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Rapid response to:


Clinical features of covid-19

BMJ 2020; 369 doi: (Published 17 April 2020) Cite this as: BMJ 2020;369:m1470

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Rapid Response:

Re: Clinical features of covid-19

Dear Editor,

Re: Clinical features of covid-19

In response to ‘The wide array of symptoms has implications for the testing strategy’. We concur with the authors that we are missing common symptoms of mild or early covid-19 infection. We note a specific ‘tertian’ pattern of illness in more prolonged cases with symptom clusters which go far beyond the cough, fever and shortness of breath required for testing.

We have noticed many people with mild presentation only complain of a throat symptom. This is expressed in unusual but consistent terms: “a dry throat”, “as if going to get a cold but didn’t” or “a weird throat”. This is usually followed by, “it’s not a sore throat.” This symptom appears to be common and may represent the only manifestation of infection. These may represent some of the many mild cases we are missing.

In more prolonged cases (weeks) where gradual clinical recovery occurs, we have observed a periodic pattern of recurrence every three days, like the ‘tertian fevers’ of some forms of malaria. In these cases, people seem to get lesser recurrences of their original symptom clusters.

We agree with the authors that the range of symptoms commonly seen are much wider than the original definition and should prompt testing so as not to miss cases.

We note

-headache which is often occipital and associated with spinal pain

-retrosternal tingling/pain


-diarrhoea and colicky abdominal pain, which may present without the cough.

These wider symptoms will hopefully soon be recorded in national public information sources.

Competing interests: No competing interests

19 April 2020
Clare R Rayner
Occupational Physician
Amali U. Lokugamage (obstetrician and gynaecologist, London)
North-West England