Non-respiratory tract symptoms associated with COVID-19

College of Physicians and Surgeons of Alberta CPSA

AHS’ COVID-19 Scientific Advisory Group (SAG) recently investigated the latest evidence from around the world pertaining to a key topic: Non-respiratory tract symptoms associated with COVID-19

While COVID-19 is generally considered an influenza-like illness (ILI) affecting the respiratory tract, there is frequent news coverage of atypical presentations, including rashes (‘COVID toes’), gastrointestinal illness, and other manifestations in most systems of the body. Although the body of evidence concerning these atypical presentations is relatively large, it is of low quality and mainly consists of case reports and small studies.

Pragmatic Considerations

  1. Clinicians should be aware of the many manifestations of COVID-19 and consider the possibility of COVID-19 even in the absence of ILI symptoms to ensure appropriate investigation of differential diagnoses. Knowledge of the local community prevalence will influence the likelihood that a particular non-respiratory presentation may be COVID-19 related. (More details and references describing manifestations such as stroke, Kawasaki disease, and rashes are in the review)

Rationale: There appears to be associations between COVID-19 and afflictions of most major body systems, however the relative likelihood of many of these presentations seems low given the low numbers of cases reported compared to the worldwide burden of COVID-19 disease. Currently patients in Alberta presenting for hospital care without symptoms typically thought to be consistent with COVID-19 are still unlikely to have COVID-19, based on a recent Alberta screening pilot involving all patients admitted through the Emergency Department in 3 hospitals, screening revealed no SARS-CoV-2 infections in over 1600 cases.

  1. The risk of transmission in non-respiratory presentations of COVID-19 would be related to both the type of interaction or procedure, and the phase of illness of the patient (for example, an immunologically mediated rash presenting after or in the absence of antecedent respiratory symptoms would be unlikely to be associated with transmission of infection.)

Rationale: Patients may present with COVID-19-related complaints in the absence of fever and cough, but could potentially still transmit infection – however, some multisystem COVID-19 manifestations may be inflammatory or immune responses to infection, in which case transmission risk would be expected to be low. In addition patients without “droplet generating” respiratory symptoms are less likely to transmit infection. Although gastrointestinal symptoms are relatively common, there have been no cases of confirmed through the fecal oral route.

To see the complete list of Rapid Response Reports, please check the COVID-19 Scientific Advisory Group website. New reports and updates appear here on a daily basis.