They say the devil is in the details. In relation to COVID-19, a recent editorial in The BMJ explains how by focusing our attention only on cases with cough, fever or difficulty breathing, we fail to identify people with “unusual manifestations, such as patients without respiratory symptoms or only symptoms very slight.”
Just as until now the informative attention has focused on its impact on hospitals and the numbers of deceased people, much of the research has been aimed at understanding the clinical features of serious cases , their management in the ICU or the factors that predict a worse evolution.
We already know that the new coronavirus SARS-CoV-2, which causes this disease, damages not only the lungs and respiratory system, but most organs and systems.
Even with many gaps, we already know that the new coronavirus SARS-CoV-2, which causes this disease, damages not only the lungs and respiratory system, but most organs and systems, such as the brain , kidneys, liver, the digestive system, the immune system, blood coagulation, or the heart and blood vessels, whose involvement seems to be one of the keys to its effects on the body.
We also know that its rapid spread is due to an overwhelming ease of transmission from people who do not have symptoms (asymptomatic), from those who will have them in a few days ( presymptomatic ), or from those who have mild symptoms .
The experience of health centers
Similar to the wide clinical range of severe cases, the range of possible mild and moderate symptoms is very extensive. So much so that, as we see in the health centers, from where we have been following these patients for two months, they can go unnoticed.
In addition to cough, fever or difficulty breathing, which may not appear, other possible symptoms are diarrhea, nausea, vomiting, loss of appetite, sore throat, headache, pain or tightness in the chest, dizziness, runny nose, hoarseness, chills , discomfort, muscle pain, hives (skin reactions) and other skin lesions, loss of smell or taste, conjunctivitis, etc. Alone, or in any combination and intensity, for a handful of days or extending several weeks.
Other possible symptoms are diarrhea, nausea, sore throat or headache, dizziness, runny nose, skin lesions, loss of smell or taste, conjunctivitis, etc.
Most of them are possible in both adults and children and, sometimes, they worsen again after a few weeks of improvement, as if the virus suddenly gained strength again in some people.
Children who present symptoms usually have milder symptoms, shorter duration, less cough or fever than adults, and a high frequency of digestive symptoms , such as loss of appetite, vomiting, or diarrhea. Those who need hospital admission, both in the ward and in the ICU, are a minority . Even the recent alert about some serious childhood cases of shock suspected of being linked to this pathology are, for the moment, very exceptional.
In mid-March we began to notice that sudden loss of smell is common in adults and that, sometimes, it appears as the only symptom . At the end of the month and through informal communications from Italian doctors through social networks, we began to relate the presence of certain skin lesions to this disease, such as a type of chilblains on the feet and hands, or hives similar to those of some allergies. . In my limited experience, these lesions seem to occur late in the disease.
A few days ago El País reported the story of the first patient who overcame this disease at the 12 de Octubre Hospital. The article mentions that after leaving the ICU, she “shortly suffered an allergy, a dermatitis all over her body as a result of the sheets rubbing against her.” I wonder if that “allergy” could not have been another symptom of COVID-19, as the Italians first saw and we are seeing now .
Know how to see the symptoms
It is insisted that, to stop the spread of this infection, rapid detection of new cases, isolation of suspected and confirmed cases, follow-up of their contacts, large serological studies that give us an idea of the extension of possible immunity in the population and hygiene and physical distancing measures. But what is not talked about and what is also fundamental in the face of ’de-escalation’ is that health personnel and citizens must clearly identify the suspicious symptoms of this disease to take measures as soon as they appear.
Those with mild symptoms are advised to stay home, but a majority still believe that if you don’t have a cough or fever, it is not coronavirus. Nothing is further from reality
While part of non-essential industrial activity resumes, children are allowed out or precise dates are set for the de-escalation phases, those with mild symptoms are advised to stay home. But a large majority still believe that if you don’t have a cough or fever, it’s not coronavirus. Nothing is further from reality.
For example, research published in JAMA points out how, of 5,700 patients hospitalized for this disease in the New York metropolitan area, only a third had fever upon admission and that the rate of coinfection with other viruses (that is, of a simultaneous infection by more than one virus) was very low (2.1%). Therefore, we cannot be guided only by the presence of fever, nor can we attribute the presence of such varied symptoms to patients being infected by several microbes at the same time.
Cohabitants with very different symptoms
In these days when a large part of the population has not left home for weeks, it is striking that in the same family in which a member has very clear symptoms of COVID-19 (“the flu of a lifetime”) or has been admitted with a confirmed diagnosis, other cohabitants present at the same time, shortly before, or shortly after, very disparate symptoms.
For example, those of bronchiolitis in a baby, or some diarrhea and a sore throat “as if they were stabbing him with knives” in his father, or fatigue and lower back pain for a week in a 30-year-old brother, or a girl with snot that he does not want to eat, or a grandfather with discomfort and a fever, or a cousin with a dry cough for three weeks and who does not smell the bleach, or a teenager with a sensation in his throat “as if they were squeezing his neck ”, or a husband with no history of migraines with a mild headache for a few days, or a girlfriend with chest tightness, hoarseness, chills and fever, or a child with “chilblains” on his feet, etc.
