Complications

Complications table
ComplicationTimeframeLikelihood

acute respiratory distress syndrome (ARDS)

short termmedium

Reported in 15% to 33% of patients in case series.[20][21][37][109][136]

Children can quickly progress to ARDS.[15]

Factors that increase the risk of developing ARDS and death include older age, neutrophilia, elevated lactate dehydrogenase level, and elevated D-dimer levels.[272]

acute liver injury

short termmedium

Reported in 14% to 53% of patients in case series. Occurs more commonly in patients with severe disease.[273] Although data support a higher prevalence of abnormal aminotransferase levels in patients with severe illness, evidence suggests that clinically significant liver injury is uncommon.[274]

cardiovascular complications

short termlow

COVID-19 is associated with a high inflammatory burden that can cause vascular inflammation, cardiac arrhythmias, and myocarditis.[275]

Acute cardiac injury has been reported in 7% to 20% of patients in case series, and indicated by elevated cardiac biomarkers.[20][37][136][276] Prevalence is high among patients who are severely or critically ill, and these patients have a higher rate of in-hospital mortality. Patients with cardiac injury were more likely to require non-invasive or invasive ventilation compared with patients without cardiac injury.[277][278][279] Patients with underlying cardiovascular disease but without myocardial injury have a relatively favourable prognosis.[280]

Generally presents in two ways: acute myocardial injury and dysfunction on presentation; and myocardial injury that develops as the severity of illness worsens.[279]

Fulminant myocarditis has been reported.[263] Early corticosteroid therapy and immunoglobulin may be beneficial in these patients.[281]

Cardiomyopathy has been reported in 33% of critically ill patients. It is unknown whether it is a direct cardiac complication of COVID-19 or due to overwhelming clinical illness.[261]

Myopericarditis with systolic dysfunction has been reported in a patient without signs/symptoms of pneumonia 1 week after the resolution of upper respiratory tract symptoms, highlighting the need for strict monitoring of patients with a history of cardiovascular disease.[282]

Infection may have longer-term implications for overall cardiovascular health; however, further research is required.[283]

secondary infection

short termlow

Reported in 6% to 10% of patients in case series.[20][136]

acute respiratory failure

short termlow

Reported in 8% of patients in case series.[21]

Leading cause of mortality in patients with COVID-19.[263]

Children can quickly progress to respiratory failure.[15]

acute kidney injury

short termlow

Reported in 3% to 8% of patients in case series.[20][21][136]

septic shock

short termlow

Reported in 4% to 8% of patients in case series.[20][21][37][136]

A systemic inflammatory response syndrome (SIRS) can sometimes accompany viral sepsis. Elevations in inflammatory chemokines and cytokines have been reported in COVID-19 patients.[20][284]

Guidelines for the management of shock in critically ill patients with COVID-19 recommend a conservative fluid strategy (crystalloids preferred over colloids) and a vasoactive agent. Noradrenaline (norepinephrine) is the preferred first-line agent, with vasopressin or adrenaline (epinephrine) considered suitable alternatives. Vasopressin can be added to noradrenaline if target mean arterial pressure cannot be achieved with noradrenaline alone.[163]

disseminated intravascular coagulation

short termlow

Reported in 71% of non-survivors.[146]

Anticoagulant therapy with a low molecular weight heparin or unfractionated heparin has been associated with a better prognosis in patients with severe COVID-19 who have a sepsis-induced coagulopathy (SIC) score of ≥4 or a markedly elevated D-dimer level.[285]

pregnancy-related complications

short termlow

Retrospective reviews of pregnant women with COVID-19 found that women appeared to have fewer adverse maternal and neonatal complications and outcomes than would be expected for those with severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS). Adverse effects on the newborn including fetal distress, premature labour, respiratory distress, thrombocytopenia, and abnormal liver function have been reported; however, it is unclear whether these effects are related to maternal SARS-CoV-2 infection. No maternal deaths have been reported so far, but miscarriage (2%), intrauterine growth restriction (10%), and preterm birth (39%) have been reported.[54][55][57][176][286]

rhabdomyolysis

short termlow

Reported as a late complication in one case report.[287]

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