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Commentary: What We Know So Far About Post-COVID Syndrome

Commentary
9/24/2020 Matthew E Levison, MD, Adjunct Professor of Medicine, Drexel University College of Medicine

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COVID-19 has spread worldwide in the past 10 months since first being recognized in Wuhan, a city of over 11 million people in central China in December 2019. Within a month, Chinese investigators identified a novel coronavirus, named SARS-CoV-2, as its cause. This virus was genetically most closely related to a coronavirus isolated from horseshoe bats in Yunnan, China. How the virus made its way from bat caves in Yunnan to Wuhan, over 1000 km (621 miles) away, remains unknown.

Even though the number of COVID-19 cases worldwide now approaches 30 million with almost 1 million dead (1), we are still amazed how little we know about this very complex disease. The clinical spectrum varies widely. Up to 40% of people infected with SARS-CoV-2 never develop symptoms. About 80% of those who do become symptomatic have a mild illness that does not require hospitalization; about 15% are sick enough to require hospitalization; but only 5% require care in an intensive care unit, usually for mechanical ventilation to treat respiratory insufficiency.

Early in the pandemic, many people believed that COVID-19 was a short-term illness. In February 2020, the World Health Organization, using preliminary data available at the time, reported the time from onset to clinical recovery for mild cases was approximately 2 weeks and that recovery took 3 to 6 weeks for patients with severe or critical disease (2). More recently, however, it has become clear that in some patients debilitating symptoms persist for weeks or even months. In some of these patients, symptoms have never gone away.

Many studies have documented lingering damage to many organs or systems, including lungs, heart, brain, kidneys, and vascular system, in patients infected with SARS-CoV-2. The damage seems to be caused by severe inflammatory responses, thrombotic microangiopathy, venous thromboembolism, and oxygen deprivation. Low blood oxygen saturation has been found even in asymptomatic and presymptomatic patients with COVID-19 pneumonia, where it has been called “silent hypoxia.” Organ damage has been documented to persist in the lungs, the heart, the brain, and the kidneys, even in some people who had only mild symptoms. The slow pace of recovery readily explains the duration of what has come to be called the “post-COVID syndrome.” Some people may also be suffering from post-intensive care syndrome, a group of symptoms that sometimes occur in people who were patients in an intensive care unit and that involves muscle weakness, balancing problems, cognitive decline, and mental health disturbances observed after discharge from critical care that usually involved a prolonged period of mechanical ventilation (3).

Persistence of symptoms also occurred after infection with another coronavirus, SARS-CoV-1, the virus that caused the severe acute respiratory syndrome (SARS) epidemic in 2002–2003. The persisting symptoms resemble chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). Persistent fatigue, muscle pain, depression, and disrupted sleep prevented patients with SARS in Toronto, most of whom were healthcare workers, from returning to work for up to 20 months after infection (4). Forty percent of 233 survivors of SARS in Hong Kong were reported to have chronic fatigue after about 3 to 4 years, and 27% met the criteria outlined by the Centers for Disease Control and Prevention (CDC) for CFS/ME (5). Many remained unemployed and have experienced social stigmatization (5).

CFS/ME-like illness, in which some people get better quickly but others remain sick for prolonged periods, has followed many other infectious diseases. Examples include influenza, Epstein-Barr virus infection (infectious mononucleosis—6), brucellosis, Q fever (Coxiella burnetii infection—7), Ebola virus infection (8), and Ross River virus infection (9).

The persisting illness following COVID-19 also is said to resemble CFS/ME (10), and people with post-COVID-19 syndrome have given themselves the name “long-haulers.” However, there is no clear picture of what constitutes post-COVID-19 syndrome. Without a formally accepted definition of post COVID-19 syndrome, it is difficult to assess how common it is, how long it lasts, who’s at risk for it, what causes it, what its pathophysiology is, and how to treat and prevent it. But several studies are now beginning to define this group of patients.

The CDC conducted a multistate telephone survey in April and June 2020 of non-hospitalized adults who had a positive reverse transcription–polymerase chain (RT-PCR) test for SARS-CoV-2 infection (11). Respondents were asked about demographic characteristics, baseline chronic medical conditions, symptoms present at the time of testing, whether those symptoms had resolved by the interview date, and whether they had returned to their usual state of health at the time of interview. Of 274 respondents symptomatic at the time of PCR testing, about one third reported not having returned to their usual state of health when interviewed 2 to 3 weeks after testing. Of younger persons, aged 18 to 34 years, with no chronic medical conditions, 20% had not returned to their usual state of health. However, older age and presence of multiple chronic medical conditions were more commonly associated with prolonged illness, which was present in 26% of those aged 18 to 34 years, 32% of those aged 35 to 49 years, and 47% of those aged50 years or older. Fatigue (71%), cough (61%), and headache (61%) were the most frequently reported symptoms. These findings indicate that COVID-19 can result in prolonged illness even among people with milder outpatient illness, including young adults. This finding is particularly concerning as outbreaks are emerging on college campuses.

