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Official reprint from UpToDate®

www.uptodate.com © 2022 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

The common cold in adults: Diagnosis and clinical

features
Authors: Daniel J Sexton, MD, Micah T McClain, MD, PhD
Section Editors: Mark D Aronson, MD, Martin S Hirsch, MD
Deputy Editor: Lisa Kunins, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2022. | This topic last updated: May 24, 2021.

INTRODUCTION

The common cold is a benign self-limited syndrome representing a group of diseases caused by
members of several families of viruses. It is the most frequent acute illness in the United States
and throughout the industrialized world [1]. The term "common cold" refers to a mild upper
respiratory viral illness. The common cold is a separate and distinctly different entity than
influenza, pharyngitis, acute bronchitis, acute bacterial rhinosinusitis, allergic rhinitis, and
pertussis.

The common cold is associated with an enormous economic burden as assessed by lost
productivity and expenditures for treatment [2]. A United States telephone survey conducted
between 2000 and 2001 indicates that about 500 million noninfluenza viral respiratory
infections occur yearly, resulting in estimated direct costs of USD $17 billion and indirect costs
of $22.5 billion annually [3].

The average incidence of the common cold is five to seven episodes per year in preschool
children, and two to three per year by adulthood [4]. Annual absences from school and work in
the United States due to colds caused 26 and 23 million lost days, respectively [2]. Colds
account for 40 percent of all time lost from jobs among employed people [1]. It is no surprise
then, that tens of millions of research dollars have been spent on ways to prevent and shorten
the course of the common cold. (See "The common cold in children: Clinical features and
diagnosis" and "The common cold in children: Management and prevention".)

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The epidemiology and clinical manifestations of the common cold are discussed here.
Treatment and prevention of colds are discussed separately. (See "The common cold in adults:
Treatment and prevention".)

VIROLOGY

Over 200 subtypes of viruses have been associated with the common cold. New viruses capable
of causing colds, such as the human metapneumovirus and bocaviruses, have been identified
using polymerase chain reaction (PCR) and pan-viral DNA microarrays (Virochip) technology. It is
anticipated that additional viruses that also cause the common cold will be identified.

Rhinoviruses, which include more than 100 serotypes, are the most common viruses associated
with cold symptoms and collectively cause 30 to 50 percent of colds. Coronaviruses cause about
10 to 15 percent of common colds. Viruses with marked seasonal variation, such as influenza
and parainfluenza, typically cause more systemic symptoms than other cold viruses; however,
they can rarely also cause illnesses similar to the common cold. Influenza virus causes about 5
to 15 percent of colds, and respiratory syncytial virus (RSV) and parainfluenza virus are each
responsible for about 5 percent ( table 1) [5-7]. (See "Epidemiology, clinical manifestations,
and pathogenesis of rhinovirus infections" and "Seasonal influenza in adults: Clinical
manifestations and diagnosis" and "Parainfluenza viruses in adults" and "Respiratory syncytial
virus infection: Clinical features and diagnosis".)

Adenoviruses and enteroviruses have also been associated with the common cold. Adenovirus
more commonly causes pharyngitis and fever than cold symptoms and may also cause
epidemics of lower respiratory infections in military quarters as well as severe lower respiratory
infections in immunocompromised patients. Infections caused by the enteroviruses (echo and
coxsackie) are frequently asymptomatic or produce an undifferentiated febrile illness, and thus
there may not be a causal association if isolated from a patient with a cold. Enteroviruses may
also be associated with distinctive clinical syndromes such as aseptic meningitis and pleuritis.
(See "Pathogenesis, epidemiology, and clinical manifestations of adenovirus infection" and
"Enterovirus and parechovirus infections: Clinical features, laboratory diagnosis, treatment, and
prevention".)

It is not possible to determine the likely viral pathogen on the basis of the observed clinical
illness; all of the above viral pathogens may cause similar symptoms. Parainfluenza and RSV are
more likely to cause cold symptoms in young children [1].

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Most of the respiratory viruses that cause colds are capable of reinfection after reexposure [1].
However, subsequent infections with the same or similar agents are generally milder and of
shorter duration [8]. The molecular and genetic basis for incomplete cross-protection following
infection with one strain is not fully understood. However, data from rhinoviruses suggest that
this may be due in part to a remarkable degree of structural and molecular variability, both
within serotypes and between the divergent field strains that frequently arise from a given
reference virus [9].

