Long COVID, What Is It and How Do We Treat It?

An interesting comment published by Burke and Del Rio in The Lancet Infectious Diseases June 18, 2020 discusses this issue.

Long COVID or post-acute SARS-CoV-2 infection is being seen in a growing number of patients reporting a variety of different symptoms following SARS-CoV-2 infection.

These symptoms are persistent, debilitating, and have yet to be fully explained by known or measurable mechanisms.

Long Covid Symptoms Include:

  • Fatigue
  • Cognitive difficulties
  • Mood dysregulation
  • Headaches
  • Insomnia
  • Dizziness
  • A variety of other neurological, neuropsychiatric, autonomic and systemic symptoms

These symptoms are being reported by patients even with mild initial infection that did not require hospitalisation or medical attention.

Many physicians have reported having such symptoms post COVID-19, which has added support to initial pleas that long COVID symptoms exist and can be debilitating.

As many have pointed out, the cluster of symptoms reported by patients post COVID-19 are not unique or specific to long COVID. Patients with similar assortments of COVID symptoms are commonly found in urology, rheumatology, infectious diseases, and other sub speciality clinics. Some patients will have similar post infectious onsets whereas others report other potential triggers, and for some there are no identifiable triggers at all.

Unfortunately, for most of these symptoms, there are no validated objective biomarkers to aid in diagnosis or to quantifiably measure an abnormal structural state. Indeed, disruptions in brain and brain body functions that probably account for such symptoms cannot yet be reliably identified by conventional blood tests or brain scans. Thus, a common denominator in this field is medical consultations largely based on diagnostic exclusion, in which the absence of further answers or direction for recovery can lead to patients being dismissed and dissatisfied.

Two broad possibilities exist to explain where long COVID might fit in this complex and controversial field.

First, COVID-19 could trigger post infectious processes that generate persistent symptoms in a unique way that is distinct from previously encountered patients. Although this would traditionally decry guiding principles, we cannot ignore SARS-CoV-2 many firsts, its use of be ACE2 receptor similar to the SARS-CoV-2 and the particularly aggressive interactions that have been observed with the brain, other organs and blood vessels in some patients.

Second, long COVID might exemplify the category of mysterious, unexplained chronic symptoms either post infectious or not and could operate via similar mechanisms to symptoms seen in other patients.

The major problems in teasing this out is that the latter, despite a long history of high numbers of patients, has remained very poorly understood and constitutes one of medicine’s largest blind spots. This results in conflicting expert nations starting with physiological explanations, some models presenting inflammatory or immune mediated cascades that might take place with primary importance on a given trigger. Whereas traditional psychological theories heavily weight psychological factors in the potential overlap between these constellations of symptoms and bodily manifestations of stress responses and anxiety.

Alternatively, contemporary neuropsychiatry models present this polarisation as a false dichotomy and highlight the potential importance of predisposing factors including genetic and psychosocial factors, that might result in the dysfunction of the brain or brain body circuits and networks that then interact with a potential triggering event.

long covid

Long Covid Care

LGP, The London General Practice has formed a multidisciplinary team to help those who are suffering with post-acute COVID or long COVID. This involves rheumatologists, physicians, rehabilitative specialists, cardiologists, respiratory physicians and psychologists. Please do not hesitate to contact us if you feel that you are suffering with post-acute COVID or long COVID symptoms.

Every proposed explanation on this topic has gaps and they are not necessarily mutually exclusive hypotheses. The comment follows that for now the most important thing to do is to study long COVID with no assumptions and to interrogate potential unique factors about COVID-19 that could explain why these symptoms seem to be triggered with a particular high propensity. The COVID-19 pandemic and the large and growing numbers of patients with long term symptoms offers an unprecedented window to study these symptoms, their interrelationships and their puzzling pathogenesis.

Attention needs to be paid to this important topic and even if a line of research does not lead to definitive answers, it is confident that there will be valuable new insights within this field. It is important that all researchers have an open mind. There is no right or wrong but careful close objective markers of these complex symptoms and easing the suffering of those affected should be paramount.

Dr Paul Ettlinger
Founder, The London General Practice

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