Long COVID study looks at why some can’t shake dizziness, fatigue and more

Authors: Helena Oliviero, The Atlanta Journal-Constitution

Georgia residents among thousands needed for a massive study to discover how the virus causes lingering symptoms.

Back in the summer of 2020, when the pandemic was still new and hospitals were overflowing, Emory Healthcare opened a facility to treat a perplexing group of COVID-19 survivors.

The patients had withstood the virus’s initial onslaught but couldn’t shake some of the symptoms.

At the time, Dr. Alex Truong thought the long COVID clinic might be needed for a year, maybe two.

But long COVID — a mysterious constellation of ailments that can go on for many weeks or months — has become a bigger problem than Truong could have ever imagined.

In the U.S. alone, 1 in 5 of the adults stricken with COVID-19 have developed conditions that could be considered long COVID, according to a recent study by the Centers for Disease Control and Prevention. Symptoms range from brain fog and unrelenting fatigue to gastric and cardiac issues. Among those 65 and older, the estimates are even higher — 1 in 4.

That translates into millions of Americans and more than 300,000 Georgians.

Other estimates vary wildly. There is no test for long COVID. No official statistics exist.

Clinicians at the Emory clinic have treated more than 1,000 COVID survivors. There’s now a four-month waiting list to be seen at the clinic.ExploreComplete coverage of COVID-19 in Georgia

“It’s been shocking,” said Truong, who is co-director of the clinic,located at Emory University Hospital Midtown. “I’ve never seen, with other infections, such widespread, all-over-the-body symptoms for this long.”

COVID can wreak havoc on a person’s body and damage organs – the lungs, heart, kidneys and liver. Experts worry that people who are infected multiple times have increased chances of developing long COVID.

How is long COVID defined?

A recent CDC study says that 1 in 5 of U.S. adults stricken with COVID-19 have developed conditions that could be considered long COVID, which the agency defines as symptoms lasting at least four weeks after infection.

The CDC says the following symptoms are the most common for this complex and poorly understood condition:

  • Tiredness or fatigue that interferes with daily life
  • Difficulty breathing, shortness of breath, chest pain
  • Difficulty thinking or concentrating (sometimes referred to as “brain fog”)
  • Headache
  • Sleep problems
  • Anxiety
  • Digestive issues
  • Joint or muscle pain

“With COVID, we tend to think about the hospitalizations and deaths, and then we kind of stop there sometimes,” said Dr. Tiffany Walker, who has treated long COVID patients at Grady Memorial Hospital. “I don’t want to paint the picture of everybody’s debilitated, but some people are, and it’s people that don’t expect it. The times that people have cried in my office because they’re just so overwhelmed is like more than anything I’ve experienced before in clinical practice.”

Walker now leads a long COVID study at Grady, which is part of a massive National Institutes of Health effort to find the connection between seemingly unrelated symptoms that have afflicted patients and confounded physicians.

Scientists still do not know how the virus triggers such a wide range of problems, from minor to incapacitating, or why issues emerge in some patients but not in others, or what exactly the risk factors are for developing them.

What’s more, there is no specific treatment for longCOVID. Instead, the current approach is to deal with each symptom individually.

It’s often hard to offer satisfying answers to patients. “It’s just very upsetting and really challenging,” Walker said. “As a physician, you really want to be able to provide a prognosis at least, at a minimum to be able to express to them, this is what you can expect.”

But doctors “don’t know enough to know what the course is going to be and who’s going to get better and who isn’t, and you don’t know enough about how to treat those that aren’t getting better,” she said.

And the world’s leading health organizations don’t even have a standard definition of what constitutes long COVID, Truong said. The CDC defines long COVID, which it calls Post-COVID Conditions, as symptoms lasting four weeks or longer after infection. The World Health Organization says people cross over into long COVID after symptoms persist for at least three months.

In 2021, 60% of patients at the Emory and Grady long COVID clinics enrolled in a study aimed at gathering more information on the illness. At the time of their enrollment, patients had already been dealing with COVID symptoms for an average of 107 days.

Even people who have mild or asymptomatic COVID-19 infections can have new health problems crop up months after they’ve tested negative.

Remaining vigilant

The CDC’s study evaluated electronic medical records for nearly 2 million people. The agency compared those who had been infected with the coronavirus and those who had not. The analysis found 38% percent of the COVID patients developed one or more new health problems, compared to 16% percent of the non-COVID patients. The health problems of about 21% of the younger COVID patients in the study, those ages 18 to 64, and nearly 27% of the older people, 65 and up, could be attributed to long COVID. The study did not look at vaccination status.

A growing number of studies suggest that getting a COVID vaccine can reduce — though not eliminate — the risk of longer-term symptoms.

Some experts think that today’s omicron strains pose a lower risk for long COVID than previous variants. But they caution: Even if omicron is less likely to cause long-lasting symptoms, particularly for people who have been vaccinated, the actual number of long COVID sufferers will still grow due to the high infection rate.

It’s often hard to determine whether health problems that emerge after a case of COVID are truly triggered by the virus.

Lead Nurse Practitioner Lori Reed, who works at the Piedmont Pulmonary COVID Recovery clinic, said some patients dealing with preexisting conditions may be more aware of them after coronavirus infections. That means it’s important for clinicians to obtain thorough medical histories to pinpoint when symptoms, such as dizziness, memory loss and headaches, started and when they worsened, she said.

