Long-Term Care Facility Residence Associated With Atypical Presentation of COVID-19

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Fever and cough are the most common symptoms of coronavirus disease 2019 (COVID-19), according to the US Centers for Disease Control and Prevention, but clinical manifestations vary and reports of hospitalized older adults with COVID-19 who do not experience the classic symptoms are on the rise.

Investigators with the University of Wisconsin School of Medicine and UW Health, a network of 3 acute-care hospitals, sought to compare the clinical course of disease and outcomes for patients reporting typical vs atypical symptoms, as well as identify what risk factors might lead to atypical presentation. Their findings from the retrospective cohort study were presented at the virtual ID Week 2020.

Using data on laboratory-confirmed COVID-19 infections logged between March 13 and May 13, 2020, the research team performed univariate analysis to compare atypical cases, defined as patients hospitalized for COVID-19-related reasons who presented without fever and cough, with patients who exhibited both symptoms.

Nearly a quarter (24%; 39/163) of hospitalized patients with COVID-19 who were included in the analysis presented atypically, and they were more likely to be older, reside in a long-term-care facility (LTCF), have underlying diabetes mellitus, stroke, cardiac disease, and deny myalgias or dyspnea, despite having no significant difference in the prevalence of hypoxia or radiological lung infiltrates.

Upon multivariate analysis, LTCF residence status was considered the only independent predictor of atypical presentation, which is noteworthy because of the risk of transmission within these facilities.

Aurora E. Pop-Vicas, MD, MPH, assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health, and presenting author of the study, spoke with Contagion® about the motivation behind the study and the context of the key findings

Contagion®: What was the impetus for this study?

Pop-Vicas: As we started admitting patients with COVID-19 infection to our hospital system in the spring of 2020 (first pandemic wave), we noticed that for some patients presenting with respiratory failure, the diagnosis of COVID-19 infection came as a surprise, as these patients had not experienced the typical symptoms of fever and cough prior to admission. Therefore, we wanted to learn more about the risk factors for and clinical outcomes of this subset of inpatients with a more atypical COVID-19 presentation—defined as lack of fever and cough.

Contagion®: What is the key takeaway for clinicians?

Pop-Vicas: We learned that long-term care facility residents—usually patients of advanced age with multiple comorbidities—are significantly more likely to have an atypical COVID-19 clinical presentation. This means that they present without fever, cough, dyspnea, or myalgias, although their incidence of severe pneumonia or respiratory failure is the same as for patients presenting with more typical symptoms.

Patients with atypical COVID-19 infection in our study were 3 times more likely to die of their infection compared with patients experiencing classic fever and cough symptoms. This finding highlights the importance of keeping a high index of suspicion for COVID-19 infection in long-term care facility residents, and the need for confirming the diagnosis in a timely manner with appropriate laboratory testing, rather than waiting for the onset of typical inflammatory-type symptoms, which may never happen in this patient population.

Contagion®: Are there plans for future research on this topic?

Pop-Vicas: Given the relatively small size of our initial cohort, we plan to validate these findings in a study of larger sample size, especially as we are now experiencing a higher surge of COVID-19 infections in the Midwest, and our hospitals are filling up. We would also like to look at transmission dynamics of COVID-19 infection in the long-term care setting, now that our diagnostic, therapeutic, and preventive modalities are advancing compared with the beginning of the pandemic.

The study, “Long Term Care Facility Residents Hospitalized with COVID-19 Infection Present with Atypical Symptoms,” was presented virtually at ID Week 2020.