When Covid-19 symptoms linger on

In one study, more than half of the Covid-19 patients had residual chest imaging abnormalities, like the areas of decreased lung capacity (white) seen in this MRI scan. — Bloomberg

Most Covid-19 patients have no symptoms or experience only mild to moderate symptoms.

Two-thirds of sufferers do not have any symptoms at all (asymptomatic), while 90% are symptom-free three weeks after their symptoms first appear.

However, the remainder experience either persistent symptoms or a pattern of symptoms improving, then reappearing (relapsing and remitting).

Recovery from Covid-19 typically takes two to six weeks after the onset of symptoms.

The term post-Covid-19 syndrome is used for clinical features that develop during or after an infection consistent with Covid-19, and continue for more than 12 weeks without an alternative diagnosis.

The features often overlap, fluctuate and change with time, and affect many body systems.

The colloquial term “long Covid” is used for clinical features that continue or develop after an acute infection.

It includes both ongoing Covid-19 (from four to 12 weeks) and post-Covid-19 syndrome (12 weeks or more).

There is increasing evidence that long Covid is a distinct syndrome, probably due to the dysfunctional immune-inflammatory response triggered by the infection.

Some researchers are of the view that it is a collection of post-intensive care syndrome, post-viral fatigue syndrome, permanent organ damage and long-term Covid-19 syndrome.

Furthermore, Covid-19 complications, drug-related side effects, thrombosis, other infections and psychological issues can also cause similar features in Covid-19 patients who have recovered.

While such patients are not infectious to others during this time, the complications they suffer from may have lasting effects on their health.

With growing recognition of long Covid, the UK National Health Service (NHS) has established special clinics to address this matter.

Similarly, the US National Institute of Allergy and Infectious Diseases has held workshops on long Covid.

Clinical guidelines have been developed or are in the process of development by various countries and the World Health Organization (WHO).

Clinical features

The features after an acute Covid-19 infection are variable and extensive.

Commonly reported signs and symptoms include:

  • General: Fatigue, fever and painFrench President Emmanuel Macron reported experiencing headaches, fatigue and a dry cough during this video update on his health while in quarantine after being diagnosed with Covid-19 in this filepic. — ReutersFrench President Emmanuel Macron reported experiencing headaches, fatigue and a dry cough during this video update on his health while in quarantine after being diagnosed with Covid-19 in this filepic. — Reuters
  • Respiratory (due to lung tissue damage): Breathlessness and cough
  • Cardiovascular (due to general damage to health and heart failure): Chest pain, chest tightness and palpitations
  • Musculoskeletal: Muscle and/or joint pain
  • Neurological (due to consequences of thromboembolic events): Cognitive impairment (loss of concentration or memory), headache, sleep disturbance, dizziness, peripheral neuropathy (numbness, pins and needles) and delirium (in older persons)
  • Psychological: Anxiety and depression
  • Gastrointestinal: Abdominal pain, nausea, diarrhoea and appetite loss (in older persons)
  • Ear, nose and throat: Tinnitus, earache, sore throat, loss of taste and/or smell
  • Skin: Rashes

A review of 1,733 adult patients (48% women, 52% men) six months after discharge from a Wuhan hospital in China is informative.

Only 4% (76 patients) were admitted to the intensive care unit (ICU).

Just over three-quarters (76%, or 1,265 patients out of 1,655) reported the persistence of at least one symptom.

Fatigue or muscle weakness was the most frequent symptom reported (63%, or 1,038 patients out of 1,655).

More than half of the patients had residual chest imaging abnormalities.

There was an independent association between disease severity during the acute phase of the infection and the extent of lung diffusion impairment at follow-up (4.6 times the likelihood).

Lung diffusion is the spontaneous exchange of gases like oxygen and carbon dioxide between the lung’s alveoli and the blood in the lung’s capillaries.

Fifty-six percent of the patients who required oxygen through either non-invasive and invasive mechanical ventilation during their hospital stay (48 patients out of 86), had lingering impaired lung diffusion capacity.

There are other reports that suggest that Covid-19 patients who were critically ill subsequently developed impaired cognitive and mental health or physical functioning long after discharge from hospital.

Although there have been more than 135,000 cases reported as at Jan 10 (2021), there is currently no published data on long Covid cases in the Malaysian setting.

Much is unknown

There is much that is still unknown about the body’s response in long Covid.

The definitions, diagnoses and types of illness that are categorised as long Covid have yet to be universally agreed upon.

Who are at risk of serious or long-term effects of Covid-19?

What are the underlying causes and mechanisms?

What is the duration of this condition?

How can the effects of such complications on health and wellbeing be prevented and/or reduced?

What are the effective treatments available to facilitate recovery?

What is the likelihood of full recovery?

Are there any effective treatments to aid patient recovery and the regain of full function?

What rehabilitation is needed?

These are all questions doctors and researchers need to find answers to in order to best help patients.

Current measures

Loss of smell is one of the symptoms that persist in long Covid. — FilepicLoss of smell is one of the symptoms that persist in long Covid. — Filepic

It is vital that discharged Covid-19 patients have long-term access to multidisciplinary healthcare, including rehabilitation and psychological or psychiatric services, as well as social and financial support where necessary.

Adequate occupational health measures are necessary for healthcare professionals and other first responders who are at particular risk.

Various organisations – the Health Ministry in particular and the Government in general – have significant roles to play in this respect.

The absence of clear definitions of long Covid, diagnostic test(s) or effective treatment(s) makes it difficult for healthcare professionals to help such patients.

Nevertheless, healthcare professionals who interact with patients have to listen to them to understand their concerns and experiences to ensure that patients do not feel that their complaints are ignored or diminished.

Clear acknowledgement and honest communication are vital.

At the same time, consideration has to be given to excluding other medical conditions that have similar clinical features.

Although vaccination may appear to be a magic bullet, it is not.

Non-pharmaceutical interventions are essential until at least, such time when there is herd immunity.

Long Covid should not be put on the backburner or forgotten even when there is herd immunity as we do not know how long the effects of this condition will linger on.

Acknowledgement of the potential scale of the problem and its complexities, as well as the need for research data and better care, would avoid future management problems.

Take home messages

The SARS-CoV-2 virus does not distinguish who to infect.

In addition, many Covid-19 patients are suffering from the long-term effects of the disease.

As such, the public health messages to everyone, particularly to young adults, people who think Covid-19 is just another viral infection and those wary of being vaccinated against the coronavirus, should be to take all necessary measures to avoid infection.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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