“One that comes up all the time is asthma because asthma can develop at any point in life,” Reed said. “We know, historically, viral illnesses can cause asthma onset, so COVID can cause asthma onset. But, with women, hormonal changes and menopause can also cause onset.”

Reed recommends patients see a doctor after a COVID infection to rule out COVID-related damage to the body, and she urges people to remain vigilant of any sign of new problems.ExploreFrom November: Georgia long-COVID patients fight for benefits, legitimacy

“Pay attention to subtle things that some people may write off,” she said. “Talk to your doctor about brain fog or things like, ‘I just forgot what I was going to make for dinner,’ or ‘You know, that bill came in, and I forgot to pay for it.’”

At long COVID clinics, a team of specialists — cardiologists, pulmonologists, neurologists, psychiatrists and others — work together to treat patients. Often, the patients undergo a comprehensive evaluation, including a series of lab tests and imaging tests, to rule out other undiagnosed medical conditions.

Lacking established therapies for long COVID symptoms, doctors often rely on approaches that have been used for other ailments with similar symptoms.

“It’s been shocking. I’ve never seen, with other infections, such widespread, all-over-the-body symptoms for this long.”

– Dr. Alex Truong, co-director of Emory Healthcare’s post-COVID clinic

Neurological stimulants such as Adderall have shown to be effective at improving energy and focus. Albuterol, an inhaled medicine frequently used to treat asthma, can improve breathing. Other medications, physical therapy and cognitive programs also can be helpful.

“I would say to people who get COVID, you didn’t ask to get COVID, and you don’t deserve to fall ill and not have answers,” said Reed. “Reach out to somebody to at least be seen and evaluated because we can do things to get you feeling better. If we can’t reverse the long-term consequences, we can at least improve your quality of life.”

A high-stakes undertaking

Close to 1,000 people in Georgia — and at least 17,000 adults across the country — are being recruited for the massive NIH study called Researching COVID to Enhance Recovery (RECOVER). Its goal is to answer fundamental questions about exactly how the virus causes long COVID, which ultimately could lead to better, more tailored treatments.

The study sites in Atlanta — Emory Hope Clinic, Grady, Morehouse School of Medicine, the Atlanta Veterans Affairs Healthcare System and Kaiser Permanente of Georgia — will work together and are slated to receive a total of about$20 million over four years for the high-stakes undertaking.

The NIH study

The Atlanta sites for the NIH are still actively recruiting patients who have had COVID-19 in the past 30 days, as well as those who have never been infected. Click here for more information.

Walker, from Grady, said clinicians have been working to recruit a diverse group of adults, and are seeking three categories of participants: those who have COVID right now, those with long COVID, and others who have never had COVID. Finding people who have never had the illness is getting increasingly difficult with an ever-changing virus and continued waves of infections.

Plenty of theories have formed around long COVID. Some researchers think people suffer prolonged symptoms because they have never really shaken COVID-19, though they think they have. Instead, the virus is still hiding in their bodies, damaging nerves and other organs. Other research suggeststhe virus may be gone, but it causes the immune system to go haywire and attack the body.

There’s also research that indicates certain medical conditions may play a role in who develops long COVID, such as Type 2 diabetes, or a reactivation of Epstein-Barr virus, which infects most people when they are young.

‘A monster’

In July 2020, Latoshia Allen Perrymond fell ill with COVID. Within a week, the 52-year-old Stone Mountain woman was struggling to catch her breath. She ended up hospitalized — for four months.

Though she survived, COVID damaged her heart and lungs. She said she’s been struggling mightily ever since. Dependent on oxygen around the clock, the former caregiver now relies on family members to help care for her.

She can no longer go on walks with her husband or cook big meals, or even sleep lying flat.

In late March, she eagerly joined the NIH study at Grady.

Like other participants in the NIH RECOVER study, she’s undergoing physical assessments.

“I feel good about the study because it means that I’m part of the answers,” she said. “I’m willing to do whatever they need because this COVID and long COVD is a monster and it’s still creepy. I’m learning to live with this new norm for me, but I hope that I can get better.”

Doctors are also eager for more answers.

“My hope is to find a pathology that unifies all of these symptoms,” said Truong. “My hope is, as the pandemic progresses, the variants become less virulent and less likely to cause long haul issues, and more and more patients are getting vaccinated. I hope we learn from this pandemic so that, when the next pandemic comes, we are a lot smarter, a lot more nimble in our approach, and more aware of the long haul issues.”

For now, the best way to try to avoid long COVID is to try to avoid the virus, Truong said. Get vaccinated and boosted and wear masks – especially indoors around crowds of people.

“It’s as simple as that,” he said. “But, unfortunately, I don’t think people want to hear it.”

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Scientists propose cause of symptoms, treatment for long COVID-19

Authors: Gary Van Beusekom | News Writer | CIDRAP News   Posted June 10, 2022

Two studies to be presented at upcoming professional society meetings suggest that some long COVID-19 symptoms may be related to the effect of SARS-CoV-2 on the vagus nerve and that the use of enhanced external counterpulsation (EECP)—which increases blood flow—can improve some of those symptoms, respectively.

Long COVID may affect up to 15% of those who survive their infections, causing symptoms such as fatigue, muscle pain, and cognitive problems that linger for months. Neither study has been peer-reviewed, and the second one comes with the added caveat that it was conducted by an EECP provider.

