What is the typical first symptom of COVID-19 (Coronavirus Disease 2019)?

First Symptom of COVID-19

The most common initial symptom of COVID-19 is fever, which occurs in approximately 92.8% of cases, followed by cough (69.8%) and fatigue. 1

Common Initial Presentation Symptoms

COVID-19 typically presents with a constellation of symptoms that may vary in frequency and severity:

• Fever (92.8%): The predominant initial symptom
• Cough (69.8%): Typically dry, non-productive
• Fatigue: Common early symptom
• Gustatory (88.8%) and olfactory (85.6%) dysfunction: These are strong predictors of COVID-19 diagnosis, even more so than self-reported fever 1

Regional Variations in Symptom Presentation

Interestingly, there are notable geographic variations in symptom presentation:

• Diarrhea: While the overall pooled prevalence is 7.7%, studies from countries outside China report a much higher prevalence (18.3%) compared to studies from China (5.8%) 2
• Nausea/vomiting: Similarly shows geographic variation with 14.9% prevalence outside China versus 5.2% in China 2

Symptom Clustering Patterns

COVID-19 symptoms can be categorized into four main groups:

1. No obvious symptoms: Asymptomatic cases
2. Mainly fever and/or dry cough: Most common initial presentation
3. Mainly upper respiratory tract infection symptoms: Including expectoration
4. Cardiopulmonary, systemic, and/or gastrointestinal symptoms: Including fatigue, headache, and digestive symptoms 3

Special Considerations

• Atypical presentations: Some patients may present with stroke or myocarditis as the first manifestation 2
• Age-related differences: Fever and bilateral pneumonia are significantly more common in patients ≥60 years old 4
• Disease progression: COVID-19 typically progresses through distinct stages, including early stage (0-4 days), progressive stage (5-8 days), peak stage (9-13 days), and absorption stage (≥14 days) 1

Laboratory Findings

Early laboratory indicators that may accompany initial symptoms include:

• Leucopenia
• Lymphocytopenia
• Elevated aspartate aminotransferase
• Elevated inflammatory markers (C-reactive protein, erythrocyte sedimentation rate)
• Elevated lactate dehydrogenase, creatinine, troponin I, fibrinogen and D-dimer 2

Clinical Implications

Understanding that fever is the most common initial symptom of COVID-19 is crucial for early identification and isolation of cases. However, clinicians should be aware that a significant proportion of patients may present with other symptoms first, particularly respiratory symptoms like cough or non-specific symptoms like fatigue. The presence of sudden loss of taste or smell should raise strong suspicion for COVID-19, as these are highly specific symptoms.