Covid-19: What it feels like

Toronto doc who has seen Covid-19 from the beginning: Most people have mild symptoms.

Diana Duong 5 minute read March 2, 2020

No one knows the novel coronavirus better than those who’ve seen it firsthand.

Sunnybrook Health Sciences Centre in Toronto was the first Canadian hospital to see cases of COVID-19. Internal medicine and infectious diseases physician Dr. Jerome Leis has seen it from the beginning. The first patient was confirmed on Jan. 25 and a second confirmed was confirmed on Feb. 26.

The first case was a 56-year-old man who started experiencing a fever and a dry cough a day after he returned from a three-month trip in Wuhan, China. He was brought to the emergency department by ambulance. Knowing his travel history, both ambulance and receiving hospital staff wore personal protective equipment (PPE). The patient had a history of well-controlled hypertension, and upon examination, showed signs of pneumonia in both lungs.

The day after hospital admission, he started experiencing a runny nose and coughed up specks of blood. His fever lasted for five days but otherwise, he was well. He did not end up requiring oxygen which Leis describes as “surprising at the time” because his chest X-rays showed significant abnormalities. He got better on his own and was discharged, where public health workers followed up with him at home.

We must remember the people with very mild symptoms are the majority of patients

The second patient, a woman in her 60s, presented to the emergency department with a cough, sore throat, body aches, the occasional fever, and an upper respiratory tract infection without pneumonia. She had returned from Iran just more than a week ago. Leis says her case was even less severe than the first case and did not require admission to the hospital. Public health officials were notified and she was instructed on how to self-isolate at home. 

Symptoms from least to most severe

The two relatively mild cases at Sunnybrook show there is a large spectrum of severity. “We must remember the people with very mild symptoms are the majority of patients,” he says. “The most severe symptoms are the minority.”

Least severe. These are people with barely any symptoms. Symptoms could be mistaken for the common cold, and could be so insignificant that patients don’t seek medical attention at all. Leis calls these ‘subclinical.’

More symptomatic.The most typical symptoms are respiratory, like dry coughs, sore throat, and fever. Leis says other symptoms like diarrhea are quite uncommon. “What’s challenging is those symptoms may be absent and will develop after a few days,” he says. “People can have really mild symptoms and then progress to the more classic respiratory symptoms.”

Localized infection without pneumonia. The next subset of patients have all of the above symptoms including localized infection to the upper respiratory tract without any pneumonia. This was the case with the second patient who was confirmed at Sunnybrook this week.

Infection with pneumonia. There are patients who develop a lower respiratory tract infection — i.e., pneumonia — but symptoms are still clearly very mild. Even though chest X-rays look significantly abnormal, they don’t feel shortness of breath, don’t require supplemental oxygen or any real any intervention. Leis says the first patient in Canada was the “perfect example” of this type of patient. “Although he was already on the spectrum of more severe disease, in the end, he did well for himself and the self-limited pneumonia got better on its own without requiring much medical intervention,” he says.

Most severe. These are patients who have pneumonia and develop shortness of breath, respiratory failure, and acute respiratory distress syndrome (ARDS). Patients are unable to breathe because there is inflammation and fluid filling up the air sacs in their lungs. The fluid and inflammation is caused by lymphocytes (the main immune cell against viruses) mobilizing into the lower part of the lung as a “very exuberant immune response to the virus.” Once ARDS develops, the mortality rate goes up significantly and the need for critical care and life support is increased.

Even with life support, there is a subset of people on a ventilator who will continue to fail and die of their illness,” says Leis. “Inflammation of the lungs can start to spread and affect other vital organs, like the kidney and liver. There are cases in literature of multi-organ failure. At that point, the mortality rate is extremely high.”

Early literature, including two studies from China that have done autopsy investigations on patients have suggested Covid-19 may have the same pathophysiology as SARS, where lymphocytes were also present on the lower lung on the autopsy of patients.

However, the mortality rate of Covid-19 is around 2%, whereas the overall fatality rate of SARS was around 10%. In comparison, MERS had a fatality rate of around 34% and Ebola, an estimated 50%.

Some of the predictors for a worse outcome include older age, chronic health conditions or co-morbidities, like cardiovascular disease and abnormal chest X-ray radiology images. “As seen in our first case, we learned that not everyone progresses,” says Leis.

What to do if you have symptoms

Those two cases were on the less-severe end of the spectrum and have improved on their own. Patients who are not progressing to worse outcomes are best managed with home isolation to minimize exposure and better utilize healthcare resources. Instead of entering a hospital where it’s crowded with teams of people, home isolation only requires one healthcare worker checking up on the patient.

Predictors for a worse outcome include older age, chronic health conditions or co-morbidities, like cardiovascular disease and abnormal chest X-ray radiology images

While most people believe that hospitals are the best place to get tested, but this is not the case. Leis reminds people to think of public health as a resource to help determine what your next steps should be if you think you may have the virus as opposed to adding to the patient burden in hospitals. For example,  If you are in Toronto, Leis recommends calling Public Health Ontario’s hotline (416-338-7600) to review symptoms by phone and receive instructions on how to self-isolate.

“We’re seeing a lot of people coming to hospitals who otherwise would not have gone to the hospital for such minor symptoms,” he says. “For public health reasons and for resource reasons, we need to change that model. It’s important that people understand public health is an excellent resource. We can do testing at home so people don’t need to come to the emergency department. This is important as the number of cases increases where we want to make sure we keep people at home who don’t need to be in the hospital.”

Diana Duong is a writer and editor at Healthing. Follow her on Twitter @dianaduo.