Long COVID, vagus nerve symptoms may overlap

At the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), slated for Apr 23 to 26 in Lisbon, Portugal, a team led by researchers in Spain will discuss the role of the vagus nerve in long COVID, according to an ECCMID news release.

The vagus nerve runs from the brain into the torso, heart, lungs, intestines, and several muscles, including those involved in swallowing. It has a role in heart rate, speech, the gag reflex, the transfer of food from the mouth to stomach, transporting food through the intestines, perspiration, and other bodily functions.

The study authors said that SARS-CoV-2 infection may lead to long COVID symptoms such as dysphonia (voice problems), dysphagia (difficulty swallowing), dizziness, tachycardia (rapid heart rate), orthostatic hypotension (low blood pressure), and diarrhea. Long COVID has been reported to last for months to more than a year.

In the observational study, the researchers evaluated the morphologic and functional aspects of the vagus nerve in 348 patients diagnosed as having long COVID at a Spanish hospital from March to June 2021. Of the 348, 228 (66%) had at least one symptom that could be attributed to vagus nerve dysfunction (VND).

The ongoing study involved the first 22 participants identified as having at least one VND symptom; 91% of them were women, and the median age was 44 years. The most common VND symptoms were diarrhea (73%), tachycardia (59%), dizziness, dysphagia and dysphonia (45% each), and orthostatic hypotension (14%).

Nineteen of 22 participants (86%) had three or more VND symptoms with a median duration of 14 months. Ultrasound examination revealed that at 6 (27%) had alterations of the vagus nerve in the neck, including thickening of the nerve and increased echogenicity, which indicates mild inflammatory changes.

Thoracic ultrasound showed flattened diaphragmatic curves, indicating abnormal breathing, in 10 participants (46%). Ten of 16 patients (63%) had lower maximum inspiration pressures, indicating weakness of the muscles involved in breathing.

Thirteen of 18 patients (72%) had impaired eating and digestive function, including self-reported dysphagia. Among 19 patients assessed for gastric and bowel function, 8 (42%) had impaired ability to move food from the esophagus to the stomach, with 2 of these 8 reporting difficulty swallowing.

Nine of 19 patients (47%) had gastroesophageal acid reflux, with 4 of these 9 again having problems moving food to the stomach and 3 with hiatal hernia (bulging of the upper stomach through the diaphragm into the chest cavity).

A Voice Handicap Index 30 test (a standard method of measuring voice function) produced abnormal results in 8 of 17 patients (47%), indicating that 7 of the 8 had dysphonia.

“Our findings so far thus point at vagus nerve dysfunction as a central pathophysiological feature of long COVID,” the researchers said in the release.

Improvement in functional scores, fatigue after EECP

In a retrospective study to be presented this week at the American College of Cardiology’s (ACC’s) virtual Cardiovascular Summit, scientists from EECP provider Flow Therapy evaluated the effect of the therapy in 50 COVID-19 survivors, according to an ACC news release. Twenty patients had coronary artery disease (CAD), while 30 did not; average age was 54 years.

EECP uses contracting and relaxing pneumatic cuffs on the calves, thighs, and lower hip area to provide oxygen-rich blood to the heart muscle, brain, and the rest of the body. Each session takes 1 hour, and patients may undergo as many as 35 sessions over 7 weeks.

All patients completed the Seattle Angina Questionnaire-7 (SAQ7), Duke Activity Status Index (DASI), PROMIS Fatigue Instrument, Rose Dyspnea Scale (RDS), and the 6-minute walk test (6MWT) before and after they completed 15 to 35 hours of EECP therapy.

The analysis showed statistically significant improvements in all areas assessed, including 25 more points for health status on the SAQ7 (range, 0 to 100), 20 more points for functional capacity on DASI (range, 0 to 58.2), 6 fewer points for fatigue on PROMIS (range, 4 to 20), 50% lower shortness of breath score on the RDS, and 178 more feet on the 6MWT.

The change from baseline among participants who had long COVID but not CAD was significant for all end points, but there was no difference between long COVID patients with or without CAD.

“Emerging data shows that long COVID is a disease that impacts the health of vessels, also known as endothelial function,” senior author Sachin Shah, PharmD, said in the release. “EECP is a disease-modifying, non-invasive therapy that has previously shown to improve endothelial function in controlled clinical trials.”

Shah said that several study participants weren’t able to work at the beginning of the study. “Remarkably, all patients at this point were able to successfully return back to work after undergoing treatment,” he said. “These patients also showed improvement in ‘brain fog,’ which is a common symptom of long COVID.”

The researchers called for larger studies with a control group receiving sham therapy to validate their findings.

Risk of blood clots in lung doubled for Covid survivors

Authors: FMT May 25, 2022

Coronavirus survivors have twice the risk of developing dangerous blood clots that travel to their lungs compared to people who weren’t infected, as well double the chance of respiratory symptoms, a large new study said Tuesday.

The research by the Centers for Disease Control and Prevention found that as many as one in five adults aged 18-64 years and one in four of those over 65 went on to experience health conditions that could be related to their bout of Covid — a finding consistent with other research.

Among all conditions, the risk of developing acute pulmonary embolism — a clot in an artery of the lung — increased the most, by a factor of two in both adults younger and older than 65, as did respiratory symptoms like chronic cough or shortness of breath.

Pulmonary embolisms usually travel to the lungs from a deep vein in the legs, and can cause serious problems, including lung damage, low oxygen levels and death.

