Long covid: How to define it and how to manage it

Authors: Nikki Nabavi, editorial scholar

“Profound fatigue” was a common symptom in most people with long covid, she said, but added that a wide range of other symptoms included cough, breathlessness, muscle and body aches, and chest heaviness or pressure, but also skin rashes, palpitations, fever, headache, diarrhoea, and pins and needles. “A very common feature is the relapsing, remitting nature of the illness, where you feel as though you’ve recovered, then it hits you back,” she said.

Nick Peters added to this definition by highlighting a “distinction between very sick people who have recovered to an extent and [and have been] left with some impact of their severe sickness, versus those who had a relatively mild sickness from the start, in whom it is ongoing.”

Alwan described the fluctuations of her own illness: “It’s a constant cycle of disappointment, not just to you but people around you, who really want you to recover.”

Paul Garner, who also has long covid, described it as a “very bizarre disease” that had left him feeling “repeatedly battered the first two months” and then experiencing lesser episodes in the subsequent four months with continual fatigue. “Navigating help is really difficult,” he said.

Tim Spector said that his team at the Covid Symptom Study had identified six clusters of symptoms for covid-19,1 a couple of which were associated with longer term symptoms, indicating a possible way of predicting early on what might occur. “If you’ve got a persistent cough, hoarse voice, headache, diarrhoea, skipping meals, and shortness of breath in the first week, you are two to three times more likely to get longer term symptoms,” he said.

He said that patterns in the team’s data suggested that long covid was about twice as common in women as in men and that the average age of someone presenting with it was about four years older than people who had what might be termed as “short covid.”

But Spector added, “We do seem to be getting different symptom clusters in different ages, so it could be that there is a different type in younger people compared with the over 65s. As we get more data we should be able to break it into these groups and work out what is going on … which could be very interesting and help us to get early interventions for those at-risk groups.”

Peters said that the data showed fatigue was the most common trait in people who had symptoms beyond three weeks. He also said that around 80% of people who had symptoms lasting more than three weeks reported “having had clear good days and bad days.”

For More Information: https://www.bmj.com/content/370/bmj.m3489

Coronavirus 2019 (COVID-19)- Using Ascorbic Acid and Zinc Supplementation (COVIDAtoZ)

Authors: Milind Desai, M. D, Suma Thomas Principal Investigators: The Cleveland Clinic

A Clinical Trail to see whether ascorbic acid and zinc gluconate which has limited side effect profile and is readily available over the counter can decrease the duration of symptoms seen in patients with new diagnosis of COVID-2019. A secondary purpose is to see whether Zinc and/or Ascorbic acid supplementation can prevent progression of the severe manifestations of the disease including development of dyspnea and acute respiratory distress syndrome which may require hospitalization, mechanical ventilation, and or lead to death.

For More Information: https://clinicaltrials.gov/ct2/show/NCT04342728

Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study

Authors: Tao Chen, doctor1,  Di Wu, doctor1,  Huilong Chen, doctor1,  Weiming Yan, research associate1,  Danlei Yang, doctor2,  Guang Chen, doctor1,  Ke Ma, doctor1,  Dong Xu, doctor1,  Haijing Yu, doctor1,  Hongwu Wang, doctor1,  Tao Wang, doctor2,  Wei Guo, doctor1,  Jia Chen, doctor1,  Chen Ding, doctor1,  Xiaoping Zhang, doctor1,  Jiaquan Huang, doctor1,  Meifang Han, doctor1,  Shusheng Li, doctor3,  Xiaoping Luo, doctor4,  Jianping Zhao, doctor2,  Qin Ning, doctor1

Among a cohort of 799 patients, 113 who died and 161 who recovered with a diagnosis of covid-19 were analysed. Data were collected until 28 February 2020.

Main outcome measures Clinical characteristics and laboratory findings were obtained from electronic medical records with data collection forms.