These days without leaving home, it is striking that in the same family in which one member has clear symptoms of COVID-19 or a confirmed diagnosis, other cohabitants present very different symptoms.
It seems logical to think that, given that they have almost only been related to each other, the germ causing these varied symptoms is the same and that it has progressively infected several family members.
If you have presented similar symptoms during the last two months, it is very likely that you have suffered from this infection, which should not make you change your hygiene and physical distancing guidelines because, we cannot know with certainty, nor do we yet know if the immunity that left after infection can protect you from new infections and the virus being transmitted to other people.
In Spain, as in many other countries, the protocols under which we work still tell us that we should suspect COVID-19 in cases of acute respiratory infection , but that definition leaves out an immense range of possible presentations.
It is urgent to modify these criteria as we have more data because if not, many of these infections will continue to go unnoticed and new people will continue to be infected, some of whom will die. This is what the Centers for Disease Control and Prevention (CDC) have just done in the United States, adding some of these symptoms to the original triad of fever, cough and respiratory distress maintained until recently.
In addition, healthcare workers must have protective equipment (PPE) to care for patients with this entire spectrum of symptoms or, otherwise, we will continue to get infected and, likewise, some of us will die.
It is urgent to modify criteria as we have more data because if not, many infections will continue to go unnoticed
We currently do not have the capacity to perform enough reliable tests to confirm or rule out the disease in people who present symptoms, a problem common to much of the planet.
Therefore, in Spain, as in other regions of community transmission of SARS-CoV-2 (those in which the virus is widely distributed ), we should suspect a possible case of COVID-19 unless we can prove otherwise in the event of the appearance. of any symptoms of acute infection - not just respiratory symptoms - and act accordingly.
If these symptoms are mild, any of them would entail applying the home isolation, hygiene and physical distance guidelines recommended by health authorities for these cases.
COVID-19 suspicions
Practically and under the current circumstances, sore throat, pharyngitis, gastroenteritis or a cold are now also a suspicion of COVID-19 because its most likely cause is the new coronavirus. If we trivialize these pictures, we are lost. In Spain we have the advantage of not also needing to rule out diseases such as malaria or dengue, which are endemic in other territories and which produce symptoms, such as fever, common to all of them.
Infection with the new coronavirus should also be suspected in characteristic cases such as, for example, sudden loss of smell or taste, or the sudden appearance of skin lesions with no other apparent cause.
We are going to be much more mistaken if we ignore the plausible reality that the vast majority of these banal conditions are currently due to a coronavirus infection.
Next, you should call the health center to let us know, evaluate diagnostic alternatives, facilitate telephone follow-up of the patient and their contacts, or to ask questions and report any worsening conditions.
Until we have enough reliable diagnostic tests , these criteria mean that we will isolate some people whose symptoms could be caused by a different germ. But, on the one hand, in many of these cases isolation and hygiene would prevent infections from this possible alternative germ, such as the flu virus.
On the other hand, the pandemic is so widespread that we are going to be much more mistaken if we ignore the plausible reality that the vast majority of these banal symptoms are currently due to a coronavirus infection.
Call the doctor
We must also insist on the need to consult by telephone with your family doctors, pediatricians, or regular nurses about this or other illnesses you suffer from and to go to the emergency room if worsening, persistent fever, sudden loss of strength, severe pain occur. headache, or intense sensations of tightness or pain in the chest that could be masking serious illnesses such as sepsis, stroke , heart attack, or pulmonary thromboembolism.
Although a few million people may have already been infected in Spain , the vast majority of the population has not. That is to say, if as we leave home we do not rigorously follow physical distancing and hygiene measures, any new case can act like a match that is lit in a box full of matches.
It would help if primary care and public health were valued and strengthened, for science to guide the steps to follow, and for politics to avoid using the crisis as a throwing weapon.
In fact, the debate does not focus on whether there will be rebounds, which are guaranteed until we have an effective vaccine . They are already happening in Hong Kong, Singapore, or Taiwan, territories more accustomed to controlling these epidemic outbreaks than we are; and also in Japan and Germany . The key lies in being able to detect and stop them early so that the health system adequately cares for those who need it without having to confine ourselves to our homes again.
It would help if primary health care and public health were valued and strengthened, if politics avoided using the crisis as a weapon, if science guided the steps to follow and if the scientific community stopped considering COVID -19 as a respiratory disease because, although SARS-CoV-2 is transmitted through respiratory secretions and causes severe pneumonia, it is rather a systemic disease that can be expressed in multiple ways.
It is a priority that we all know this diversity so that we isolate ourselves at the slightest suspicion. The devil, indeed, is in the mild symptoms.
Aser García Rada is a pediatrician in Primary Care in Madrid, doctor of Medicine (UCM), actor and freelance journalist.
