Recently, emerging studies have detailed new and uncommon manifestations of the novel coronavirus. Some describe eye-associated symptoms, such as conjunctivitis or red-eye, which was noticed since January, leading to suspicions that COVID-19 may be transmitted through the eye.

Later, the American Academy of Ophthalmology suggested a low “risk of spreading COVID-19 through tears, but the virus can cause conjunctivitis and may be transmitted by aerosol contact with the conjunctiva”.

Hopefully, these new studies will help ophthalmologists and other health workers around the world become aware and cautious regarding the ocular symptoms of COVID-19. In Indonesia, eye specialist Ferdiriva Hamzah has warned peers about this possible uncommon manifestation of COVID-19.

Another clinical feature found in a number of COVID-19 patients is a skin rash, which could mislead the diagnosis.

I believe there are still possibilities of unknown clinical manifestations related to COVID-19. This possibility poses a challenge for medical staff in handling COVID-19 in emergency and intensive care units, as it requires higher caution and vigilant of these new symptoms.

As a virus that had just been discovered at the end of 2019 and only found in Indonesia in February, it is certainly not easy to study the possible clinical manifestations in Indonesian society. This is mainly due to the lack of information or research so far, both domestically and internationally.

Unsurprisingly, there are many “missed” cases in emergency units because of the increasingly diverse symptoms that may be found in COVID-19 patients. Many COVID patients may come to the emergency room with no respiratory symptoms at all, making it hard to diagnose the patient.

One colleague cited a patient with a history of routine dialysis who came into the emergency room with shortness of breath. Shortness of breath in patients with kidney failure plus a history of dialysis is considered quite normal, so the patient was categorized as non-COVID but still handled with the standard precautions of using personal protection equipment (PPE), X-ray examinations and a swab. However, the patient’s swab tested positive!

This may be one of many stories that shows how complex the range of COVID-19 symptoms may have become.

The above example occurred in one of the referral hospitals for COVID-19 with adequate facilities. What if it happens in a hospital with limited facilities amid very limited PPE? Special attention must be paid especially to medical staff. At least, 24 physicians have died from COVID-19, as reported by the Indonesian Medical Association (IDI). Some of these doctors had tested positive for COVID-19, while others were patients under surveillance.

Also, there is a need for synergy between the government, related professional organizations such as IDI and physicians to stay cautious and always look for and disseminate the latest information regarding new and uncommon manifestations of COVID-19. The people also need to be encouraged to be honest in answering questions from medical staff; we suspect many are not forthcoming in describing their symptoms.

The public should not be afraid of the stigma surrounding COVID-19 because honesty assists health professionals in the process of handling and reducing the possibility of mistreating COVID-19 cases, which is now known to have such a variety of unique manifestations.

Let’s help all health professionals in facing such challenges each and every day to flatten the curve by doing everything we can, including by staying at home as well as physical distancing, maintaining self-hygiene and honesty in answering their questions. Open and reliable information is key to solving these mysterious new manifestations of COVID-19.

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Physician from Airlangga University (Unair), director of Kuliah Online

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