Results The median age of deceased patients (68 years) was significantly older than recovered patients (51 years). Male sex was more predominant in deceased patients (83; 73%) than in recovered patients (88; 55%). Chronic hypertension and other cardiovascular comorbidities were more frequent among deceased patients (54 (48%) and 16 (14%)) than recovered patients (39 (24%) and 7 (4%)). Dyspnoea, chest tightness, and disorder of consciousness were more common in deceased patients (70 (62%), 55 (49%), and 25 (22%)) than in recovered patients (50 (31%), 48 (30%), and 1 (1%)). The median time from disease onset to death in deceased patients was 16 (interquartile range 12.0-20.0) days. Leukocytosis was present in 56 (50%) patients who died and 6 (4%) who recovered, and lymphopenia was present in 103 (91%) and 76 (47%) respectively. Concentrations of alanine aminotransferase, aspartate aminotransferase, creatinine, creatine kinase, lactate dehydrogenase, cardiac troponin I, N-terminal pro-brain natriuretic peptide, and D-dimer were markedly higher in deceased patients than in recovered patients. Common complications observed more frequently in deceased patients included acute respiratory distress syndrome (113; 100%), type I respiratory failure (18/35; 51%), sepsis (113; 100%), acute cardiac injury (72/94; 77%), heart failure (41/83; 49%), alkalosis (14/35; 40%), hyperkalaemia (42; 37%), acute kidney injury (28; 25%), and hypoxic encephalopathy (23; 20%). Patients with cardiovascular comorbidity were more likely to develop cardiac complications. Regardless of history of cardiovascular disease, acute cardiac injury and heart failure were more common in deceased patients.

Conclusion Severe acute respiratory syndrome coronavirus 2 infection can cause both pulmonary and systemic inflammation, leading to multi-organ dysfunction in patients at high risk. Acute respiratory distress syndrome and respiratory failure, sepsis, acute cardiac injury, and heart failure were the most common critical complications during exacerbation of covid-19.

For More Information: https://www.bmj.com/content/368/bmj.m1091

The hallmarks of COVID-19 disease

Authors: Daolin Tang ,Paul Comish,Rui Kang 

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel coronavirus that has caused a worldwide pandemic of the human respiratory illness COVID-19, resulting in a severe threat to public health and safety. Analysis of the genetic tree suggests that SARS-CoV-2 belongs to the same Betacoronavirus group as severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). Although the route for viral transmission remains a mystery, SARS-CoV-2 may have originated in an animal reservoir, likely that of bat. The clinical features of COVID-19, such as fever, cough, shortness of breath, and fatigue, are similar to those of many acute respiratory infections. There is currently no specific treatment for COVID-19, but antiviral therapy combined with supportive care is the main strategy. Here, we summarize recent progress in understanding the epidemiological, virologic, and clinical characteristics of COVID-19 and discuss potential targets with existing drugs for the treatment of this emerging zoonotic disease.

For More Information: https://journals.plos.org/plospathogens/article?id=10.1371%2Fjournal.ppat.1008536

Persistent Symptoms in Patients After Acute COVID-19

Authors: Angelo Carfì, MD1Roberto Bernabei, MD1Francesco Landi, MD, PhD1et al

In Italy, a large proportion of patients with coronavirus disease 2019 (COVID-19) presented with symptoms (71.4% of 31 845 confirmed cases as of June 3, 2020).1 Common symptoms include cough, fever, dyspnea, musculoskeletal symptoms (myalgia, joint pain, fatigue), gastrointestinal symptoms, and anosmia/dysgeusia.24 However, information is lacking on symptoms that persist after recovery. We assessed persistent symptoms in patients who were discharged from the hospital after recovery from COVID-19.

For More Information: https://jamanetwork.com/journals/jama/fullarticle/2768351

Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)

Authors: CDC

  • New information on potential for under-detection of occult hypoxemia by pulse oximetry, especially among persons with dark skin
  • New information on dermatologic manifestations associated with COVID-19
  • New information on prolonged shedding of replication-competent SARS-CoV-2 in severely immunocompromised persons
  • New information on reports of reinfection with variant viruses

Clinical Presentation, Clinical Course, Laboratory and Radiographic Findings, Clinical Management and Treatment, Discontinuation of Transmission-Based Precautions or Home Isolation

This document provides guidance on caring for patients infected with SARS-CoV-2, the virus that causes COVID-19. The National Institutes of Health (NIH) have published guidelines for the clinical management of COVID-19external icon prepared by the COVID-19 Treatment Guidelines Panel. The recommendations are based on scientific evidence and expert opinion and are regularly updated as more data become available.