EPIDEMIOLOGY

Seasonal patterns — Seasonal patterns of infection can be observed for some of the viruses
that cause the common cold. Rhinoviruses and the various parainfluenza types typically cause
outbreaks of infection in fall and late spring, while respiratory syncytial virus (RSV) and
coronaviruses typically produce epidemics in winter and spring [1,5,10]. Enteroviruses most
often cause illness in the summer but can be detected throughout the year. Adenoviruses are
usually not seasonal, but outbreaks may occur in military facilities, daycare centers, and
hospital wards.

Transmission — Common cold viruses can be spread by three mechanisms [2]:

● Hand contact (via direct contact with an infected person or via indirect contact with a
contaminated environmental surface)
● Small particle droplets (droplet nuclei or aerosols) that become airborne from sneezing or
coughing
● Large particle droplets (droplet transmission) that typically require close contact with an
infected person

The importance of hand-to-hand virus transmission has been repeatedly demonstrated [11]. In
one classic study, volunteers were exposed to rhinovirus; 0 of 8 subjects became ill in the group
where fingers were treated with 2 percent aqueous iodine, compared with infection in 6 of 10
subjects in the control group [12].

Cold-inducing viruses may remain viable on human skin for up to two hours. The risk of person-
to-person transfer is dependent upon the amount of time people spend together, the proximity
of their contact with one another, and the amount of virus shed by the infected patient. (See
"Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections".)

Respiratory viruses including influenza and RSVs can be spread by both large droplet (classic
droplet transmission) and small droplet (also called droplet nuclei, or aerosolized particles),
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although the relative contribution of each particle type to overall spread of a given virus is
unproven [5,13]. (See "Respiratory syncytial virus infection: Clinical features and diagnosis",
section on 'Transmission and incubation period'.)

Viral spread from contaminated fomites is another mechanism of transmission. Rhinoviruses

may survive on environmental surfaces for several hours, thus allowing spread from contact
with contaminated surfaces [14,15]. Interestingly, porous materials such as tissues and cotton
handkerchiefs do not appear to support virus survival and thus secondary contact with these
materials is an inefficient mode of virus transmission [16]. Decontamination of environmental
surfaces with virucidal disinfectants such as phenol/alcohol may help decrease the rate of
transmission of cold-inducing viruses [14].

A randomized double-blind study of the effectiveness of various antibacterial home-cleaning

products failed to show a difference, compared with standard products, in the incidence of
respiratory symptoms among study patients [17]. This finding is not a surprise as antibacterial
cleaning products would not be expected to have an effect on viral pathogens. Despite these
negative findings, and the unresolved question of whether direct hand-to-hand contact or
droplet spread is the more important route of transmission, it is reasonable to assume that
proper disposal of nasal secretions and adequate handwashing will help to prevent the spread
of colds.

Unproven factors — The possibility that recirculating air in commercial airliners might
increase common cold transmission has been proposed. However, a study of 1100 United
States air passengers (53 percent aboard airplanes with recirculated cabin air and 47 percent
aboard aircraft with exclusively fresh air ventilation) found no difference in the postflight rate of
persons reporting a cold, runny nose or a constellation of eight other respiratory symptoms
[18]. While this single study does not definitively rule out the possibility that recirculating air in
airplanes increases transmission risk, it does indirectly support the contention that hand-to-
hand transmission is more important than droplet transmission.

Saliva is not an efficient means of spread of most cold viruses. Over 90 percent of people with
colds have no detectable virus in their saliva [1].

Period of infectivity — Studies that have involved experimental inoculation of subjects with
viruses causing the common cold have shown that peak viral shedding with rhinovirus occurs
on the second day of illness [19,20]. Viral shedding peaks on the third day of the illness after
inoculation, which coincides with a peak in symptoms. However, low levels of viral shedding
may persist for up to two weeks. Studies have also shown that nasal washings taken five days

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after onset of a cold illness can produce symptoms of infection when experimentally inoculated
into volunteers [19].

RISK FACTORS

Risk factors for the common cold include exposure to children in daycare settings; at-home
caregivers have greater risk of cold than those who work outside the home [4]. Psychological
stress increases the risk of colds [21], and moderate physical exercise decreases the risk [22].
Individuals who have less sleep and preexisting sleep disturbances may have an increased
susceptibility to cold virus infection [23].

There is no scientific basis for the popular notion that a cold climate increases susceptibility to
respiratory illness. As an example, investigators working in a research base in Antarctica noted
that the frequency of colds was equivalent in men after six months in the Antarctic and men
just arriving from the United States to begin their Antarctica residence [24].

