• Hugo Creeth

What illnesses does COVID-19 cause?

Coronaviruses infect the lungs and airways. Most people with COVID-19 have mild disease and never require hospitalisation. For people who develop severe disease, pneumonia is the most common form of illness. Acute COVID-19 disease is harmful because it prevents the normal passage of oxygen from the lungs into the bloodstream.

Coronaviruses enter the human body by being inhaled or via direct touch to the mouth, nose and eyes. They bind to and infect the cells lining the upper and lower airways and lungs. On average, symptoms will develop five days after infection, but this can range from two to 12 days. The time between infection and symptoms developing is called the incubation period. In an unknown number of people, the infection may resolve itself without the individual experiencing any symptoms at all.[2] This is probably due to a fast and effective response by the immune system.

Initial symptoms

Symptoms generally occur after the virus causes direct damage to the cells of the airways and lung, or when the virus triggers an immune response. Irritation of the airway produces a sore throat and cough and sometimes a blocked or runny nose. A cough is a reflex to clear the airway of perceived phlegm, though COVID-19 usually produces a dry cough.

As part of the immune response to infection, signalling molecules called cytokines are produced. Cytokines help to mediate immunity through communication between cells, but they can also have a number of adverse effects during the course of illness. They contribute to fever and fatigue, muscle aches, headache and a loss of appetite. Diarrhoea, nausea and vomiting are rarer but may occur when the virus is present in the gut. The duration of symptoms ranges from one to three weeks depending on the severity of illness.


About 80% of people with COVID-19 have mild disease and never require hospitalisation. For those who do develop more serious illness, it is most frequently a form of pneumonia.

This is where the body’s immune system fighting the virus causes inflammation and damage in an area of the lung. These areas are visible on X-ray or computerised tomography (CT) scans as white patches.

In COVID-19 pneumonia usually appears in patches in the lower parts or outer edges of both lungs. Even in people without symptoms, pneumonia sometimes shows up on CT scans.

In most cases of COVID-19, the pneumonia resolves completely, often without serious illness. However, sometimes the pneumonia can worsen, causing severe disease.

Severe disease

One of the defining features of severe disease is shortness of breath. When pneumonia extends to a large enough area in the lungs, it prevents the lungs from functioning normally so less oxygen can enter the blood. The body responds by breathing faster and this is experienced as feeling short of breath. At lower oxygen levels, the affected person can look and feel drowsy. Nurses and doctors look out for severe disease by measuring breathing rate and oxygen levels in the blood. Severe disease should be identified early because patients may need hospital treatment, rather than having to self-isolate at home. Among severe cases, approximately one in ten will not survive.

Acute respiratory distress syndrome (ARDS)

In a proportion of patients with severe disease, the virus over stimulates the immune system, rapidly causing damage to the gas exchange sacs in the lung. These sacs start to leak and fill up with fluid, which prevents oxygen from passing into the blood or waste gases from passing out. ARDS is usually detected because the individual becomes severely unwell over just a few hours. Doctors can use a chest X-ray or scan to identify ARDS because they often show changes that are distinct from those caused by pneumonia.

Injury to the heart

In critical illness with COVID-19, the heart can be affected too. In the worst cases of this infection, the heart may be damaged but it is not yet known whether this is due to direct effects of the virus or to the body’s response to the presence of virus in the lungs.

Injury to the Brain?

There is emerging evidence that when it comes to the brain and nerves, the virus appears to have four main sets of effects:

  1. A confused state (known as delirium or encephalopathy), sometimes with psychosis and memory disturbance.

  2. Inflammation of the brain (known as encephalitis). This includes a form showing inflammatory lesions – acute disseminated encephalomyelitis (ADEM) – together with the effects of low oxygen in the brain.

  3. Blood clots, leading to stroke (including in younger patients).

  4. Potential damage to the nerves in the body, causing pain and numbness (for example in the form of post-infectious Guillain-Barré syndrome, in which your body’s immune system attacks your nerves).

To date, the patterns of these effects seem similar across the world. Some of these illnesses are fatal and, for those who survive, many will bear long-term consequences.

This raises an important question: will COVID-19 be associated with a large epidemic of brain illness, in the same manner that the 1918 influenza pandemic was linked (admittedly somewhat uncertainly) to the epidemic of encephalitis lethargica (sleeping sickness) that took hold until the 1930s? At this stage, it’s hard to say but as the evidence becomes clearer we will begin to find out more.

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