A Peterborough man whose symptoms ebbed and flowed for nearly two weeks and is now recovering from suspected pneumonia. A health-care worker whose sickness started with an upset stomach and a strange inability to burp. And a Toronto man whose entire household is now sick with different symptoms and who temporarily lost his sense of taste — but never spiked a fever or developed a cough.
In the last month, these three people have all tested positive for COVID-19. They are now part of the province’s ballooning coronavirus case count, a grim tally that according to Star data reached 3,675 Friday when both laboratory-confirmed and probable cases are included.
While all three Ontarians share the same diagnosis, their experiences have been varied and not necessarily captured by the province’s online “self-assessment” tool for COVID-19, which emphasizes respiratory symptoms like cough, shortness of breath and fever.
In an outbreak where scarce test kits are being rationed and patients are increasingly asked to self-screen, the question becomes all the more crucial: what are the symptoms of “typical” COVID-19?
For Ontario patients and health-care workers now confronting the pandemic firsthand, the answer can be aggravatingly elusive.
“At the start of this illness (COVID-19), on the day you’re first symptomatic, it’s mild for almost everybody; you don’t suddenly have respiratory failure,” said Dr. Brooks Fallis, Division Head and Medical Director, Critical Care at William Osler Health System. “Those mild symptoms could be something else but it could also be COVID … People should be isolating themselves with any symptom of illness, any symptom at all.
“We have to behave the opposite of how we’ve always behaved in regards to illness; lots of people won’t progress to critical illness. But if everybody walks around with their mild illness and spreads it, then hundreds of thousands of people will be sick at the same time and the proportion that needs hospitals will be very, very large.”
“Mild” cases of the coronavirus are less concerning to the general public but infectious-disease experts know they are the accelerant that inflames this pandemic and spreads COVID-19 to patients who do end up on ventilators and inside hospital morgues. Collectively, mild cases make up the bulk of COVID-19 infections — the estimated 80 per cent that does not require hospitalization and ranges from asymptomatic cases to people who develop noncritical pneumonia.
Health workers who are now seeing mild COVID-19 cases are looking to a small but growing body of research for guidance on how to recognize symptoms of this new virus, which has only been known to the world for three months.
Currently, the largest and most influential report to characterize the disease is the World Health Organization-China joint mission, which examined more than 55,900 laboratory-confirmed cases. The report, released in February, concluded that fever is overwhelmingly the most common symptom amongst COVID-19 patients, reported in 88 per cent of cases, followed by dry cough (67.7 per cent), fatigue (38.1 per cent), sputum production (33.4 per cent) and shortness of breath (18.6 per cent).
Other flu-like symptoms — like sore throat, headache, muscle aches and chills — were also reported, along with nausea, nasal congestion, diarrhea and eye inflammation. But other reports that have since come out seem to muddy the waters.
A large study from China published in the New England Journal of Medicine found that only 44 per cent of patients had fever when admitted to hospital. A small report from Seattle, also published in the NEJM, found that cough and shortness of breath were the most dominant symptoms. A pre-print study from China examining 204 cases concluded that digestive issues “are common in patients with COVID-19” — but noted that this, too, required more scientific investigation before conclusions can be drawn.
These reports are biased toward the rhetorical tip of the iceberg — the sickest patients and people with laboratory-confirmed diagnoses. Far less is known about the cases that make up the bulk of this pandemic’s caseload.
Meanwhile, a growing number of small studies and anecdotal reports are streaming out of coronavirus hot spots warning of a variety of other potential symptoms including neurological symptoms and the sudden loss of taste or smell, all of which will require more rigorous research to tease out whether these are actually signs of COVID-19 or indicative of other infections that may be circulating simultaneously.
There is still so much we don’t know about a “typical” case, says Dr. Shaan Chugh, an internist with Trillium Health Partners, who is treating COVID while also planning his health centre’s strategic response.
“These patients most of the time will follow the fever, cough, shortness of breath — what we call respiratory symptoms — but I would say maybe 20 to 30 per cent of the time, they’ve come in with very odd presentations,” he said. “We had a patient who came in because he passed out and because they were old, we did a swab (for COVID-19) and it came back positive.
“These patients really do not follow a one-size-fits-all type of approach and can have really weird symptoms,” he continued. “As weeks are going by, we’re just learning more about this.”
For Daryl Chapman,he might have never identified his symptoms as COVID-19 when they started showing up in mid-March: sore throat, terrible headaches, body aches, inflamed eyes and milky vision. But he knew they were likely signs of a coronavirus infection because of a phone call from his employer several days earlier, informing him he’d been exposed to a confirmed case at work.
But Chapman never developed fever or cough — both widely considered to be signature symptoms of COVID-19. His wife and two daughters live in the same household and are also now sick, though none of them have had a fever either (while they don’t qualify for testing under current guidelines, they are presumed positive because of their symptoms and close contact with Chapman). Oddly, all four people in the house have experienced slightly different symptoms.
His most striking symptom, Chapman says, was one he had never heard about until recently: the sudden inability to taste any food.
“My wife had made homemade macaroni and cheese; it had consistency but no flavour,” he recalled. “And then I had ice cream too, it was chocolate ice cream. You couldn’t taste chocolate, you could just tell it was ice cream in your mouth.”
For Nadja, a Toronto-area health-care worker, strange gastrointestinal issues that suddenly began on the evening of March 11, two days after her return home from a trip to the U.K., were the first indication she was unwell.