Risk factors for increased severity of upper respiratory infection (URI) include [1]:

● Underlying chronic diseases

● Congenital immunodeficiency disorders
● Malnutrition
● Cigarette smoking

CLINICAL FEATURES

Symptoms of the common cold are largely due to the immune response to infection, rather
than to direct viral damage to the respiratory tract. Symptoms may substantially vary from
patient to patient; rhinitis and nasal congestion are most common. Other common symptoms
include sore throat, cough, and malaise. Fever is uncommon in adults with a cold but may be
present in children; conjunctivitis occurs variably in both age groups. The intensity and type of
symptoms of the common cold may also be related to host factors including age, underlying
illnesses, and prior immunological experience, as well as to the type of infecting virus [6].

The most common and characteristic initial symptoms are nasal discharge, nasal obstruction,
and a dry or "scratchy throat" [2]. Cough is common and tends to appear after the onset of
nasal discharge and obstruction. When present, cough often persists past the time that nasal
and throat symptoms resolve [25]. Although cough may be prominent and prolonged in some
patients, rales and signs of lower respiratory tract involvement typically are not present in

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adults. Fever, when present, tends to be low grade. Many patients also complain of sneezing,
malaise, headache, and pressure or discomfort in their ears and face.

Nasal discharge in patients with the common cold may be clear or purulent. Many patients and
clinicians erroneously place diagnostic importance upon the color of nasal discharge when
making decisions about antibiotic use [26]. In fact, colored nasal discharge is a normal self-
limited phase of the uncomplicated common cold. The presence of purulence alone cannot
distinguish between a cold and a sinus infection. (See 'Acute rhinosinusitis' below.)

Incubation period and symptom duration — The incubation period (from the time of contact
with infectious material until the onset of symptoms) for most common cold viruses is 24 to 72
hours, although in an experimental setting symptom onset can occur as early as 10 to 12 hours
after exposure [5]. Colds usually persist for 3 to 10 days in the normal host [1,5], although
clinical illness may last as long as two weeks in up to 25 percent of patients, particularly
smokers [2]. Cough can persist for weeks after resolution of other signs and symptoms [27].

DIAGNOSIS

The diagnosis of the common cold is clinical, based upon reported symptoms and/or observed
signs. Physical examination may reveal conjunctival injection, nasal mucosal swelling, nasal
congestion, and pharyngeal erythema. Adenopathy is typically absent or minimal; in the
absence of secondary bronchospasm, the lung examination is typically clear.

Several clinical scoring systems, such as the Wisconsin Upper Respiratory Symptom Survey
(WURSS) [28] and the Jackson cold scale [29], have been developed to differentiate viral colds
from other causes of respiratory illness and to quantitate illness severity. While commonly used
in clinical studies, they have inadequate sensitivity and specificity (85 and 44 percent and 81 and
66 percent, respectively) for use in clinical practice [30].

Radiologic studies are not routinely indicated. Chest radiograph to evaluate for lower
respiratory tract infection is indicated if the physical examination suggests signs of
consolidation or other parenchymal disease. Sinus radiographs or computed tomography (CT)
scan are not indicated; some form of mucosal abnormality on CT scan may be observed in as
many as 42 percent of asymptomatic individuals [31,32]. In one study of 31 patients with self-
diagnosed "colds" confirmed by viral culture, mucosal thickening or air-fluid levels of the
maxillary sinuses were found on CT scan within two to three days of symptom onset in 87
percent [33].

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Other than influenza-specific assays (when indicated by temporal epidemiology and clinical
symptoms), viral polymerase chain reaction (PCR) and bacterial cultures from nasal swabs or
washings are not generally indicated.

Although there are novel molecular assays for the detection of many common cold viral
pathogens, there are no targeted antiviral therapies approved for use in uncomplicated upper
respiratory viral infections in normal hosts.

Furthermore, detection of viral shedding does not necessarily correlate with clinical disease;
asymptomatic viral shedding, particularly with rhinovirus, is extremely common. For example,
up to 6 percent of asymptomatic adults and up to 35 percent of asymptomatic pediatric
patients have a positive viral PCR at any given time [34-36].

The potential benefit of nasal bacterial cultures was examined in a double-blind, placebo-
controlled trial involving 314 patients who presented with symptoms typical of the common
cold. Subjects were randomly assigned to receive five days of treatment with amoxicillin-
clavulanate (375 mg three times daily) or placebo [37]. Seventy-two of 300 patients who had
nasal aspirates performed had negative bacterial cultures, 167 had cultures that were positive
only for bacteria not responsible for respiratory infections, and 61 had cultures positive for
Haemophilus influenzae, Moraxella catarrhalis, or Streptococcus pneumoniae. Antibiotic therapy
benefited only those in the latter group; 27 percent of those in the latter group versus 4 percent
of placebo-treated patients had better symptom scores on antibiotics. Because the majority of
bacterial cultures of nasal discharge taken from patients with colds are negative or reveal
nonpathogenic bacteria, and because results of cultures are not immediately available to guide
treatment, we consider bacterial cultures of nasal secretions in patients with the common cold
cost-ineffective, impractical, and unnecessary.

