What are the symptoms and treatment options for COVID-19, particularly in older adults or those with underlying health conditions such as diabetes, heart disease, or lung disease?

COVID-19 Symptoms

COVID-19 presents most commonly with fever (92.8% of patients), dry cough (69.8%), and loss of taste or smell (anosmia 85.6%, ageusia 88.8%), with the latter being stronger predictors of COVID-19 than self-reported fever. 1

Primary Symptoms

• Fever is the most common symptom, present in 88-93% of patients 2, 1, 3
• Dry cough occurs in approximately 70% of patients 1, 4
• Anosmia (loss of smell) is present in 85.6% of patients and is a stronger predictor of COVID-19 than fever 1
• Ageusia (loss of taste) occurs in 88.8% of patients and significantly differentiates COVID-19 from influenza 1
• Fatigue is reported in 38.5% of patients 1, 4
• Dyspnea (shortness of breath) is associated with severe disease (odds ratio 2.43) and occurs in approximately 45% of patients 2, 1

Secondary Symptoms

• Myalgia (muscle pain) is present in 27.7% of patients 1
• Sore throat occurs in 5-30% of patients 1, 3
• Headache is reported in 7-25% of patients 1, 3
• Nasal congestion occurs in 28.3% of patients 3
• Gastrointestinal symptoms (diarrhea, nausea, vomiting) are present in 6.1% of patients and may occur without respiratory symptoms 1, 4
• Rhinorrhea (runny nose) is present in 4% of patients 1

Disease Severity Classification

Mild cases (81%) are characterized by non-pneumonia symptoms including fever, cough, sore throat, and malaise without dyspnea or abnormal chest imaging 2, 1

Moderate illness (not specified percentage) involves lower respiratory disease with oxygen saturation ≥94% on room air at sea level 2

Severe cases (14%) are defined by: 2, 1

• Respiratory rate ≥30 breaths/minute
• Oxygen saturation ≤93% on room air
• PaO2/FiO2 ratio <300 mmHg
• Lung infiltrates >50% within 24-48 hours

Critical cases (5%) involve respiratory failure, septic shock, and/or multiple organ dysfunction 2, 1

High-Risk Populations Requiring Vigilance

Older adults and those with underlying conditions face substantially higher mortality risk. Patients with diabetes, cardiovascular disease, hypertension, chronic lung disease, or obesity have a two- to four-fold increase in mortality and severity compared to those without these conditions. 5, 6

Specific high-risk factors include: 2, 5

• Age ≥65 years
• Diabetes mellitus
• Cardiovascular disease
• Hypertension (present in 57% of hospitalized patients)
• Chronic kidney disease
• Obesity (BMI ≥30, present in 42-56% of hospitalized patients)
• Active malignancy on chemotherapy
• Immunocompromised state

Treatment Approach for High-Risk Patients

High-risk patients should receive nirmatrelvir/ritonavir (Paxlovid) 300 mg/100 mg orally twice daily for 5 days, initiated within 5 days of symptom onset, which demonstrates a 39% relative risk reduction in hospitalization and 61% reduction in death. 7

Remdesivir is indicated as an alternative antiviral for hospitalized patients or non-hospitalized patients with mild-to-moderate COVID-19 at high risk for progression, with a loading dose of 200 mg on Day 1 followed by 100 mg daily maintenance doses. 8

For hospitalized patients requiring invasive mechanical ventilation and/or ECMO, the recommended remdesivir treatment duration is 10 days; for those not requiring mechanical ventilation, 5 days is recommended, with possible extension to 10 days if clinical improvement is inadequate 8

Critical Clinical Pitfalls

• Do not dismiss isolated gastrointestinal symptoms (nausea, vomiting, diarrhea) as they can occur without respiratory symptoms and may precede typical COVID-19 symptoms 1
• Loss of taste and smell are significantly more common in COVID-19 than influenza and should prompt immediate testing 1
• Asymptomatic infection is possible, particularly in children, yet these patients can still transmit the virus 1
• Elderly patients may develop hypoxemia without respiratory distress, requiring careful monitoring of oxygen saturation 2
• Co-infection with influenza and COVID-19 is possible and can worsen outcomes 1

Timing Considerations

The median time from symptom onset to pneumonia development is approximately 5 days, and the median time to severe hypoxemia and ICU admission is 7-12 days 2