For More Information: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Pathology and Pathogenesis of SARS-CoV-2 Associated with Fatal Coronavirus Disease, United States

Authors: Roosecelis B. Martines, Jana M. Ritter1, Eduard Matkovic, Joy Gary, Brigid C. Bollweg, Hannah Bullock, Cynthia S. Goldsmith, Luciana Silva-Flannery, Josilene N. Seixas, Sarah Reagan-Steiner, Timothy Uyeki, Amy Denison, Julu Bhatnagar, Wun-Ju Shieh, Sherif R. Zaki, and COVID-19 Pathology Working Group

An ongoing pandemic of coronavirus disease (COVID-19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Characterization of the histopathology and cellular localization of SARS-CoV-2 in the tissues of patients with fatal COVID-19 is critical to further understand its pathogenesis and transmission and for public health prevention measures. We report clinicopathologic, immunohistochemical, and electron microscopic findings in tissues from 8 fatal laboratory-confirmed cases of SARS-CoV-2 infection in the United States. All cases except 1 were in residents of long-term care facilities. In these patients, SARS-CoV-2 infected epithelium of the upper and lower airways with diffuse alveolar damage as the predominant pulmonary pathology. SARS-CoV-2 was detectable by immunohistochemistry and electron microscopy in conducting airways, pneumocytes, alveolar macrophages, and a hilar lymph node but was not identified in other extrapulmonary tissues. Respiratory viral co-infections were identified in 3 cases; 3 cases had evidence of bacterial co-infection.

For More Information: https://wwwnc.cdc.gov/eid/article/26/9/20-2095_article

Top Ten COVID-19 Anxiety Reduction Strategies

Authors: Ken Goodman, LCSW

To stop the spread of COVID-19, we’ve had to practice social distancing. But to stop the spread of anxiety, we must distance ourselves from the media. All anxiety stems from uncertainty and an active imagination which produces catastrophic thoughts. The media, which is 24/7 Coronavirus and virtually all negative, is the driver of those thoughts. My patients who are the most anxious about the Coronavirus are those who are consuming the most news from social media, online, and traditional outlets. The more anxious you feel, the more you should distance from the media. And if you are extremely fearful, stop altogether. Do no Google or research. Stop checking the latest news about the virus. Any vital information you need to know, you will find out.

For More Information: https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/top-ten-covid-19-anxiety-reduction-strategies

Considerations for Certain Concomitant Medications in Patients With COVID-19

Authors: NIH

  • Patients with COVID-19 who are receiving concomitant medications (e.g., angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], statins, systemic or inhaled corticosteroids, nonsteroidal anti-inflammatory drugs, acid-suppressive therapy) for underlying medical conditions should not discontinue these medications during acute management of COVID-19 unless discontinuation is otherwise warranted by their clinical condition (AIIa for ACE inhibitors and ARBs; (AIII) for other medications).
  • The COVID-19 Treatment Guidelines Panel recommends against using medications off-label to treat COVID-19 if they have not demonstrated safety and efficacy in patients with COVID-19, except in a clinical trial.

For More Information: https://www.covid19treatmentguidelines.nih.gov/therapies/concomitant-medications/

Pathophysiology of COVID-19: Mechanisms Underlying Disease Severity and Progression

Authors: Mary Kathryn BohnAlexandra HallLusia SepiashviliBenjamin JungShannon Steele, and Khosrow Adeli

Abstract

The global epidemiology of coronavirus disease 2019 (COVID-19) suggests a wide spectrum of clinical severity, ranging from asymptomatic to fatal. Although the clinical and laboratory characteristics of COVID-19 patients have been well characterized, the pathophysiological mechanisms underlying disease severity and progression remain unclear. This review highlights key mechanisms that have been proposed to contribute to COVID-19 progression from viral entry to multisystem organ failure, as well as the central role of the immune response in successful viral clearance or progression to death.

For More Information: https://journals.physiology.org/doi/full/10.1152/physiol.00019.2020