In another study in Rome, Italy of 143 patients (mean age 57 years) after about a 2-week-hospitalization for COVID-19, many patients still struggled with symptoms 60 days on average after onset of their illness; 87% still had at least one symptom, and 55% had 3 or more symptoms (12). Quality of life had worsened for 44%, with fatigue (53.1%), difficulty breathing (43%), joint pain, (27%) and chest pain (22%) persisting in many. None had fever or any signs or symptoms of acute illness.

Much information, however, that characterizes the post-COVID-19 syndrome’s demographics, time-course, and symptomatology has been generated and analyzed by long-haulers themselves who belong to the online Body Politic COVID-19 Support Group and who have expertise in research, survey design, and data analysis. The online survey they developed and targeted to those whose symptoms persisted for more than 2 weeks received 640 responses from April 21 to May 2, 2020 (13).

The respondents were predominately young (63% between the ages of 30 to 49 years), white (77%), and female (77%), and live in the United States (72%) or the U.K. (13%). Most were never hospitalized, or, if hospitalized, never admitted to an ICU or placed on a ventilator, so their cases technically counted as “mild.” Many were seen in an emergency department/urgent care facility but were not admitted. All respondents were included, regardless of SARS-CoV-2 RT-PCR testing status. In about 25%, the RT-PCR was positive; but almost 50% of participants never were tested because testing during those months (March and April 2020) was often limited to people hospitalized with severe respiratory problems, their symptoms were said to be “classic,” making testing unnecessary at a time when PCR testing kits were in short supply, or testing was denied because their symptoms did not match preset criteria.

Another 25% of respondents tested negative, but a negative result does not mean these people didn’t have COVID-19. Some negative tests were likely false-negative results, which occur up to 30 percent of the time (14). Others were tested relatively late in the course of their illness, at a time when virus may no longer be detectable (15). In the survey, respondents with negative RT-PCR test results were in fact tested a week later than those with positive test results.

The reported symptoms were diverse and spanned the respiratory tract, and the neurological, cardiovascular, gastrointestinal, and various other systems. The top 10 symptoms, reported by 70% or more respondents, included shortness of breath, tightness of the chest, fatigue, chills or sweats, body aches, dry cough, “elevated temperature” (98.8 to 100° F), headache, and brain fog/difficulty concentrating. Extreme fatigue to the point of preventing someone from getting out of bed, severe headache, fever (above 100.1° F), and loss of taste or smell were reported by 40 to 50% of respondents. Seventy percent (70%) experienced fluctuations in the type and 89% in the intensity of symptoms over the course of being symptomatic. Some patients noted that symptoms came back or intensified with physical activity or were strongest in the evening. About 70% had been physically fit before the onset of symptoms, but 70% reported being sedentary after the onset of symptoms.

About 10% of respondents had recovered in, on average, about 4 weeks. The 90% who had not recovered experienced symptoms for an average of 40 days. A large proportion of respondents experienced symptoms for 5 to 7 weeks. The chance of full recovery by day 50 was estimated to be smaller than 20%.

Results of surveys such as this, however, are subject to bias. Respondents to surveys might differ from non-respondents; for example, there might have been gender bias in that women might more likely join support groups and complete online surveys; patients with more severe illness might be unable to respond or be unable to recall events accurately. Online surveys may also be skewed toward more affluent, younger, and more computer savvy respondents and omit economically disadvantaged minorities, the homeless, those lacking broadband and computers, and those fearful of responding, such as undocumented migrants.

Since issuing their report, the Body Politic COVID-19 Support Group team has met with staff from the Centers for Disease Control and Prevention and the World Health Organization (16) and issued a second survey to fill in gaps in their first report; examine antibody testing results, neurological symptoms, and the role of mental health; and increase geographic and demographic diversity (17).

