or cold inappropriately]
  • Lymphadenopathy [enlarged lymph nodes]
  • Dysautonomia [see symptoms below]

Table 2: (autonomic symptoms)

  • Tachycardia [rapid heartbeat] upon mild exercise or standing
  • Night sweats
  • Gastroparesis [loss of normal stomach contractions]
  • Constipation
  • Peripheral vasoconstriction [constriction of arteries and veins– resulting in cold hands and feet]

Most patients with persistent symptoms were not sick enough to be admitted to the hospital. Most had resolution of the more severe, acute symptoms mentioned above, but not all. Some are still sick more than 100 days after falling ill. Some are recovering and some are not.

Is this like myalgic encephalitis?

Some of the symptoms are reminiscent of another, poorly characterized syndrome called myalgic encephalitis or chronic fatigue syndrome (ME/CFS.) This syndrome has no known cause; most sufferers believe that the onset of their condition coincided with an acute viral infection, although it is difficult to pin this down since they usually aren’t diagnosed until months to years after their onset.

The “long haul” syndrome’s resemblance to ME/CFS may be purely coincidental, but the association with a viral illness is highly suggestive of some underlying causal similarity.

I have posted about the effects of the virus on the heart (more than 70% of mildly ill patients have hidden heart damage) and the brain (an unknown proportion of patients have hidden brain injuries.)

There may be additional, as yet untallied effects of the virus. These may relate to damage to the autonomic nervous system, the liver, kidneys, and gastrointestinal tract, and to other organs as well. No-one knows, but with the pandemic creating millions of patients, we are sure to find out over the coming months and years.

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