Long Covid

 Long Covid or Post Covid Symptoms: What is it?

Introduction:

“Long Covid” is a new term getting popular to explain the illness in people that have either recovered from covid-19 but are still report long-lasting unusual effects of the infection or have had the standard symptoms that last much longer than would be expected. Many people, including doctors who were infected, have shared such experiences on different media.

British definition (NICE- National Institute for Health and Care Excellence) of long covid is the persistence of signs and symptoms of acute covid infection for more than 4 weeks. It includes both ongoing symptomatic COVID-19 (from 4 to 12 weeks) and post-COVID-19 syndrome (12 weeks or more). If signs and symptoms of COVID‑19 from 4 weeks up to 12 weeks it is called ongoing symptomatic COVID-19. On the other hand, the post-COVID-19 syndrome is referred to as signs and symptoms that develop during or after an infection consistent with COVID‑19, continue for more than 12 weeks, and are not explained by an alternative diagnosis. It usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body.

What are the other similar terminologies?

Other similar terms are post-acute sequelae of SARS-CoV-2 infection, post-acute sequelae of COVID-19 (PASC), Post-acute COVID-19 syndrome, chronic COVID syndrome (CCS), and long-haul COVID.

How common is it?

The prevalence varies in different studies, varies from 13.7% to 63.5%. So about 1 in 7 Covid positive patients is supposed to suffer from long Covid.

In one study conducted by the Office for National Statistics in Britain among a sample of over 20,000 study participants who tested positive for COVID-19 between 26 April 2020 and 6 March 2021, 13.7% continued to experience symptoms for at least 12 weeks. The most common symptoms experienced after 4 weeks were fatigue (11.8%), cough (11%), headache (10%), and muscle pain (7.7%). At 12 weeks, the prevalence of symptoms was slightly lower but still higher than the control group.

Writing in JAMA, a team of researchers from Italy reported that almost nine in 10 patients (87%) discharged from a Rome hospital after recovering from covid-19 were still experiencing a minimum of one symptom 60 days after onset. They found that 13% of the 143 people were completely freed from any symptoms, while 32% had one or two symptoms, and 55% had three or more. Although none of the patients had a fever or any signs or symptoms of acute illness, many still reported fatigue (53%), dyspnoea (43%), joint pain (27%), and pain (22%). Two-fifths of patients reported a worsened quality of life.

Meanwhile, the team behind the united kingdom Covid-19 Symptom Study app, which collects symptom information from nearly four million users, says their data show that one in 10 people with covid-19 is sick for 3 weeks or more

In March 2021, the Indonesian Doctors Association, during a survey of 463 people, suggested that 63.5% of respondents self-reported lingering symptoms after SARS-CoV-2 infection. The precise set of symptoms wasn’t specified, however, consistent with the article, fatigue and cough were the foremost commonly reported symptoms, followed by muscle pain and headache.

What might be the causes of long covid?

It is not known why symptoms persist in some persons and why some people’s recovery is prolonged. Following are the possible causes of long covid:

• The inflammatory, and other aberrant immune reactions,
• Deconditioning of the body because of lack of exercises and movement,
• Effects of high doses of steroids in Covid treatment
• Mental factors like post-traumatic stress
• Damage of organs like lungs, kidney, joints
• Damage of nerves and inflammation of nerves
• Persistent viremia,
• Weak or absent antibody response,
• Relapse or reinfection.

Who are most likely to suffer from long covid?

There are several studies conducted to find the risk factors for long COVID. The following are some risk factors, but many are yet to be identified.

Risk factors:

• Age: over 50
• Sex: Women- They are more likely to develop long covid than men, although they are less likely to develop severe acute Covid.
• Obesity/ Over-weight
• History of Asthma
• Multiple symptoms during the onset of illness. If someone suffers from more than five symptoms during acute covid ( like a cough, headache, fatigue, muscle pain, diarrhea, loss of sense of smell, loss of taste, etc), he/she is more likely to suffer from long covid.

What are the most common symptoms of long covid?

The list of symptoms is long and some are completely unexplainable. These are:

• Extreme weakness and fatigue
• Prolonged cough
• Persistent low-grade fever and malaise
• Inability to concentrate (brain fog)
• Memory loss
• Mood swing, accompanied by anxiety and depression
• Sleep disturbances
• Tinnitus
• Headaches
• Joint pain
• Muscle pain
• Needle pains in arms and legs
• Diarrhea and/or vomiting
• Persistent loss of taste and smell
• Sore throat and difficulties in swallowing
• New onset of diabetes
• New hypertension
• Heartburn and acidity
• Skin rash & itching
• Difficulties in breathing
• Chest pain
• Palpitations

Which systems are affected most in long covid?

• Respiratory system
• Cardiovascular system
• Brain, nervous system & psychological functions
• Musculoskeletal system
• Kidney & excretory system
• Liver & Gastrointestinal system

Effects of long Covid according to system

1. Respiratory system:

The most dramatic effect of cytokine storm is mismatched ventilation-perfusion ratio and hypoxia in acute Covid. But lungs may not recover quickly and completely. There might be damage of alveoli, lung fibrosis, and secondary infection like tuberculosis. These damages are manifested as a persistent cough, difficulty in breathing, and chest pain. Almost 15% of patients of long covid have lung-related problems.