Many long-haulers report their persisting symptoms are being downplayed. They are told they are perhaps exaggerating, imagining, or even inventing their life-altering illness. Simple physical activities, like getting out of bed, grooming, preparing simple meals, and showering, can be exhausting for some. Being unable to care for themselves and their families, being unable to work, and losing income and possibly employer-based health insurance bring additional burdens. Healthcare planners and policy makers must prepare to meet the needs of the many people that have been affected by this illness and their families while ongoing studies investigate causes and ways to mitigate the post-COVID syndrome.

 

References

 

1. Worldometer 2020 Accessed September 21, 2020. https://www.worldometers.info/coronavirus/

2. World Health Organization: Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). Geneva, WHO. 16-24 February, 2020. Accessed September 21, 2020. https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf

3. Jaffri A, Jaffri UA: Post-intensive care syndrome after COVID-19: A crisis after a crisis? Heart Lung June 18, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301100/

4. Moldofsky H. Patcai J: Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study. BMC Neurol 11:1–7, 2011. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071317/

5. Lam MHB, Wing YK, Yu MWM, et al: Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors: long-term follow-up. Arch Intern Med 169:2142-2147, 2009.https://pubmed.ncbi.nlm.nih.gov/20008700/

6. Katz BZ, Shiraishi Y, Mears CJ, et al: Chronic fatigue syndrome following infectious mononucleosis in adolescents: A prospective cohort study. Pediatrics 124: 189-193, 2009. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2756827/

7. Morroy G, Keijmel SP, Delsing CE, et al: Fatigue following acute Q fever: A systematic literature review. PloS One 11(5): e0155884, 2016. doi:10.1371/journal.pone.0155884 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4880326/

8. PREVAIL III Study Group, Sneller MC, Reilly C, et al: A longitudinal study of Ebola sequelae in Liberia. N Engl J Med 380(10):924-934, 2019. https://pubmed.ncbi.nlm.nih.gov/30855742/

9. Centers for Disease Control and Prevention: Myalgic encephalomyelitis/Chronic fatigue syndrome: Possible causes. Updated July 12, 2018. Accessed September 22, 2020. https://www.cdc.gov/me-cfs/about/possible-causes.html

10. Perrin R, Riste L, Hann M: Into the looking glass: Post-viral syndrome post COVID-19. [published online ahead of print, 2020 Jun 27]. Med Hypotheses 144:110055, 2020. doi:10.1016/j.mehy.2020.110055 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320866/

11. Tenforde MW, Kim SS, Lindsell CJ, et al: Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multi-state health care systems network-United States, March-June 2020. MMWR 69:993-998, July 31, 2020. https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm?s_cid=mm6930e1_e&deliveryName=USCDC_921-DM33740

12. Carfi A, Bernabei R, Landi F, et al: Persistent symptoms in patients after acute COVID-19. JAMA 324:603-605, 2020. https://jamanetwork.com/journals/jama/fullarticle/2768351 https://pubmed.ncbi.nlm.nih.gov/32644129/

13. Patient-led Research for COVID-19: Report: What does Covid-19 recovery actually look like? May 11, 2020. Accessed September 22, 2020. https://patientresearchcovid19.com/research/report-1/

14.Krumholz HM: If you have coronavirus symptoms, assume you have the illness, even if you test negative. New York Times April 1, 2020. Accessed September 22, 2020. https://www.nytimes.com/2020/04/01/well/live/coronavirus-symptoms-tests-false-negative.html

15. Kucirka LM, Lauer SA, Laeyendecker O, et al: Variation in false-negative rate of reverse transcriptase polymerase chain reaction-based SARS-CoV-2 tests by time since exposure. Ann Intern Med 173:262-267, 2020. https://www.acpjournals.org/doi/10.7326/M20-1495

16. Collins F: Body Politic COVID-19 Support Group: Citizen scientists take on the challenge of long-haul COVID-19. NIH Director’s Blog September 3, 2020. Accessed September 22, 2020. https://directorsblog.nih.gov/tag/body-politic-covid-19-support-group/

17. Akrami A, et al: Online survey on recovery from COVID-19 (survey 2). Patient-led research for Covid-19. Accessed September 22, 2020. https://patientresearchcovid19.com/survey2/

COVID-19 Resources Home Page

Matthew Levison, MD

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Tongue Discoloration and Other Changes
A 12-year-old girl is brought to the office by her grandmother because she has had pain in her mouth for the past week. The patient appears to be drooling. Physical examination shows a smooth red tongue. Tenderness is noted on palpation of the oral mucosa. Based on these findings, this patient most likely has a deficiency of which of the following?