reported in all age groups, both genders, and a variety of co-morbid conditions 26 . Our understanding of why certain patients will remain asymptomatic or have longer pre- symptomatic phases of infection remains unclear. Acutely symptomatic patients can present with a variety of symptoms, owing to the ACE2 receptor utilized by the virus to enter cells being expressed on tissues in nearly all organ systems of the body 19 . The most commonly reported include fever (77.4%-98.5%), cough (59.4%-81.8%), malaise (38.1%-69%), dyspnea (3.2%-55.0%), myalgia (11.1%-34.8%), sputum production (28.2%-56.5%), anosmia (25%), and headache (6.5%-33.9%) 27 . To a lesser extent sore throat (12%), arthralgia (11%), confusion (11%), dizziness (11%), and diarrhea (10%) have also been reported 27 . The prevalence of certain symptoms has evolved during the pandemic. For example, gastrointestinal symptoms including not only diarrhea, but also nausea, vomiting, and elevated liver function tests seem to have become more commonly reported in later phases of the outbreak 28 . When present, symptoms on average last approximately 8 days 27 . In patients with respiratory complaints, abnormalities on chest imaging are common. CT findings associated with COVID-19 are especially well described. Findings are typically bilateral, although unilateral abnormalities have been described particularly in mild cases or early in a patient’s course. Ground glass opacities and consolidation are the most common finding (94.5%); less common, but still frequently described findings include air bronchograms, linear opacities, interlobular septal thickening, bronchiectasis, pleural effusion, and nodules 29 . It is notable that these findings are non-specific and can be associated with a variety of disease processes, particularly other viral pneumonias. For this reason, the American College of Radiology does not recommend using CT as a first-line or diagnostic test for COVID-19 30 . As per NIH treatment guidelines 31 , moderate illness is defined as lower respiratory disease based on clinical assessment or imaging, but with SpO2 of greater than 94% on room air. Severe illness is defined as SpO2 <94% on room air, a respiratory rate of greater than 30 breaths per minute, PaO2/FiO2 of less than 300 mm Hg, or infiltrates in greater than 50% of the lung on imaging. Individuals who are aged 65 years or older or with comorbidities such as cardiovascular disease, chronic lung disease, chronic kidney disease, or diseases that affect the immunesystem(including diabetes) are considered at high risk for developing more severe illness 32 . One study estimates that 1 in 5 people of the global population, or 1.6 billion people, have at least one of these underlying conditions and are therefore at increased risk 33 . An updated list of medical conditions that increase risk or might increase risk for severe illness from COVID-19 is maintained by the CDC on its website 32 .
Furthermore, disparity among U.S. ethnic groups is also present withCOVID-19. AfricanAmerican/Black andHispanic populations are at higher risk of SARS-CoV-2 infection and COVID-19-related death. Though further study is needed to conclusively determine a cause, current data suggests this disparity is due to increased exposure risk and/or limited access to healthcare rather than increased susceptibility 34 . Numerous existing severity scores for community acquired pneumonia have been evaluated to assess their ability to accurately risk stratify patients with COVID-19. One retrospective study by Fan et al. compared A-DROP, CURB- 65, PSI, SMART-COP, NEWS2, CRB-65, and qSOFA, with the A-DROP scoring system being most accurate in predicting in-hospital death 35 . Modified severity scores have also been proposed to include expanded versions of A-DROP 36 , as well as entirely novel scoring systems such as the 4C Mortality Score or the COVID Inpatient Risk Calculator (CIRC). The 4C Mortality Score was developed in the UK, and includes 8 variables: age, sex, number of comorbidities, respiratory rate, peripheral oxygen saturation, level of consciousness, urea level, and C reactive protein. A score of 15 points or higher was associated with a mortality rate of 62%, and a score of less than 3 carried a mortality rate of 1%. The scoring system showed excellent discrimination and calibration, and by the authors’ analysis this system out performed previously developed CAP severity scores 37 . The COVID Inpatient Risk Calculator (CIRC) was developed by researchers at Johns Hopkins 38 . This model uses demographics, comorbidities, symptoms, vital signs, and a range of lab values todetermine the likelihood of a patient progressing to severe disease or death within 7 days of admission. For example, using CIRC, a 78-year-old Black man, with a history of MI and stroke, admitted from a nursing home with a fever, respiratory and constitutional symptoms, has an 18% chance of progressing to severe disease or death by day 4 of his hospital admission, and a 22% chance of progressing to severe illness or death by day 7 38 . A rare complication of COVID-19 has been Multisystem Inflammatory Syndrome in both children and adults, known as MIS-C and MIS-A respectively. This syndrome was first described in the UK when a small cluster of children began returning to the hospital 2-4weeks after initial infectionwith what appeared to be Kawasaki’s disease or toxic shock-like syndrome 39 . A broad range of symptoms were described, but most cases were associated with shock, cardiac dysfunction, gastrointestinal symptoms, and markedly elevated inflammatory markers. There were also reported cases that occurred during acute infection with COVID-19, and these patients tended to have milder associated symptoms 40 . Though fewer in number, similar cases have been described in adults. Similarly, adult cases tended to include shock, cardiovascular dysfunction, gastrointestinal symptoms, dermatologic, and neurologic manifestations. 7
Made with FlippingBook Digital Publishing Software