What percentage of COVID-19 (Coronavirus Disease 2019) cases present with fever?

Fever Prevalence in COVID-19 Cases

Fever is present in approximately 58.6-77% of COVID-19 cases, making it the most common symptom of the disease. 1

Clinical Presentation of COVID-19

Common Symptoms by Frequency

• Fever: 58.6-77% 1
• Cough: 41-67% 1
• Fatigue: 20.3-50% 1
• Breathlessness/dyspnea: 37-49.3% 1
• Gustatory dysfunction: 88.8% (strong predictor of COVID-19) 2
• Olfactory dysfunction: 85.6% (strong predictor of COVID-19) 2

Gastrointestinal Symptoms

• Diarrhea: 7.7% overall prevalence 2
  • Higher prevalence outside China (18.3%) compared to within China (5.8%) 2
• Nausea/vomiting: 14.9% outside China versus 5.2% in China 2
• Abdominal pain: 6.6-8.8% 1

Variations in Fever Presentation

Factors Affecting Fever Presentation

• Geographic variations: Similar to GI symptoms, fever prevalence may vary by region
• Patient populations: Immunocompromised patients (e.g., those with hematological malignancies) may present with atypical symptoms 1
• Age: Elderly patients might develop hypoxemia without fever or respiratory distress 1
• Medication use: Patients on IL-6 inhibitors or JAK inhibitors may have masked fever due to decreased acute phase response 1

Disease Severity Distribution

• Mild: 81% of cases 2
• Severe: 14% of cases 2
• Critical: 5% of cases 2

Special Considerations

Immunocompromised Patients

Patients with hematological malignancies may present with a higher rate of fever (58.6-77%) compared to the general population, but can also have atypical presentations 1. These patients have a higher risk of severe disease and mortality.

Pediatric Patients

• Up to 45% of children may be asymptomatic 2
• In pediatric patients with cancer, fever is present in 52-58% 1

Elderly Patients

Elderly patients might develop hypoxemia without fever or respiratory distress, making diagnosis more challenging 1. This "silent hypoxemia" requires vigilance in assessment.

Clinical Implications

Diagnostic Value

While fever is the most common symptom, gustatory (88.8%) and olfactory (85.6%) dysfunctions are stronger predictors of COVID-19 diagnosis than self-reported fever 2. This is important for clinicians to recognize when evaluating patients with suspected COVID-19.

Disease Progression

COVID-19 typically progresses through distinct stages 2:

• Early stage (0-4 days)
• Progressive stage (5-8 days)
• Peak stage (9-13 days)
• Absorption stage (≥14 days)

Pitfalls to Avoid

1. Relying solely on fever for diagnosis: Up to 23-41% of patients may not present with fever, particularly in early disease
2. Overlooking atypical presentations: Especially in elderly or immunocompromised patients
3. Medication masking: Certain medications (NSAIDs, cytokine inhibitors) may mask fever 1
4. Geographic variations: Be aware that symptom prevalence varies by region 2

Conclusion

While fever remains the most common symptom of COVID-19 (58.6-77% of cases), clinicians should be aware that a significant proportion of patients may not present with fever. Olfactory and gustatory dysfunction may be more reliable diagnostic indicators. Special attention should be paid to vulnerable populations like the elderly and immunocompromised, who may present atypically.