The study was based on more than 350,000 patient records of people who had Covid-19 from March 2020 – November 2021, paired with 1.6 million people in a “control” group who had sought medical attention in the same month as a corresponding “case” patient but weren’t diagnosed with Covid.

The team assessed the records for the occurrence of 26 clinical conditions previously associated with long Covid.

Patients were followed one month out from the time they were first seen until they developed a subsequent condition, or until a year had passed, whichever came first.

The most common conditions in both age groups were respiratory symptoms and musculoskeletal pain.

In patients under 65, risks after Covid elevated for most types of conditions, but no significant differences were observed for cerebrovascular disease, mental health conditions, or substance-related disorders.

“Covid-19 severity and illness duration can affect patients’ health care needs and economic well-being,” the authors wrote.

“The occurrence of incident conditions following infection might also affect a patient’s ability to contribute to the workforce and might have economic consequences for survivors and their dependents,” as well as placing added strain on health systems.

Limitations of the study included the fact that data on sex, race, and geographic region were not considered, nor was vaccination status. Because of the time period, the study also didn’t factor in newer variants.

Long COVID’s daunting toll seen in study of pandemic’s earliest patients

Authors: Melissa Healy   6 hrs ago

COVID-19 patients in Wuhan were among the pandemic’s first victims, and a comprehensive new study finds that a year after shaking the coronavirus, survivors were more likely than their uninfected peers to suffer from mobility problems, pain or discomfort, anxiety and depression.

detailed accounting of 1,276 people hospitalized for COVID-19 in the pandemic’s opening months reveals that a full year later, almost half continued to report at least one lingering health problem that is now considered a symptom of “long COVID.”

One out of five said they had continued fatigue and/or muscle weakness, and 17% said they were still experiencing sleep difficulties. Just over one in four said they were suffering anxiety or depression in the wake of their bout with the SARS-CoV-2 virus.

For the growing number of patients who identify themselves as COVID “long haulers,” the new accounting offers cause for optimism — and concern. The period from six to 12 months after infection brought improvement for many. But most patients struggling with symptoms at the six-month mark were not yet well six months later.

The findings, catalogued by a team of Chinese researchers, were published late Thursday in the medical journal Lancet.

“This is not good news,” said David Putrino, a rehabilitation specialist who works with COVID long haulers at Mount Sinai Hospital in New York. “If you run the numbers here, about one-third of the group that had persistent symptoms are getting better after 12 months, while two-thirds are not.”

Putrino also called the findings a “wake-up call” to public health officials that even when the pandemic is over — a distant enough prospect in the midst of a fourth wave of infections — its downstream consequences will not be.

“We’re going to need resources for many years to come to deal with these patients,” he said.

There will be a lot of them. More than 87,000 COVID-19 patients are being hospitalized each day in the United States, and 2.7 million have receiving hospital care in the past year alone.

The half who contend with persistent symptoms will show up in doctors’ offices with clusters of vague and perplexing complaints including brain fog, heart palpitations, pain and exhaustion. And despite emerging evidence that time and specialized treatment can help many to improve, few will have the wherewithal to spend months in intensive rehabilitation for their symptoms, Putrino said.

An editorial published alongside the new study noted that only 0.4% of COVID long haulers are receiving rehabilitative treatment for their symptoms.

Even as scientists puzzle over the common biological mechanisms of long COVID’s diverse symptoms, healthcare providers “must acknowledge and validate the toll of the persistent symptoms of long COVID on patients, and health systems need to be prepared to meet individualised, patient-oriented goals, with an appropriately trained workforce,” Lancet’s editors wrote.

The new research also offered some glimmers of hope.

When the study’s COVID-19 patients were examined at six months, 68% said they had at least one of 15 symptoms considered hallmarks of long COVID, which is also known as Post-Acute Sequelae of COVID, or PASC. At one year, 49% were still afflicted by at least one of those symptoms.

The proportion of patients with ongoing muscle weakness and fatigue dropped from 52% to 20% during that time. Patients experiencing loss of smell dropped from 11% to 4%, and those afflicted with sleep problems fell from 27% to 17%. The 22% who reported hair loss at six months dwindled to 11% a full year out.

At the same time, the numbers of patients reporting breathing difficulties saw a slight increase, rising from 26% at six months to 30% after a year. Likewise, patients who reported new depression or anxiety increased from 23% to 26% during that period.

Study co-author Xiaoying Gu from the China-Japan Friendship Hospital in Beijing said the slight uptick in anxiety and depression was, like all of long COVID’s symptoms, hard to explain.

The psychiatric symptoms “could be caused by a biological process linked to the virus infection itself, or the body’s immune response to it,” he said. “Or they could be linked to reduced social contact, loneliness, incomplete recovery of physical health or loss of employment associated with illness.”

Patients who required mechanical ventilation were more likely than those with less severe illness to have measurable lung impairment and abnormal chest X-rays at both six and 12 months.

But in the tally of more subjective long COVID symptoms, the difference between the most severely ill and those who required no supplemental oxygen at all was very small.

That finding underscores the fact that even patients who are only mildly ill are at risk of developing a range of persistent symptoms.

Of the study population’s 479 patients who held jobs when the pandemic struck, 88% had returned to work a year after their illness. Most of the 57 who did not return said they either could not or were unwilling to do the tasks required of them.