2. Heart and vascular system

This is another system affected most with serious consequences. The heart muscles might be damaged by viral infection or inflammation known as myocarditis or cardiomyopathy. This is manifested as palpitation, chest pain, shortness of breathing, swelling of legs, etc. Abnormal clotting is another problem that may block coronary arteries and may cause a heart attack. This is mostly seen in acute covid but can be seen in long covid too as a late manifestation. Other than the damage of the heart, there may be damage to other organs like the kidney, eye, brain, etc due to blockage of blood vessels supplying these organs. Deep vein thrombosis and dislodgment of these thrombi and occlusion of other organs is a serious long-term complication. New-onset hypertension in previously normotensive persons is another long-term consequence of covid infection.

3. Nervous system and brain

There might be damage to the areas of the brain. Damages of large areas are manifested as stroke with paralysis or even death in some cases. This is mostly seen in acute covid due to thrombus formation of blood vessels of the brain. But damages of small areas are not so dramatic and seen in long covid commonly. These are manifested as loss of memory, convulsions or seizures, headache, vertigo, brain fog, etc. Brain fog is a term used for a combination of symptoms of cognitive function derangement like forgetfulness, lack of concentration, lack of clarity of mind, confusion.

Apart from the damage of brain cells, there may be damage to nerves also. Lack of sense of smell or taste is very common in long covid too like in acute covid. There may be inflammation of nerves called neuritis and changes in nociceptors causing increased pain sensation. This may lead to nerve pain, tingling sensation, and pain all over the body.

4. Musculoskeletal system

Musculoskeletal pain is a common symptom in covid and long covid patients. Inflammation of joints, muscles, and tendons is very common and cause pain, swelling of joints, weakness, fatigue. Many long covid patients continue to suffer from headaches, neck pain, back pain, knee pain and swelling, shoulder pain, small joint pain. Some patients who are prone to develop arthritis genetically are unmasked and develop frank arthritis called reactive arthritis. Muscle inflammation or myositis is another long-term effect. The patients who were already suffering from different types of chronic pain like spondyloarthritis, rheumatoid arthritis, fibromyalgia are the worst sufferers. Pain management in covid is an important challenging task of physicians treating Covid and long Covid patients.

5. Liver and digestive system

About 30% of corona infected patients suffer from liver inflammation and liver enzymes are elevated. Sometimes the enzymes remain elevated and take a long time to come to normal range. These patients present with dyspepsia, flatulence, indigestions, pain abdomen, diarrhea, nausea, vomiting, loss of appetite, etc. These symptoms may persist longer and may be aggravated with the addition of steroids, pain killer medicines, etc.

6. Psychological system

Neuropsychological changes are most common and last long. Anxiety and depression are very common along with post-traumatic stress disorders. One study mentions that post-traumatic stress symptoms are found in 96.2% of admitted patients with mild symptoms. A web-based survey by CDC on mental health during covid 19 pandemics mentions that 30.9 % suffer from anxiety and depression, 26.3% of them suffered from a stress-related disorder, and 10.7 % had suicidal thoughts. Many of these psychological changes persist for a longer time.

7. Other systems

The kidney and excretory system may be damaged with inflammation and micro-embolism. Urea & creatinine level may be elevated and remain elevated for a longer time. Skin also may be damaged and present with skin allergies, skin rashes, etc.

How to treat long covid?

Treatment depends on the diagnosis. Normally infection and viremia do not last more than 20 days after the onset of symptoms unless the immune system of the patient is weak. But inflammation may continue and in some situations, damage may take time to heal.

The most important is to follow doctors’ advice. There are lots of fake, distorted, unscientific information in social media which may be harmful. Before following any instructions check whether these guidelines are issued by a reputed agency like NICE, CDC, WHO, or some Governmental agencies. Even some reports from medical journals may not be controversial and must not be followed unless it comes as a guideline from reputed or Governmental agencies. The best advice for patients is to follow doctors’ advice.

What is done by a doctor?

They make a diagnosis of the reasons behind your problem. It is important to check blood inflammatory markers and doctors may advise tests like D-dimer, CRP, Ferritin. It is also important to check complete blood counts, fasting and post-prandial blood sugar, creatinine, liver function tests, serum electrolytes, creatinine kinase, etc as and when needed. They may advise for a CT scan, X-ray, ECG, Echo to understand the extent of the damage. But all these should be done as advised by doctors.

What can be done at home?

Mild symptoms are recovered spontaneously. So don’t be anxious. You can do the following things at home.

• Read and know about long covid, but don’t get panicked
• Monitoring oxygen saturation with a pulse oximeter
• Light and graded exercises
• Meditations and yoga
• Good and adequate sleep
• Multivitamin supplements
• Avoiding spicy foods, excessive tea/coffee
• Quit smoking
• Fruits, salads, and green leafy vegetables in food
• Can take paracetamol for pain management, acidity medicines if needed.
• Consult doctors at least once for the persistence of any symptoms
• Can avail telemedicine consultation with doctors for majority conditions.

References:

1. https://www.nice.org.uk/guidance/ng188/chapter/Context
2. https://www.forbes.com/sites/alicegwalton/2021/04/11/how-common-is-long-covid-new-studies-suggest-more-than-previously-thought/?sh=4419d3256ee0
3. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/1april2021
4. https://www.bmj.com/content/370/bmj.m2815
5. https://www.abc.net.au/news/2021-03-06/indonesians-open-up-about-the-impact-of-long-covid/13214778
6. https://www.bmj.com/content/370/bmj.m3026
7. https://www.kcl.ac.uk/news/study-identifies-those-most-risk-long-covid
8. https://www.psychiatrictimes.com/view/post-covid-stress-disorder-emerging-consequence-global-pandemic
9. https://www.bmj.com/content/370/bmj.m3026

The visual summary by BMJ