Confirmed Coronavirus Disease

Omaha Childrens Clinic follows CDC Guidelines.

Summary of Recent Changes

• New information on the potential for under-detection of occult hypoxemia by pulse oximetry, especially among persons with dark skin
• New information on dermatologic manifestations associated with COVID-19
• New information on prolonged shedding of replication-competent SARS-CoV-2 in severely immunocompromised persons
• New information on reports of reinfection with variant viruses

This document provides guidance on caring for patients infected with SARS-CoV-2, the virus that causes COVID-19. The National Institutes of Health (NIH) have published guidelines for the clinical management of the COVID-19external icon prepared by the COVID-19 Treatment Guidelines Panel. The recommendations are based on scientific evidence and expert opinion and are regularly updated as more data become available.

For guidance related to children with COVID-19, please see the Pediatric Considerations section below.

Clinical Presentation

Incubation period

The incubation period for COVID-19 is thought to extend to 14 days, with a median time of 4-5 days from exposure to symptoms onset. One study reported that 97.5% of people with COVID-19 who have symptoms will do so within 11.5 days of SARS-CoV-2 infection.

Presentation

The signs and symptoms of COVID-19 present at illness onset vary, but over the course of the disease many people with COVID-19 will experience the following:

• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

Symptoms may differ with the severity of the disease. For example, shortness of breath is more commonly reported among people who are hospitalized with COVID-19 than among people with milder disease (non-hospitalized patients). Atypical presentations of COVID-19 occur often, and older adults and people with medical comorbidities may experience fever and respiratory symptoms later during the course of illness than people who are younger or who do not have comorbidities. In one study of 1,099 hospitalized patients, fever was present in only 44% at hospital admission but eventually, 89% of patients had a fever sometime during hospitalization. Fatigue, headache, and muscle aches (myalgia) are among the most commonly reported symptoms in people who are not hospitalized, and sore throat and nasal congestion or runny nose (rhinorrhea) also may be prominent symptoms. Many people with COVID-19 experience gastrointestinal symptoms such as nausea, vomiting or diarrhea, sometimes prior to having fever and lower respiratory tract signs and symptoms. Loss of smell (anosmia) or taste (ageusia) has been commonly reported, in a third of patients in one study, especially among women and younger or middle-aged patients.

Dermatologic Manifestations

Dermatologic manifestations may be associated with COVID-19. Although the frequency remains unknown, reports have ranged from 0.2%, early in the pandemic, to as high as 20.4%. Association with disease severity and timing of skin symptoms among COVID-19 patients is unclear. The clinical presentation appears varied, though in a study of 171 persons with laboratory-confirmed COVID-19 (ranging from mild to severe disease), the most common skin manifestations reported were: a maculopapular rash (22%), discolored lesions of the fingers and toes (18%), and hives (16%). Among all study participants with COVID-19 and any skin manifestations, approximately 60% reported fever and/or cough.  Evaluating skin manifestations in COVID-19 patients remains challenging as symptoms can resemble a variety of other disease conditions. Additionally, COVID-19 treatments also may cause certain skin side effects. Images of cutaneous findings are available from the American Academy of Dermatologyexternal icon.

Asymptomatic and Presymptomatic Infection

Several studies have documented infection with SARS-CoV-2, the virus causing COVID-19, in patients who never have symptoms (asymptomatic) and in patients not yet symptomatic (presymptomatic). Since people who are asymptomatic are not always tested, the prevalence of asymptomatic infection and detection of presymptomatic infection is not yet well understood. Current data, based on reverse transcription-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 and on serologic studies, suggest asymptomatic infections can be common and that the total number of infections is likely greater than the number of cases reported. Patients may have abnormalities on chest imaging before the onset of symptoms.

Asymptomatic and Presymptomatic Transmission

Increasing numbers of epidemiologic studies have documented SARS-CoV-2 transmission during the presymptomatic incubation period.^{(19,28,29,32)} Studies using RT-PCR detection have reported low cycle thresholds, indicating larger quantities of viral RNA, among people with asymptomatic and presymptomatic SARS-CoV-2 infection. Likewise in viral culture, viral growth has been observed in specimens obtained from patients with asymptomatic and presymptomatic infection. The proportion of SARS-CoV-2 transmission due to asymptomatic or presymptomatic infection compared with symptomatic infection is not entirely clear; however, recent studies do suggest that people who are not showing symptoms may transmit the virus