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Background: Symptom recognition is necessary to identify people with possible Covid-19 Clinical case definitions vary in type and number of symptoms included No large studies have investigated how these perform for hospitalized patients of different ages and sex Methods: We used international prospective observational data from patients admitted to hospital with laboratory-confirmed Covid-19 We investigated how symptoms varied by age and sex We performed logistic regression to assess the relationship of age and sex with the most prevalent symptoms in our dataset and with published case definitions, allowing for clustering by country as a random intercept Results: 60 161 patients from 43 countries were included, with median age 70 years (interquartile range 55- 82) Fever (68%), cough (68%) and shortness of breath (63%) were the most prevalent symptoms Their prevalence was greater among patients aged 30-60 years (respectively 79%, 78%, 66%), and lower in children (=70 years: 61%, 62%, 61%) The most sensitive case definition assessed was one or more of cough, shortness of breath, fever, muscle pains or sore throat, met by 92% of the whole cohort Confusion was the most prevalent symptom for patients whose symptoms did not meet any of the assessed case definitions Regression models showed significant differences in symptoms with age, and considerable heterogeneity between countries Conclusions: Older adults and children admitted to hospital with Covid-19 are less likely to present with typical symptoms of cough, fever and shortness of breath Vigilance for atypical symptoms towards extremities of age increases sensitivity of identifying Covid-19 Summary: Typical symptoms of fever, cough and shortness of breath are less common in people admitted to hospital with Covid-19 toward extremities of age Published case definitions appear less sensitive toward extremes of age, and atypical symptoms need to be recognised
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