COVID-19 Pandemic: Clinical

Presentation, Diagnostics
David Krason, MD
Hospital Medicine / Infectious Disease / Infection
Control
Jiahui International Hospital
April 4, 2020
Agenda I. Introduction
II. Clinical Features
III. Diagnostics
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COVID-19: A new infection in humans

• December 2019: a mysterious new lung infection arises in Wuhan, Hubei

Province
• December 31, 2019: China informs the World Health Organization (WHO) of a
new virus causing pneumonia
• The new virus, a coronavirus, is named the SARS-CoV-2
• Coronavirus are a large family of viruses that are found in many animals,
including bats, cattle, and camels.

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SARS-CoV-2: Clinical Features

• Symptoms: overall highly variable: have high index of suspicion for isolation
and testing
• Asymptomatic infection is described and may represent a substantial portion
infections
• General/Constitutional:
o fever (99% over 99F in one study, but up to 40% afebrile on admission in

another)
o fatigue (70%)

o anorexia (40%)

o myalgias (35%)

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SARS-CoV-2: Clinical Features

• Pulmonary:
o dry cough (59%)

o dyspnea (31%)

o sputum production (27%)

o Look out for “silent hypoxemia” -- profound hypoxemia without respiratory

distress
o Also sudden, progressive hypoxia leading to urgent intubation

o ARDS present in all intubated patients

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SARS-CoV-2: Clinical Features

• Cardiovascular:
o arrhythmia (17% of all patients, 44% of ICU patients)

o cardiac injury/MI (7% of all patients, 22% of ICU patients)

o cardiomyopathy in 33% of patients

o Presence of shock highly variable (1%-35%)

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SARS-CoV-2: Clinical Features

• GI:
o anorexia, abdominal pain, diarrhea, N/V -- rare in early case series but

common (49%) in later ones

o often proceeds respiratory symptoms

o Anecdotally, many clinicians are seeing GI symptoms prior to or in absence

of other symptoms

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SARS-CoV-2: Clinical Features

• Renal:
o AKI initially appeared rare and mild but appears more common and more

severe in later studies, sometimes requiring CRRT

o commonly with proteinuria & albuminuria

• Neuro:
o encephalopathy, stroke

• HEENT:
o anosmia, altered taste

o conjunctivitis and chemosis

• Heme:
o thromboses, vasculitic symptoms

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SARS-CoV-2: Clinical Features

• Special populations:
• Children: symptoms also highly variable, but most common symptoms are:
o cough (48%)

o pharyngeal erythema (46%)

o fever (42%)

• Pregnancy: very little known, but small cases series without clear difference in
outcomes of mild disease or clear adverse impact on fetus/childbirth
o perhaps have less fever

o If you have a pregnant patient, please refer for the PRIORITY study to help

us learn more about symptoms & outcomes in pregnancy.

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SARS-CoV-2: Clinical Features

• Spectrum of disease:
o 81% mild/moderate, 14% severe, 5% critical in adults

o 4% asymptomatic, 51% mild, 39% moderate, 6% severe in children

• Course:
• Average 7 days from symptom onset to hospitalization
• Most admitted to ICU within 24hrs of admission and appear to have a
prolonged ICU course
• Long course of severe disease with average 25 days from symptom onset to
hospital discharge or 18 days from onset to death.

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SARS-CoV-2: Laboratory Findings

• Viral studies:
• RT-PCR:
• sensitivity is variable and appears low (51-67%) for single nasopharyngeal
PCR but increases with repetition
o Increased sensitivity with BAL (93%), sputum (72%) but caution as

aerosolization risk
o Quantitative monitoring of viral load may correlate with disease progression

• Serological tests:
o little data but early studies appear to show Ab titers inversely correlated

with viral load

o seroconversion generally occurring ~10d from symptom onset

• Combining PCR with IgM testing can significantly increase detection rate to
98.6%

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From: Detection of SARS-CoV-2 in Different Types of Clinical Specimens

JAMA. Published online March 11, 2020. doi:10.1001/jama.2020.3786

Table Title:
Detection Results of Clinical Specimens by Real-Time Reverse Transcriptase–Polymerase Chain Reaction

Date of download: 4/2/2020 Copyright 2020 American Medical

Association. All Rights Reserved.
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SARS-CoV-2: Laboratory Findings

• Blood counts
• Normal WBC with lymphopenia common
• Inflammatory markers
• Elevated inflammatory markers (D-dimer, CRP, IL-6, ferritin, LDH) common and
may be prognostic
o Elevated D-dimer, PT, LDH, IL-6, troponin, CRP, myoglobin more common in

severe disease
• Procalcitonin usually negative or indeterminate, may be elevated in
superinfection
o Small case series in children showed most (80%) with procal >0.05, though

unclear if due to COVID or coinfection.

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SARS-CoV-2: Laboratory Findings

• Chemistries
• Prevalence of AKI unclear with wide range reported (0.5-23%) but may be
more common than initially thought, sometimes requiring CRRT
o AKI is an independent risk factor for mortality

• Proteinuria in 44-67%
• Significant albuminuria in 33%
• Elevated LFTs may occur but typically not substantial hepatitis

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SARS-CoV-2: Imaging Findings

• CXRs with hazy, bilateral reticular opacities or GGOs; sensitivity variable, but
increased after 72hrs
• CT is highly sensitive (98%) but less specific than viral testing, shows
progression over disease course
o CT abnormalities prior to laboratory confirmation in 70%

• However, screening with CT not generally recommended due to nonspecific nature of

findings, radiation exposure, and resource utilization (e.g., disinfection times)
o Early in disease (including before symptom onset) may see unilateral,
multilobar, peripheral GGOs
• Progression to bilateral (90%), diffuse (50%) GGOs in most patients
o Consolidation with halo sign may be seen in pediatric patients.

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SARS-CoV-2: Imaging Findings

o Lesions predominantly bilateral, lower lobe > upper lobe

o Progression to multifocal consolidation, air bronchograms, traction

bronchiectasis, crazy paving appears to be correlated with more severe

disease
• Lung US findings include pleural thickening/irregular pleural lines, B lines, and
subpleural consolidations; seems more sensitive than CXR and less than CT
but need to capture a lot of lung area
o Butterfly Lung US training videos (no paywall)

o Ultrasound Leadership Academy lung US training (no paywall)

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SARS-CoV-2: Summary

• Incubation period is variable but a medium of 5 days

• Clinical presentation is commonly fever and respiratory symptoms, though
often variable with GI symptoms and anosmia, altered taste
• Broad spectrum of clinical presentation: mild to proinflammatory / cytokine
storm / ARDS
• Risk factors for severe disease: comorbidities, age, certain labs
• IgM and CT may be useful adjuncts for diagnosis.

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SARS-CoV-2: References

• References
• https://www.cdc.gov/coronavirus/2019-ncov/index.html
• https://www.nih.gov/health-information/coronavirus
• https://coronavirus.jhu.edu/map.html
• https://apollo.massgeneral.org/dept-medicine/covid-19/
• http://www.cidrap.umn.edu/covid-19

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