LONG COVID- Long Road for Patients and Health Systems

The risk of COVID-19 has been largely communicated only in terms of deaths and hospital capacity, with less emphasis on long term sequelae.

Around one in three people with symptomatic COVID-19 still, experience debilitating symptoms 12 weeks after onset.

Definition– No standardised definition.

Some of the case series defined it as persistent symptoms and/or delayed or long-term complications of SARS-CoV-2 infection beyond 4 weeks from the onset of symptoms.

Based on recent literature, it is further divided into two categories:

(1) subacute or ongoing symptomatic COVID-19, which includes symptoms and abnormalities present from 4–12 weeks beyond acute COVID-19; and (2) chronic or post-COVID-19 syndrome, which includes symptoms and abnormalities persisting or present beyond 12 weeks of the onset of acute COVID-19 and not attributable to alternative diagnoses.

Characteristics –

1. experienced by all age groups
2. Both critically ill and non-critically ill patients with COVID-19 affected.
3. wide-ranging, multisystemic, and predominantly fluctuating or relapsing.

Symptoms –

Pulmonary

• Dyspnea decreased exercise capacity and hypoxia are commonly persistent symptoms and signs

• Reduced diffusion capacity, restrictive pulmonary physiology, and ground-glass opacities and fibrotic changes on imaging

Hematologic

• Thromboembolic events have been noted to be <5% in post-acute COVID-19 in retrospective studies

• The duration of the hyperinflammatory state induced by infection with SARS-CoV-2 is unknown

Cardiovascular

• Persistent symptoms may include palpitations, dyspnea and chest pain

• Long-term sequelae may include increased cardiometabolic demand, myocardial fibrosis or scarring (detectable via cardiac MRI), arrhythmias, tachycardia and autonomic dysfunction

Neuropsychiatric

• fatigue, myalgia, headache, dysautonomia and cognitive impairment (brain fog)

• Anxiety, depression, sleep disturbances and PTSD

• The pathophysiology of neuropsychiatric complications is mechanistically diverse and entails immune dysregulation, inflammation, microvascular thrombosis, iatrogenic effects of medications and psychosocial impacts of infection

Renal

• Resolution of AKI during acute COVID-19 occurs, however reduced eGFR has been reported at 6 months follow-up

Endocrine

• new or worsening control of existing diabetes mellitus, subacute thyroiditis and bone demineralization

Gastrointestinal 

• Prolonged viral fecal shedding can occur in COVID-19 even after negative nasopharyngeal swab testing

• COVID-19 has the potential to alter the gut microbiome,

Dermatologic

• Hair loss is the predominant symptom

Figure 1 from Nature Medicine | VOL 27 | April 2021 | 601–615

Evidence – 

from Nature Medicine | VOL 27 | April 2021 | 601–615

Limitations – 

Different follow-up periods were used in different studies.

Different nomenclature and different definitions are used.

Summary – 

No standardised definition at the moment.

Need further research and a system-based approach in tackling this problem

Our Recommendations –  

We need International collaborative efforts to –

1) Recognise and define this problem 2) Standardised reporting system to capture the incidence 3) Structured multi-disciplinary rehabilitation. programme for COVID survivors 4) Further research to develop effective strategies for prevention.