The findings from the Wuhan patients also tracked with the widespread observation that persistent post-COVID infection symptoms are more common in women than in men. Women who had been hospitalized for COVID-19 were twice as likely as their male counterparts to report depression or anxiety 12 months later. In addition, they were close to three times as likely to show evidence of impaired lung function, and 43% more likely to report symptoms of fatigue and muscle weakness.

All of the study’s participants were treated at a single hospital in Wuhan, where reports of a mysterious new form of pneumonia first surfaced in December 2019. The researchers followed a large group of patients sickened in the first five months that the outbreak.

That makes the Lancet report one of the earliest and largest accounts of lingering COVID-19 symptoms to be tallied and vetted by other researchers, and the only one to compare such patients to a group of uninfected peers matched on a wide range of demographic and health attributes.

One thing is already clear, the journal editors noted: “Long COVID is a modern medical challenge of the first order.”

This story originally appeared in Los Angeles Times.

Covid-19 Vaccine Analysis: The most common adverse events reported so far

Authors: DATED: AUGUST 6, 2021 BY SHARYL ATTKISSON 

As of July 19, 2021 there were 419,513 adverse event reports associated with Covid-19 vaccination in the U.S., with a total of 1,814,326 symptoms reported. That’s according to the federal Vaccine Adverse Event Reporting System (VAERS) database.

Report an adverse event after vaccination online here.

Each symptom reported does not necessarily equal one patient. Adverse event reports often include multiple symptoms for a single patient.

Reporting of illnesses and symptoms that occur after Covid-19 vaccination does not necessarily mean they were caused by the vaccine. The system is designed to collect adverse events that occur after vaccination to uncover any patterns of illnesses that were not captured during vaccine studies.

Read CDC info on Covid-19 vaccine here.

Scientists have estimated that adverse events occur at a rate many fold higher than what is reported in VAERS, since it is assumed that most adverse events are not reported through the tracking system. Reports can be made by doctors, patients or family members and/or acquaintances, or vaccine industry representatives. 

Read: Exclusive summary: Covid-19 vaccine concerns.

Some observers claim Covid-19 vaccine adverse events are not as likely to be underreported as those associated with other medicine, due to close monitoring and widespread publicity surrounding Covid-19 vaccination.

Approximately 340 million doses of Covid-19 vaccine have been given in the U.S. Slightly less than half of the U.S. population is fully vaccinated.

According to the Centers for Disease Control (CDC) and Food and Drug Administration (FDA), the benefits of Covid-19 vaccine outweigh the risks for all groups and age categories authorized to receive it.

Watch: CDC disinformation re: studies on Covid-19 vaccine effectiveness in people who have had Covid-19.

The following is a summary of some of the most frequent adverse events reported to VAERS after Covid-19 vaccination. (It is not the entire list.)

Most common Covid-19 vaccine adverse events reported as of July 19, 2021

Yellow highlighted adverse events are subjects of investigations, warnings or stated concerns by public health officials. For details, click here.

128,370 Muscle, bone, joint pain and swelling including:

  • 39,902 Pain in extremity
  • 37,819 Myalgia, muscle pain, weakness, fatigue, spasms, disorders, related
  • 30,138 Arthralgia, joint pain or arthritis, swelling, joint disease, bone pain, spinal osteoarthritis
  • 14,682 Back pain, neck pain
  • 5,829 Muscle and skeletal pain, stiffness, weakness

119,866 Injection site pain, bleeding, hardening, bruising, etc.

105,332 Skin reddening, at injection site or elsewhere, rash, hives

100,564 Fatigue, lethargy, malaise, asthenia, abnormal weakness, loss of energy

89,302 Headache, incl. migraine, sinus

68,252 Vomiting, nausea

68,064 Fever

63,133 Chills

60,913 Pain

49,574 Dizziness

34,076 Flushing, hot flush, feeling hot, abnormally warm skin

31,785 Lung pain or abnormalities, fluid in lung, respiratory tract or lung congestion or infection, wheezing, acute respiratory failure including:

  • 23,005 Dyspnoea, difficulty breathing
  • 1,398 Pneumonia
  • 1,128 Respiratory arrest, failure, stopped or inefficient breathing, abnormal breathing
  • 563 Covid-19 pneumonia
  • 265 Mechanical ventilation
  • 217 Bronchitis

30,909 Skin swelling, pain, tightness, face swelling, swelling under skin, hives, angioedema including:

  • 7,579 Skin pain, sensitivity, burning, discoloration, tenderness

25,319 Heart failure, heart rhythm and rate abnormalities, atrial fibrillation, palpitations, flutter, murmur, pacemaker added, fluid in heart, abnormal echocardiogram including:

  • 3,105 Heart attack or cardiac arrest, sudden loss of blood flow from failure to pump to heart effectively, cardiac failure, disorder

22,085 Itchiness

29,861 Sensory disturbance including:

  • 8,236 Tinnitus, hearing noise
  • 7,951 Abnormal vision, blindness
  • 6,349 Ageusia, loss of taste, altered taste, disorders
  • 2,249 Anosmia, loss of smell, parosmia (rotten smell)
  • 2,075 Hypersensitivity
  • 1,560 Sensitivity or reaction to light 
  • 890 Hearing loss, deafness

Post-acute COVID-19 syndrome

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic, which has resulted in global healthcare crises and strained health resources. As the population of patients recovering from COVID-19 grows, it is paramount to establish an understanding of the healthcare issues surrounding them. COVID-19 is now recognized as a multi-organ disease with a broad spectrum of manifestations. Similarly to post-acute viral syndromes described in survivors of other virulent coronavirus epidemics, there are increasing reports of persistent and prolonged effects after acute COVID-19. Patient advocacy groups, many members of which identify themselves as long haulers, have helped contribute to the recognition of post-acute COVID-19, a syndrome characterized by persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms. Here, we provide a comprehensive review of the current literature on post-acute COVID-19, its pathophysiology and its organ-specific sequelae. Finally, we discuss relevant considerations for the multidisciplinary care of COVID-19 survivors and propose a framework for the identification of those at high risk for post-acute COVID-19 and their coordinated management through dedicated COVID-19 clinics.

