CME INDIA Presentation by Dr. S. K. Gupta, MD (Med), FICP, CFM (France) Clinical Asst. Professor GS Medical College, CCSU, Uttar Pradesh, India. Visiting Consultant, Max Super Specialty Hospital, New Delhi. Inputs from Dr. Arjun Khanna, MD, DNB (Internal Medicine), DM (Pulmonary and critical care medicine), FCCP, FAPSR, FNCCP, Senior Consultant, Pulmonary and critical care medicine, Yashoda Superspeciality hospital, Kaushambi, UP.
“The syndrome itself is still poorly understood, but it is “sweeping in its volume” of effects.”- Dr. Kristin Englund, founder and director of Cleveland Clinic’s post-COVID recover Clinic.
Englund refers to long COVID as the “pandemic after the pandemic.”
3 most common Symptoms out of 200
- Covid has settled, severity of the Covid waves has come down, but Long Covid continues to trouble patients and would be next health crisis to be battled.
What is Long Covid?
- WHO has developed a clinical case definition of post COVID-19 condition?
“Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis.”
- So, Long Covid is a diagnosis of Exclusion
- The definition may change as new evidence emerges and our understanding of the consequences of COVID-19 evolves.
Common Symptoms:
- There are more than 200 symptoms listed for Long Covid. But 3 most commonly encountered symptoms affecting majority of cases are
1. Fatigue
2. Shortness of Breath
3. Fog (Brain Fog)
How severe are the symptoms?
- Severity varies from patient to patient but symptoms generally have an impact on everyday functioning.
- Long Covid patients show fresh symptoms or continued symptoms from initial disease?
- Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time.
Common characteristic of Post Covid Symptoms?
- Symptoms frequently get worse after physical or mental activity. The symptoms may affect a number of organs or systems, occur in diverse patterns.
What are the blood tests to diagnose Long Covid?
- Long Covid is a condition for which there is currently no standard objective diagnostic test or biomarker. Even raised CRP may be misleading with variable results in different patients over period of time. CT scan Lung can show residual peripheral ground glass opacities, fibrosis which may improve or worsen over time. Values of d-Dimer may be misleading.
Which patients are more likely to have Long Covid?
- Long Covid can affect anyone who has had Covid. Cases are reported even after mild or asymptomatic disease. But Long Covid is more commonly seen in women. Obesity, associated co-morbidities like COPD, Diabetes, CKD, autoimmune disorders, immunocompromised states, past history of neuropsychiatric symptoms could be predisposing factors.
- Patients who had longer illness requiring hospitalization, prolonged ICU stay are more likely to have lingering persistent or recurring symptoms.
Treatment:
- 3 points to be remembered:
- Fatigue is the most common symptom of Long Covid. Rest, Graded exercise and activity limitations are helpful in majority of cases. Activity goals should to be individualised. NSAID drugs may be helpful to some patients in alleviating pain. General measures like massage, Vitamin C are often used with variable results. Rest, and adequate sleep are most helpful.
- Shortness of Breath is the most troublesome symptom. The cause of dyspnoea must be investigated and treated accordingly. Long Covid associates dyspnoea may mostly be a diagnosis of exclusion. Patients with falling SpO2 may require oxygen inhalation. Even 1 to 2 litres of oxygen few hours a day may suffice. Some patients may be benefitted by use of Intermittent non-invasive ventilation (BIPAP). Routine use of oral steroids is not indicated for the treatment of Long Covid associated breathlessness. Corticosteroids may be useful early in course of disease in some patients but have limited or no role about six months after the initial Covid. Drugs like Nintedanib and Pirfenidone are often misused and should be left to specialist. Diarrhoea could be disturbing side effect of these drugs requiring change of dose or drug.
- Brain Fog can present with variety of symptoms from inability to think to anxiety nervousness. Reassurance rest and short courses of anxiolytics can help most of the patients.
- Diagnosing and managing symptoms of Long Covid can be tricky, as some symptoms of long COVID-19 overlap with those of other conditions and people may have a tendency to blame everything to Covid as they recover from the challenging illness.
Prognosis:
- No one knows what the time duration of long Covid will be, or what proportion of patients will recover completely or will have long-term symptoms. It may vary from person to person. However, most patients can be helped.
Puzzle still remains unsolved
- Many unanswered questions remain mystery about Long Covid especially about pathophysiology: Does an autoimmune reaction drive Long Covid? Does the coronavirus linger in reservoirs within the body and reactivate later? What protection against long Covid do vaccines and treatments offer, if any?
Long story short, we still have a lot to learn about Long Covid-19.
- But reality is that patients suffer and need help. Empathy, reassurance and team approach remain helpful in most of the patients.
CME INDIA Tail Piece
“There is a lot of temptation to say ‘Look, it’s going to be endemic. Just go out and get it over with,’” he says. “But we’re seeing first-hand how much it just devastates an individual to live with long Covid.” – Putrino
Dr. Rajkamal Chaudhary, Asso. Prof. Med. Bhagalapur:
Public Health Experts have already said COVID-19 disease is a multi-system disease and can involve any system of your body, can produce any Symptoms which you don’t expect to have and you don’t think.
You have already seen in the past involvement of CVS, Respiratory, Neurology, GIT, Liver, Rheumatology, Endocrine & What not?
You are lucky if you don’t suffer from COVID-19 but in case you suffer you should be aware of any symptoms happening even after 5 years or so. COVID-19 is not a manufactured artificial disease but a fact and reality.
References:
- https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1
- https://www.scientificamerican.com/article/long-haul-covid-cases-could-spike-after-latest-wave/
- https://www.nature.com/articles/d41586-022-00428-5
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