The vast majority of patients who present with typical signs and symptoms of the common cold
do not require any laboratory testing. However, in rare situations where corroboration of a
presumed viral etiology of symptoms would be useful (eg, for patient education or
management of a particularly severe presentation), procalcitonin testing may provide
supporting evidence that a patient has a viral infection, thus avoiding unnecessary antibiotics
[38-40].

DIFFERENTIAL DIAGNOSIS

Although the common cold is usually diagnosed clinically and readily identified by symptoms,
several other conditions may mimic the common cold:

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● Allergic or seasonal rhinitis

● Coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2)
● Bacterial pharyngitis or tonsillitis
● Acute bacterial rhinosinusitis
● Influenza
● Pertussis

The common cold can be differentiated from simple rhinitis, by the presence of sore throat and
cough, and from bacterial tonsillitis, by the presence of prominent rhinorrhea and nasal
stuffiness. Patients with acute rhinosinusitis typically experience facial pain in conjunction with
purulent nasal discharge, while patients with influenza typically have a high fever, headache,
and myalgias. Pertussis in particular has experienced a marked resurgence [41] and may begin
with symptoms similar to the common cold. However, pertussis is also associated with
prolonged coughing, typically paroxysmal, and with vomiting and sometimes apnea. Pertussis
may present atypically, particularly in previously immunized adults, and the persistence of
severe coughing for more than two weeks is suggestive of pertussis. (See "Allergic rhinitis:
Clinical manifestations, epidemiology, and diagnosis" and "Evaluation of acute pharyngitis in
adults" and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis"
and "Seasonal influenza in adults: Clinical manifestations and diagnosis" and "Pertussis
infection in adolescents and adults: Clinical manifestations and diagnosis".)

Clinically differentiating common cold symptoms from SARS-CoV-2-19 infection is challenging,

as there is a high degree of variability in the presentation of COVID-19 and many symptoms
overlap with those of the common cold. Findings that may make COVID-19 more likely include a
history of exposure to someone with known SARS-CoV-2 infection, presence of anosmia or
ageusia, and progressive moderate to severe shortness of breath (see "COVID-19: Clinical
features"). However, given the clinical overlap between the two syndromes, testing for SARS-
CoV-2 in the setting of symptoms of the common cold is reasonable as long as SARS-CoV-2
transmission continues at moderate to high rates in local communities. (See "COVID-19:
Diagnosis", section on 'Whom to test'.)

COMPLICATIONS

Acute rhinosinusitis — Patients with the common cold may also develop acute rhinosinusitis.
Viral sinusitis occurs far more frequently than secondary bacterial sinusitis. Patients with acute
rhinosinusitis have purulent nasal discharge and nasal obstruction or facial
pain/pressure/fullness or both. However, these symptoms may also occur to a variable degree
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in patients with a simple common cold. The diagnosis of viral and bacterial acute rhinosinusitis
is discussed separately. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations
and diagnosis".)

Lower respiratory tract disease — Most patients with common colds do not have lower
respiratory tract signs or symptoms. However, certain pathogens that cause the common cold,
particularly respiratory syncytial virus (RSV) and parainfluenza virus, can also produce lower
respiratory tract findings. These findings can range from bronchitis, to bronchiolitis, to
pneumonia. For example, RSV is an important cause of lower respiratory tract disease among
children, older adults, and immunocompromised patients in addition to its ability to trigger
symptoms of the common cold [42-44]. (See "Respiratory syncytial virus infection: Clinical
features and diagnosis" and "Acute bronchitis in adults".)

Asthma exacerbation — Viral upper respiratory infections (URIs) have also been linked to up to
40 percent of acute asthma attacks in adults [45,46]. It is uncertain whether increased airway
hyperreactivity is the result of local inflammation caused by viral infection of lower airway
epithelial cells [47], or if infection is limited to the upper airway with inflammatory mediators
acting distantly in the lower airways. (See "Risk factors for asthma".)

Rhinovirus has emerged as the most frequent common cold virus associated with asthma
exacerbations. It is thought that the epithelial airway antiviral response to rhinovirus may be
defective in patients with asthma [48]. However, in a study that compared experimental
inoculation of rhinovirus in 20 subjects with mild persistent allergic asthma and 18 healthy
adults, there was no difference in peak cold symptom score, peak nasal viral titers, peak airway
flow, or measures of cellular and cytokine responses [49].