Main

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogen responsible for coronavirus disease 2019 (COVID-19), has caused morbidity and mortality at an unprecedented scale globally1. Scientific and clinical evidence is evolving on the subacute and long-term effects of COVID-19, which can affect multiple organ systems2. Early reports suggest residual effects of SARS-CoV-2 infection, such as fatigue, dyspnea, chest pain, cognitive disturbances, arthralgia and decline in quality of life3,4,5. Cellular damage, a robust innate immune response with inflammatory cytokine production, and a pro-coagulant state induced by SARS-CoV-2 infection may contribute to these sequelae6,7,8. Survivors of previous coronavirus infections, including the SARS epidemic of 2003 and the Middle East respiratory syndrome (MERS) outbreak of 2012, have demonstrated a similar constellation of persistent symptoms, reinforcing concern for clinically significant sequelae of COVID-19 (refs. 9,10,11,12,13,14,15).

Systematic study of sequelae after recovery from acute COVID-19 is needed to develop an evidence-based multidisciplinary team approach for caring for these patients, and to inform research priorities. A comprehensive understanding of patient care needs beyond the acute phase will help in the development of infrastructure for COVID-19 clinics that will be equipped to provide integrated multispecialty care in the outpatient setting. While the definition of the post-acute COVID-19 timeline is evolving, it has been suggested to include persistence of symptoms or development of sequelae beyond 3 or 4 weeks from the onset of acute symptoms of COVID-19 (refs. 16,17), as replication-competent SARS-CoV-2 has not been isolated after 3 weeks18. For the purpose of this review, we defined post-acute COVID-19 as persistent symptoms and/or delayed or long-term complications of SARS-CoV-2 infection beyond 4 weeks from the onset of symptoms (Fig. 1). Based on recent literature, it is further divided into two categories: (1) subacute or ongoing symptomatic COVID-19, which includes symptoms and abnormalities present from 4–12 weeks beyond acute COVID-19; and (2) chronic or post-COVID-19 syndrome, which includes symptoms and abnormalities persisting or present beyond 12 weeks of the onset of acute COVID-19 and not attributable to alternative diagnoses17,19. Herein, we summarize the epidemiology and organ-specific sequelae of post-acute COVID-19 and address management considerations for the interdisciplinary comprehensive care of these patients in COVID-19 clinics 

For More Information: https://www.nature.com/articles/s41591-021-01283-z

Long covid: Damage to multiple organs presents in young, low risk patients

Authors: Gareth Iacobucci BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4470 (Published 17 November 2020)Cite this as: BMJ 2020;371:m4470

Young, low risk patients with ongoing symptoms of covid-19 had signs of damage to multiple organs four months after initially being infected, a preprint study has suggested.1

Initial data from 201 patients suggest that almost 70% had impairments in one or more organs four months after their initial symptoms of SARS-CoV-2 infection.

The results emerged as the NHS announced plans to establish a network of more than 40 long covid specialist clinics across England this month to help patients with long term symptoms of infection.

The prospective Coverscan study examined the impact of long covid (persistent symptoms three months post infection) across multiple organs in low risk people who are relatively young and had no major underlying health problems. Assessment was done using results from magnetic resonance image scans, blood tests, and online questionnaires.

The research has not yet been peer reviewed and could not establish a causal link between organ impairment and infection. But the authors said the results had “implications not only for [the] burden of long covid but also public health approaches which have assumed low risk in young people with no comorbidities.”

The study enrolled participants at two UK sites in Oxford and London between April and August 2020. Two hundred and one individuals (mean age 44 (standard deviation 11.0) years) completed assessments after SARS-CoV-2 infection a median of 140 days after initial symptoms.

Participants were eligible if they tested positive for SARS-CoV-2 by random polymerase chain reaction swab (n=62), a positive antibody test (n=63), or had typical symptoms and were determined to have covid-19 by two independent clinicians (n=73).

The prevalence of pre-existing conditions was low (obesity: 20%, hypertension: 6%, diabetes: 2%, heart disease: 4%), and less than a fifth (18%) of individuals had been hospitalised with covid-19.

The most commonly reported ongoing symptoms—regardless of hospitalization status—were fatigue (98%), muscle ache (88%), shortness of breath (87%), and headache (83%). There was evidence of mild organ impairment in the heart (32% of patients), lungs (33%), kidneys (12%), liver (10%), pancreas (17%), and spleen (6%).

For More Information: https://www.bmj.com/content/371/bmj.m4470

Long covid—mechanisms, risk factors, and management

Authors: Harry Crook, research assistant1,  Sanara Raza, research assistant1,  Joseph Nowell, research assistant1,  Megan Young, clinical research officer1,  Paul Edison, clinical senior lecturer, honorary professor12

Abstract

Since its emergence in Wuhan, China, covid-19 has spread and had a profound effect on the lives and health of people around the globe. As of 4 July 2021, more than 183 million confirmed cases of covid-19 had been recorded worldwide, and 3.97 million deaths. Recent evidence has shown that a range of persistent symptoms can remain long after the acute SARS-CoV-2 infection, and this condition is now coined long covid by recognized research institutes. Studies have shown that long covid can affect the whole spectrum of people with covid-19, from those with very mild acute disease to the most severe forms. Like acute covid-19, long covid can involve multiple organs and can affect many systems including, but not limited to, the respiratory, cardiovascular, neurological, gastrointestinal, and musculoskeletal systems. The symptoms of long covid include fatigue, dyspnea, cardiac abnormalities, cognitive impairment, sleep disturbances, symptoms of post-traumatic stress disorder, muscle pain, concentration problems, and headache. This review summarizes studies of the long term effects of covid-19 in hospitalized and non-hospitalized patients and describes the persistent symptoms they endure. Risk factors for acute covid-19 and long covid and possible therapeutic options are also discussed.

Introduction

Coronavirus disease 2019 (covid-19) has spread across the world. As of 4 July 2021, more than 183 million confirmed cases of covid-19 have been recorded worldwide, and more than 3.97 million deaths have been reported by the World Health Organization .1 The clinical spectrum of covid-19 ranges from asymptomatic infection to fatal disease.23 The virus responsible for causing covid-19, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), enters cells via the angiotensin-converting enzyme 2 (ACE2) receptor.4 Once internalized, the virus undergoes replication and maturation, provoking an inflammatory response that involves the activation and infiltration of immune cells by various cytokines in some patients.5 The ACE2 receptor is present in numerous cell types throughout the human body, including in the oral and nasal mucosa, lungs, heart, gastrointestinal tract, liver, kidneys, spleen, brain, and arterial and venous endothelial cells, highlighting how SARS-CoV-2 can cause damage to multiple organs.67

The impact of covid-19 thus far has been unparalleled, and long term symptoms could have a further devastating effect.8 Recent evidence shows that a range of symptoms can remain after the clearance of the acute infection in many people who have had covid-19, and this condition is known as long covid. The National Institute for Health and Care Excellence (NICE) defines long covid as the symptoms that continue or develop after acute covid-19 infection and which cannot be explained by an alternative diagnosis. This term includes ongoing symptomatic covid-19, from four to 12 weeks post-infection, and post-covid-19 syndrome, beyond 12 weeks post-infection.9 Conversely, The National Institutes of Health (NIH) uses the US Centers for Disease Control and Prevention (CDC) definition of long covid, which describes the condition as sequelae that extend beyond four weeks after initial infection.10 People with long covid exhibit involvement and impairment in the structure and function of multiple organs.11121314 Numerous symptoms of long covid have been reported and attributed to various organs, an overview of which can be seen in fig 1. Long term symptoms following covid-19 have been observed across the spectrum of disease severity. This review examines the long term impact of symptoms reported following covid-19 infection and discusses the current epidemiological understanding of long covid, the risk factors that may predispose a person to develop the condition, and the treatment and management guidelines aimed at treating it.

Multi-organ complications of covid-19 and long covid. The SARS-CoV-2 virus gains entry into the cells of multiple organs via the ACE2 receptor. Once these cells have been invaded, the virus can cause a multitude of damage ultimately leading to numerous persistent symptoms, some of which are outlined here.

For More Information: https://www.bmj.com/content/374/bmj.n1648

COVID-19-Associated Bronchiectasis and Its Impact on Prognosis

Authors: Aasir M. SulimanBassel W. BitarAmer A. FarooqiAnam M. ElarabiMohamed R. AboukamarAhmed S. Abdulhadi

Abstract

Coronavirus disease 2019 (COVID-19), which initially emerged in Wuhan, China, has rapidly swept around the world, causing grave morbidity and mortality. It manifests with several symptoms, on a spectrum from asymptomatic to severe illness and death. Many typical imaging features of this disease are described, such as bilateral multi-lobar ground-glass opacities (GGO) or consolidations with a predominantly peripheral distribution. COVID-19-associated bronchiectasis is an atypical finding, and it is not a commonly described sequel of the disease. Here, we present a previously healthy middle-aged man who developed progressive bronchiectasis evident on serial chest CT scans with superimposed bacterial infection following COVID-19 pneumonia. The patient’s complicated hospital course of superimposed bacterial infection in the setting of presumed bronchiectasis secondary to COVID-19 is alleged to have contributed to his prolonged hospital stay, with difficulty in weaning off mechanical ventilation. Clinicians should have high suspicion and awareness of such a debilitating complication, as further follow-up and management might be warranted.

Introduction

Beginning in December 2019, a series of pneumonia cases were reported in Wuhan City, Hubei Province, China. Further investigations revealed that it was a new type of viral pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), which was termed coronavirus disease 2019 (COVID-19). Symptoms are variable, nonspecific, and include dry cough, fever, fatigue, myalgia, dyspnea, anosmia, and ageusia [1]. The real-time reverse transcription-polymerase chain reaction (rRT-PCR) test is the current gold standard for confirming infection and is performed using nasal or pharyngeal swab specimens.

