Focus on uncommon symptoms of COVID-19: Potential reason for spread of infection.

Focus on uncommon symptoms of COVID-19: Potential reason for spread of infection.

Dear editor

The coronavirus disease 2019 (COVID-19) pandemic continues to spread with more than 27 million cases and more than 896 thousand deaths so far [1]. India has confirmed more than 42, 84,100 cases of COVID-19 so far, making it the world’s second worst-hit country in terms of number of cases and third in terms of total deaths [1]. Presence of comorbidities worsens the outcome of disease and is associated with poor prognosis and increased mortality [[2], [3], [4], [5]]. The vaccine for the infection is in different phases of clinical trials and till then various drugs have been tried with questionable effects [[6], [7], [8], [9]]. SARS-CoV-2 infection can be asymptomatic or be associated with COVID-19, which presents with spectrum of respiratory clinical manifestations ranging from fever, dry cough, dyspnea, pulmonary edema, acute respiratory distress syndrome, and multiple organ failures, requiring hospitalization in intensive care unit and leading to death in severe cases. In the initial report of 138 patients from Wuhan, China, fever was present in 98.6%, dry cough in 60% and diarrhea and headache was present in 10% and 6% respectively [10]. The understanding of SARS-CoV-2 infection symptoms among general population is of upper respiratory tract infection with common symptoms of runny nose, fever, sore throat and breathing difficulty in severe cases. And hence the health authorities limited the testing to just those who reported with upper respiratory tract infection signs such as fever, sore throat, cough and breathlessness People are unaware of less common symptoms such as headache, nausea, vomiting, diarrhea, anosmia, and ageusia.

Literature has shown headache as the 5th most common COVID-19 symptom after fever, cough, myalgia, and dyspnea [11]. Headache in COVID -19 has been shown to be present in 6.5%–53% of patients in recent studies [12,13]. The striking features of the headache is sudden to gradual onset and poor response to common analgesics, or high relapse rate, that was limited to the active phase of the COVID-19 [14]. The prevalence of headaches in COVID-19 infection seems to be underestimated in terms of variety and clinical description because of the current focus has likely been directed toward severe respiratory patients.

Occurrence of gastrointestinal symptoms, including diarrhea in COVID -19 is not uncommon. In a systematic review and meta-analysis of 6064 patients of COVID-19 reporting gastrointestinal symptoms, the pooled prevalence of digestive symptoms was 15% (95% CI 10–21), the most common of which were nausea or vomiting, diarrhea, and anorexia. The authors report that around 10% of patients had no respiratory features but only presented with gastrointestinal symptoms when infected with SARS-CoV-2 [15]. In a large case series of 1141 patients admitted to hospital with COVID-19, 16% presented with gastrointestinal symptoms only [16]. The characteristics of gastrointestinal symptoms in COVID-19 are more insidious than the respiratory symptoms, making them easy to overlook and hence the presence of diarrhea should generate suspicion of a possible SARS-CoV-2 infection and should be investigated to reach an early diagnosis of COVID-19. The patients with diarrhea were more likely to have a delayed diagnosis, leading to potential problems for themselves and individuals with whom they came into contact.

Viral upper respiratory tract infection classically manifests as rhinorrhea, pharyngodynia, sore throat, nasal congestion, leading to conductive olfactory loss. Patients with COVID-19 can present with a sudden onset of anosmia without any other symptoms such as rhinitis or nasal obstruction [17]. In a retrospective study of 114 confirmed COVID-19 patients, 47% (n = 54) of patients presented with anosmia. Of these 54 patients, 85% patients had dysgeusia [18]. Incidence of olfactory dysfunction in COVID-19 patients varied widely among studies, with rates ranging from 33.9 to 68% [19,20]. In mid of April, Centers for Disease Control and Prevention (CDC) summarized and updated the most common symptoms of COVID-19, adding “new loss of taste or smell” to the list of symptoms [21]. Otolaryngologists should always be vigilant when dealing with patients with anosmia so as not to delay COVID-19 diagnosis.

India is currently reporting highest number of new cases of COVID-19 day-wise, globally with over 90000 new cases per day. Universal masking and social distancing is associated with a significantly lower rate of contracting COVID-19 [22]. Patients with fever and upper respiratory tract symptoms are easy to identify and are tested and treated, however patients with uncommon symptoms are more likely to have delay in diagnosis and becomes spreaders of the infection especially during mass gatherings. The worry for treating doctors is that people who have only these symptoms are not going to suspect COVID-19 and continue to take over the counter medications which will further delay the diagnosis and fuel the pandemic in a rapid and dangerous manner. Hence awareness about the uncommon symptoms of COVID -19 among population is important to fight the war against this global pandemic.

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On the behalf of all the authors in paper, I corresponding author hereby accept that there are no conflicts of interest.