“I can’t explain the feeling; it’s something I’ve never felt before,” said Nadja, 45, who asked the Star not to publish her last name because of her work in health care. “There was this pressure in my stomach, like I needed to figure out how to burp and I just couldn’t get it out.”
With her travel history, Nadja wondered if she had COVID-19 and Googled the virus to see if there was a link to gastrointestinal issues but didn’t find information that matched her symptoms.
But by Friday, Nadja had a scratchy throat, chills, headache and an unremitting cough. She continued to feel ill through the weekend, spiking a fever, and on Sunday went to the emergency department at Markham Stouffville Hospital, where she was tested for COVID-19. Eight days later, she would get a call from a Toronto Public Health nurse who confirmed she had the virus.
Nadja is relieved she recovered from COVID-19 with a mild form of the illness, though she stresses her symptoms were not those of a typical cold. She spent two days in bed, sweating and shivering, and couldn’t stop coughing. She also felt intense pressure in her sinuses and had swollen, itchy eyes, a sensation she tried to relieve with cool pressure from ice packs.
She wonders how many people are unaware they have COVID-19 because their symptoms range beyond those typically listed on public health websites. “The whole time I was self isolated, people didn’t think I had it because the symptoms weren’t matching what we were reading about.”
Dr. David Kaplan, a family physician at North York General Hospital, is monitoring about a half a dozen patients with presumed cases of COVID-19 by telephone and video conferencing. These patients, who so far have mild symptoms, currently do not qualify for a lab test, but are assumed to have the virus based on their illness and travel and personal histories.
“They’re calling to tell me they have a cough or fever after coming back from New York City or Iran or China or know someone who has the virus,” said Kaplan, an associate professor of family and community medicine at the University of Toronto. “So far, it’s been a lot of reassuring people, which family doctors are really good at. We know our patients, how they’ve responded to past illnesses; we’re uniquely suited to looking after patients who have mild symptoms.”
For Kaplan and other family physicians, it’s doubly challenging to learn about a new illness while treating patients remotely. A recent infographic in the medical journal BMJ outlines how physicians can monitor patients with the virus without face-to-face visits, even including tips on how to roughly estimate a person’s blood oxygen levels by video.
While many people with mild symptoms of COVID-19 recover well at home, some will need to seek hospital care. Kaplan is telling patients to monitor their breathing, advising them to go to an emergency department if they are unable to walk up a flight of steps or can only speak single words before having to draw breath. A deep, unrelenting fatigue or unexpected mental confusion are other cues to get to hospital, he said.
One of Kaplan’s patients is in hospital with a more severe case of COVID-19. He regularly checks in with that patient’s family to provide updates from the hospital and to care for the family members’ emotional health because they can’t visit due to recent hospital visitor restrictions. It’s something he expects he will do much more in the coming weeks and months.
Gabriel Huebsch, one of Ontario’s earliest confirmed cases and Peterborough’s second known patient, received support throughout his illness from public health workers, who checked in on him nearly every day.
The 36-year-old was exposed to COVID-19 on March 2, when he went to a friend’s house for a board game night. Huebsch spent several hours sitting next to the friend, who had recently returned from Spain and Portugal. A third person was also there and everyone shared chips from the same bowl. At this point, most people weren’t thinking about COVID-19; Ontario only had 18 confirmed cases, Peterborough had none.
Six days later, a heavy fatigue came over him; Huebsch went to a play and could hardly stay awake. The next day, he called in sick at work and noticed a heaviness in his chest, along with a terrible headache. At dinner, a salad his partner made for him triggered a strange reaction; it smelled revoltingly acrid, like ammonia.
They considered whether he might have COVID-19 but brushed it off. Six days later, he learned that his friend who had hosted the board game night had been confirmed as Peterborough’s first case. He was quickly contacted by Peterborough Public Health and soon tested positive as well. Curiously, his other friend from the board game night tested negative, as did Huebsch’s live-in partner.
What Huebsch finds most striking is the non-linear trajectory of his illness. Over two weeks, he felt sick, got better, but then developed increasingly serious respiratory symptoms like chest heaviness and “the worst breathing issues I’ve had in my life.”
“It’s the really bizarre up-and-down nature of it,” he said. “Where it feels like you’re getting better and out of nowhere, one individual symptom pops up.”
His doctor believes he developed pneumonia and one month after he got infected, Huebsch still feels occasionally winded. He now wants to share his story because he sees a lot of misunderstanding around what a “mild” case looks like and how seriously people should be taking this disease.
“There’s a huge gap between how scientists and reporters have communicated things, and what that data actually means. Early on when they were saying 80 per cent of cases are mild — what they meant was not requiring hospitalization,” he said. “For me, there’s a possibility that I have permanent lung damage. That’s crazy.”
For Chapman, he knows his case is “mild” but the word does not begin to capture the fear that now permeates his household. He wonders: What have I brought into my home?
“The pleading in your head starts. ‘Please don’t let her cough get worse.’ ‘Oh my God, my chest hurts, do I say anything? I don’t want them to be scared,’” he wrote in an email. “We do not have the worst of the symptoms and no one has had to be hospitalized but still there is a constant fear in knowing that it may still come. It is real, it is in our house.”
Are you a COVID-19 patient or front-line health worker who would like to share your story? Contact us at email@example.com and firstname.lastname@example.org
Jennifer Yang is a Toronto-based staff reporter. Follow her on Twitter: @jyangstar
Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie