Wednesday, April 28, 2021

"Long Covid:" does it exist? What is it?

Hopefully most of you realize that Covid-19 is not “just like the flu.” The death rate is much higher and there are many more complications involving other organ systems, including blood clots. As we (hopefully) dig our way out of the pandemic thanks to vaccinations and see fewer desperately ill patients on ventilators and many fewer deaths, another issue has been getting attention. Many people who have recovered from the worst of the illness, and many who had only mild symptoms or none are complaining of on-going problems.

The medical profession does not yet understand the cause of these symptoms, and there is vigorous debate over whether the complaints are psychosomatic or physical. The NIH plans to fund research into Covid “long-haulers,” but that research is unlikely to answer our questions in the near future.

The issue is two-fold: persisting symptoms in those who were seriously ill and new symptoms in those (often younger people) who had no or only mild symptoms when infected.

It is not surprising that the sickest Covid-19 patients, those hospitalized, remained sub-par for many weeks or months. An Italian study looked at 143 patients 60 days after onset of illness and 36 days after hospital discharge and found that only 12% felt back to normal. Half still complained of fatigue and shortness of breath and a quarter had joint and/or chest pain. A Swedish study found that among patients needing ICU care, over half still had abnormal lung function four months after discharge. A French study contacted 478 patients who had been admitted to a university hospital for Covid, also four months after discharge, and found that half had at least one complaint not present pre-Covid. Those who complained of shortness of breath were offered a chest CT scan and 61% of these showed persisting abnormalities.

We can hope that time will resolve or at least lessen these persisting symptoms.

More difficult to understand are the new complaints in patients who were not seriously ill.

A Swedish group looked at 323 health care workers who had serum evidence of Covid but had not reported symptoms. Compared to their co-workers with no evidence of prior infection, 5 times as many (15% vs 3%) had at least one moderate or severe complaint 8 months or more after their exposure. In Mexico, researchers looked at 115 patients with mild symptoms and a positive PCR who recovered at home with no treatment; 30 days after the positive test, some 60% had persisting fatigue and shortness of breath. In California, of 1400 patients with a positive PCR and minimal symptoms, 27% studied 60 days later reported symptoms. The symptoms in all of these groups included chest pain, cough, shortness of breath, joint pain and impaired thinking (“brain fog).

While skeptics might say these were all due to anxiety, there is evidence of very “real” and very severe illness coming after infection with the coronavirus. In Singapore, where the virus spread rapidly among “guest workers” from other Asian countries, there was mass testing. Researchers there reported a series of strokes in young (mean age 41) men who had positive Covid antibody testing but had never experienced obvious illness. A larger study in the U.S. used electronic medical records to compare patients diagnosed with Covid-19 with a matched group who had been diagnosed with flu or other respiratory illnesses at six months after diagnosis. The Covid patients had 2.5 times as many brain hemorrhages, ischemic strokes and new diagnoses of dementia. They also found higher numbers with insomnia, anxiety, psychosis and substance use disorders.

What is “long Covid?” The only honest answer is that at this point we really do not know. One theory is viral persistence. Another is auto-immunity. Favoring the former are reports that many patients with persistent symptoms report marked improvement after vaccination. Favoring the latter is that women are disproportionately affected, and we know that women have more auto-immune disorders than do men. And yes, some of the symptoms may be psychosomatic. Having a scary illness would tend to make one focus on bodily symptoms.

What can we do?

If you are a physician, I would ask you to maintain some humility and remain open-minded about an illness still under study. Do not dismiss the complaints as being due to anxiety.

If you have persisting symptoms and have not been vaccinated, I would encourage you to get the vaccine, as patients with mild or no symptoms are at risk of reinfection and many of your fellow sufferers have improved after vaccination.

If you have never had Covid, take this as one more reason to get a vaccine as soon as you can.

All of us: stay tuned!

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