What is the likely diagnosis and treatment for symptoms of cough, congestion, fatigue, burning lips, and fever?

Likely Diagnosis and Management of Cough, Congestion, Fatigue, Burning Lips, and Fever

This symptom constellation—fever, cough, congestion, and fatigue with burning lips—most strongly suggests a viral respiratory infection, with COVID-19 and other respiratory viruses as primary considerations, and burning lips potentially indicating mucosal inflammation or early herpetic involvement.

Most Likely Diagnoses

Primary Consideration: Viral Respiratory Infection

• Fever, cough, and fatigue are the cardinal symptoms of COVID-19, with 92.8% of patients presenting with fever, 69.8% with cough, and fatigue being a prominent feature 1
• Nasal congestion occurs in approximately 4% of COVID-19 cases, though upper respiratory symptoms are common in other viral infections 1
• The "burning lips" symptom is unusual but may represent mucosal inflammation, early viral exanthem, or herpetic involvement that can accompany respiratory viral infections 2
• Influenza presents similarly with weakness (94%), cough (93%), and nasal congestion (91%), making it a strong differential 2

Alternative Considerations

• Acute bronchitis presents with productive cough, muscle aches, fatigue, and low-grade fever—matching most of this presentation except the burning lips 3
• Hand-foot-and-mouth disease (enterovirus) can cause fever, cough, nasal congestion, and oral lesions that may manifest as burning sensation around the mouth 2
• Measles presents with the "3 C's" (cough, coryza, conjunctivitis) plus high fever, though the rash typically follows rather than presents as burning lips 2

Immediate Diagnostic Steps

Clinical Assessment

• Characterize the lip symptoms precisely: vesicular lesions suggest herpes simplex or hand-foot-and-mouth disease; erythema suggests viral exanthem; crusting suggests impetigo 2
• Assess for respiratory distress: respiratory rate >30/min, SpO2 <90%, or dyspnea indicates severe disease requiring urgent evaluation 1
• Evaluate for red flag symptoms: persistent fever >5 days, hemoptysis, weight loss, purpuric rash, altered consciousness, or neck stiffness mandate urgent workup 2

Targeted Testing

• Obtain COVID-19 testing (PCR or rapid antigen) given the epidemiological context and symptom profile matching COVID-19 1, 2
• Chest radiograph is NOT indicated unless there are clinical features suggesting pneumonia (new focal chest signs, fever >4 days, dyspnea, vital sign abnormalities) 3
• Consider rapid influenza testing if within 48 hours of symptom onset and antiviral therapy is being considered 2, 4
• If vesicular lip lesions are present, consider HSV PCR or viral culture 2

Treatment Protocol

Symptomatic Management (First-Line for Mild Disease)

• Provide reassurance that viral respiratory infections are self-limited, typically resolving within 1-3 weeks 3
• Prescribe antitussive agents for cough relief: codeine 15-30 mg or dextromethorphan 30 mg every 6 hours 3
• First-generation antihistamine plus decongestant (brompheniramine/pseudoephedrine) decreases cough severity and hastens resolution in viral respiratory infections 3
• Naproxen has demonstrated benefit for cough in controlled studies 3
• Acetaminophen or ibuprofen for fever and myalgias (general medical knowledge)

Antiviral Therapy Considerations

• If influenza is confirmed and symptom onset is within 48 hours, prescribe oseltamivir 75 mg twice daily for 5 days, which reduces median time to improvement by 1.3 days 4
• COVID-19 antiviral therapy (nirmatrelvir/ritonavir or remdesivir) should be considered if high-risk features are present and within 5-7 days of symptom onset (general medical knowledge)

Specific Management for Burning Lips

• If herpetic lesions are suspected, prescribe acyclovir or valacyclovir (general medical knowledge)
• If mucosal inflammation without vesicles, recommend topical emollients and avoidance of irritants (general medical knowledge)

Isolation and Infection Control

• Maintain at least 1 meter distance from others and wear a mask 1
• Well-ventilated single room isolation if COVID-19 is suspected 1
• Clean and disinfect household articles using 500 mg/L chlorine-containing disinfectant frequently 1
• Practice respiratory hygiene: cover mouth and nose with tissue or sleeve when coughing, wash hands for at least 20 seconds 1

Follow-Up and Reassessment

If Symptoms Persist 3-8 Weeks (Post-Infectious Cough)

• Prescribe inhaled ipratropium bromide 2-3 puffs four times daily as first-line therapy for post-infectious cough 5
• Consider inhaled corticosteroids if cough adversely affects quality of life 5
• Prednisone 30-40 mg daily for 5-7 days may be used for severe paroxysms after ruling out asthma and GERD 5

If Symptoms Persist >8 Weeks (Chronic Cough)

• Reclassify as chronic cough and initiate systematic evaluation: treat sequentially for upper airway cough syndrome, then asthma, then GERD 5, 3
• Obtain chest radiograph to rule out persistent pneumonia, masses, interstitial disease, or congestive heart failure 5

Red Flags Requiring Urgent Re-Evaluation

• Respiratory distress, persistent fever >5 days, signs of dehydration, purpuric/petechial rash, or neurological signs 2
• Respiratory rate >30/min, SpO2 <90%, or PaO2 <60 mmHg indicates hypoxemic respiratory failure requiring immediate oxygen therapy 1

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics empirically—this presentation is viral, and antibiotics are not indicated unless bacterial superinfection is documented 3, 6
• Do NOT overlook COVID-19 testing in the current epidemiological context, as this diagnosis has significant public health and isolation implications 1
• Do NOT use nasal decongestant sprays for >3-5 days due to rebound congestion risk 5
• Do NOT dismiss the burning lips symptom—characterize it carefully as it may indicate herpetic infection requiring specific antiviral therapy or a viral exanthem with diagnostic significance 2
• Do NOT order chest X-ray reflexively—it is only indicated if pneumonia is clinically suspected 3