Computerized tomography of the thorax (CT thorax), as a routine imaging tool for pneumonia diagnosis, is of great importance in the early detection and treatment of patients affected by COVID-19. Chest CT may detect the early parenchymal abnormalities in the absence of positive rRT-PCR at initial presentation [2]. Since chest CT was introduced as a diagnostic tool for COVID-19 pneumonia, many typical features of this disease were described such as bilateral multi-lobar ground-glass opacification (GGO) with a prevalent peripheral or posterior distribution, mainly in the lower lobes; sometimes, consolidative opacities superimposed on GGOs could be found [3]. To our knowledge, bronchiectasis is not a classical finding in COVID-19 pneumonia, with a paucity of reporting on its development and progression during the disease course.

For More Information: https://www.cureus.com/articles/59350-covid-19-associated-bronchiectasis-and-its-impact-on-prognosis

Reactogenicity Following Receipt of mRNA-Based COVID-19 Vaccines

Authors: Johanna Chapin-Bardales, PhD, MPH1Julianne Gee, MPH1Tanya Myers, PhD, MSc1

In December 2020, 2 mRNA-based COVID-19 vaccines (Pfizer-BioNTech and Moderna) were granted Emergency Use Authorization by the US Food and Drug Administration as 2-dose series and recommended for use by the Advisory Committee on Immunization Practices.13 In late February 2021, the US Food and Drug Administration granted Emergency Use Authorization for a third COVID-19 vaccine, a single-dose adenovirus vector-based vaccine from Janssen (Johnson & Johnson).

In clinical trials of the mRNA-based 2-dose vaccines, participants reported local and systemic reactions (reactogenicity).4,5 Frequently reported reactions included injection site pain, fatigue, and headache; greater reactogenicity was reported following the second dose.4,5 Continued monitoring of reactogenicity of COVID-19 vaccines outside of clinical trial settings may provide additional information for health care practitioners and the public about transient local and systemic reactions following COVID-19 vaccination.

V-safe Active Surveillance System

To facilitate rapid assessment of COVID-19 vaccines, in 2020, the Centers for Disease Control and Prevention (CDC) established v-safe, a new active surveillance system for collecting near–real-time data from COVID-19 vaccine recipients in the US. V-safe participants voluntarily self-enroll and receive periodic smartphone text messages to initiate web-based health surveys from the day of vaccination (day 0) through 12 months after the final dose of a COVID-19 vaccine.6 From day 0 through day 7 after each vaccine dose, participants are asked questions about solicited local and systemic reactions (eg, injection site pain, fatigue, headache). These solicited reactions do not include allergic reactions or anaphylaxis; however, v-safe does allow participants to enter free-text information about their postvaccination experience and asks about adverse health events (eg, received medical care). Medically attended events are followed up on through active telephone outreach; future analyses will address these adverse vaccine experiences. This report describes information on solicited local and systemic reactogenicity reported to v-safe on days 0 to 7 after each dose of vaccine from December 14, 2020, through February 28, 2021. Responses were limited to individuals who were vaccinated by February 21, 2021, to allow a 7-day reporting period after the day of vaccination. Preliminary data from v-safe through January 13, 2021, have been previously reported.7 This activity was reviewed by the CDC and was conducted consistent with applicable federal law and CDC policy (see Additional Information).

Self-reported Local and Systemic Reactions Among V-safe Participants

By February 21, 2021, more than 46 million persons received at least 1 dose of an mRNA-based COVID-19 vaccine.8 A total of 3 643 918 persons were enrolled in v-safe and completed at least 1 health survey within 7 days following their first vaccine dose; 1 920 872 v-safe participants reported receiving a second vaccine dose and completed at least 1 daily health survey within 7 days following the second dose. Solicited local and systemic reactions during days 0 to 7 after each dose were assessed.

Most v-safe participants reported an injection site reaction (dose 1: 70.0%; dose 2: 75.2%) or a systemic reaction (dose 1: 50.0%; dose 2: 69.4%) during days 0 to 7 after vaccination (Table). The most frequently reported solicited local and systemic reactions after the first dose of COVID-19 vaccine were injection site pain (67.8%), fatigue (30.9%), headache (25.9%), and myalgia (19.4%). Reactogenicity was substantially greater after the second dose for both vaccines, particularly for systemic reactions, including fatigue (53.9%), headache (46.7%), myalgia (44.0%), chills (31.3%), fever (29.5%), and joint pain (25.6%).Table.  Solicited Local and Systemic Reactionsa to mRNA-Based COVID-19 Vaccines Reported 0 to 7 Days After Vaccination—Centers for Disease Control and Prevention V-safe Surveillance System, December 14, 2020, to February 28, 2021 View LargeDownload

Solicited Local and Systemic Reactionsa to mRNA-Based COVID-19 Vaccines Reported 0 to 7 Days After Vaccination—Centers for Disease Control and Prevention V-safe Surveillance System, December 14, 2020, to February 28, 2021

A greater percentage of participants who received the Moderna vaccine, compared with the Pfizer-BioNTech vaccine, reported reactogenicity; this pattern was more pronounced after the second dose (Table). When stratified by age (<65 vs ≥65 years), differences in reactogenicity by vaccine remained consistent with overall findings (data not shown). Local and systemic reactions were less commonly reported by v-safe participants 65 years and older compared with those younger than 65 years, but greater reactogenicity after the second dose was observed for both age groups (eFigure in the Supplement). For both doses of both vaccines, the percentage of v-safe participants who reported local and systemic reactions was highest on day 1 after vaccination and declined markedly through day 7.

For More Information: https://jamanetwork.com/journals/jama/fullarticle/2778441