Rhinovirus-induced changes in airway reactivity may persist for up to four weeks following
infection [50]. These changes in airway reactivity may explain why some individuals develop a
persistent cough following upper respiratory tract infections. However, other causes of cough,
such as pertussis, should be considered when individuals develop persistent cough following a
presumed viral respiratory tract infection. (See "Pertussis infection in adolescents and adults:
Clinical manifestations and diagnosis".)

Acute otitis media — Viral URI often causes eustachian tube dysfunction; impaired clearance
and pressure regulation of the middle ear may then lead to acute otitis media [51]. Although
otitis media following URI is more common in children than adults, 50 to 80 percent of normal
adults developed eustachian tube dysfunction after they were experimentally exposed to
rhinovirus or influenza A virus [52]. In addition to inducing eustachian tube disturbance,
respiratory viruses can be isolated directly from middle-ear fluid, suggesting that viruses may

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also actively invade the middle ear and cause acute otitis media [53]. (See "Acute otitis media in
children: Epidemiology, microbiology, and complications", section on 'Viral pathogens'.)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Sinusitis in adults (The Basics)")

● Beyond the Basics topics (see "Patient education: Acute sinusitis (sinus infection) (Beyond
the Basics)" and "Patient education: The common cold in adults (Beyond the Basics)")

SUMMARY

● The common cold is the most frequent acute illness in the industrialized world, with two to
three episodes of illness per year in adults. (See 'Introduction' above.)

● Over 200 subtypes of viruses have been associated with the common cold. Rhinoviruses
cause 30 to 50 percent of colds but are also commonly found in asymptomatic subjects. It
is not possible to identify the likely viral pathogen on the basis of clinical symptoms. (See
'Virology' above.)

● The majority of upper respiratory infections (URIs) are transmitted by hand contact; cold-
inducing viruses may remain viable on human skin for up to two hours. Recirculated air on
commercial airplanes and cold temperature exposure do not seem to increase risk. (See
'Transmission' above and 'Risk factors' above.)

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● Symptoms of the common cold are largely due to the immune response to infection. Colds
usually persist for 3 to 10 days in the normal host, although clinical illness may last as long
as two weeks in up to 25 percent of patients. (See 'Clinical features' above.)

● With the exception of mild or early COVID-19 due to severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) infection, the diagnosis of the common cold is clinical, based
upon reported symptoms and/or observed signs. Sinus radiographs or computed
tomography (CT) scan are not indicated; some form of mucosal abnormality on CT scan
may be observed in as many as 42 percent of asymptomatic individuals. Molecular tests
for viral etiologies other than SARS-CoV-2 are not generally helpful or indicated for
uncomplicated disease. Cultures of nasal secretions are not practical or cost-effective to
identify patients with bacterial infection. Colored nasal secretions should not be
considered as evidence of secondary bacterial infection. (See 'Diagnosis' above.)

● Complications of the common cold may include acute rhinosinusitis, lower respiratory
tract disease, asthma exacerbation, or acute otitis media. (See 'Complications' above.)

Use of UpToDate is subject to the Terms of Use.

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Topic 6865 Version 29.0

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GRAPHICS

Viral cause of the common cold

Virus Estimated annual proportion of cases

Rhinoviruses 30 to 50 percent

Coronaviruses 10 to 15 percent

Influenza viruses 5 to 15 percent

Respiratory syncytial virus 5 percent

Parainfluenza viruses 5 percent

Adenoviruses <5 percent

Enteroviruses <5 percent

Metapneumovirus Unknown

Unknown 20 to 30 percent

Reproduced with permission from: Heikkinen T, Jarvinen A. The common cold. Lancet 2003; 361:51. Copyright ©2003
Elsevier.

Graphic 79871 Version 3.0

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Contributor Disclosures
Daniel J Sexton, MD Equity Ownership/Stock Options: Magnolia Medical Technologies [Medical
diagnostics]. Consultant/Advisory Boards: Magnolia Medical Technologies [Medical diagnostics]. All of the
relevant financial relationships listed have been mitigated. Micah T McClain, MD,
PhD Grant/Research/Clinical Trial Support: United States Department of Veterans Affairs Merit Review
[Tick-borne diseases]. All of the relevant financial relationships listed have been mitigated. Mark D
Aronson, MD No relevant financial relationship(s) with ineligible companies to disclose. Martin S Hirsch,
MD No relevant financial relationship(s) with ineligible companies to disclose. Lisa Kunins, MD No
relevant financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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