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Post Covid Care

A clinical primer for the expected and potential post-COVID-19 syndromes

Joseph Varon, MD, FACP, FCCP, FCCM, FRSM

Post COVID syndromes

With 30 million infections already documented Worldwide and the potential to infect over a 100 million people, the long-term consequences of COVID-19 infections will be a major health care focus for years after the contagion subsides. The common complications are expected to be accompanied by familiar patterns of pain and aversive sensations.

Known complications of Coronavirus- 19 infections

Acute COVID-19 infections resemble other viral respiratory tract infections, presenting with fever, fatigue, dry cough, myalgias, and dyspnea .

Headaches, sore throat, rhinorrhea, gastrointestinal, gustation are also commonly reported presenting features.

Covid physiopathology

COVID-19 penetrates human cells through its exquisite specificity to the angiotensin-converting enzyme-2 receptor.

The angiotensin-converting enzyme-2 receptor is widely expressed in human tissue, most notably in lung alveolar cells, small intestine enterocytes, and the vascular endothelium

COVID Complications

The complications of COVID are most often related to overexuberant immunological responses to the viral infection in the tissues or protective membranes of affected organs. The most severe damage seems to be a consequence of substantial monocyte and macrophage recruitment into affected tissues and their unchecked activation.

Inflammatory consequences….

  • Acute respiratory distress syndrome and pleuritis in the lung
  • Myocarditis and pericarditis in the heart
  • Encephalitis and meningitis in the brain
  • Conjunctivitis
  • Pancreatitis
  • Oral ulcers
  • Kawasaki disease in infected children

Inflammatory consequences….

Visceral thrombosis represents a second mechanism in which COVID-19 can create complications. Microthrombi during COVID-19 infections have been documented to occur in nearly every organ. Dramatically elevated levels of D-dimer and fibrin degradation products are a hallmark of the coagulopathy

Organ-specific presentations

Lungs

  • Pneumonia
  • Pleurisy
  • Chronic cough
  • Pulmonary emboli can lead to chronic pleuritic pain
  • Shortness of breath
  • Decreased exercise tolerance
  • Fatigue issues

Heart

  • Myocardial injury
  • Myocarditis can lead to chronic cardiac chest pain
  • Exercise intolerance
  • Fatigue

Musculoskeletal

  • Muscle pain
  • Myalgia
  • Joint pain have been reported as a presenting feature in 35% to 50% of all cases.
  • It is also a symptom that frequently persist after initial recovery

Gastrointestinal

  • Nausea
  • Vomiting
  • Diarrhea
  • Loss of appetite
  • Abdominal pain are common presenting features, reported to occur in 1 of 5 of COVID-19
  • infections

Blood

  • COVID-19 infection has been shown to trigger painful flares in Sickle cell disease.

Autoinmune

  • The rare relationship between acute COVID-19 infection and the development of pediatric inflammatory multisystemic syndrome, which is a variant of Kawasaki Disease, has been demonstrated, with 497% increase in number of cases reported in France during the first 4 months of pandemic.
  • Idiopathic thrombocytopenic purpura
  • Guillain–Barre syndrome
  • Autoimmune hemolytic anemia

Cancer

  • Coronaviruses are not currently recognized as viruses with oncogenic potential.
  • Society are ubiquitous and not characterized in the standard of practice health care. It is possible that COVID-19 may confer an increased risk of developing malignancy that can only be recognized over time with epidemiological surveillance.

Neurological

  • Headache: prevalence 11% to 40% moderate to severe bilateral pressing/pulsing pain. tempoparietal, periorbital, or bifrontal areas. Not responsive to typical analgesics
  • Additionally: thrombotic, demyelinating, inflammatory, and direct viral insult.
  • Long term effects:deficits in motor, sensory function, cognition, pain, bowel bladder function.
  • Also reported: demyelination of GBS.
  • Diminish and alter taste and smell. Reports of not recovering these senses. Consequences: nutritional, safety, and psychological.
  • Also reported: psychosis, structured delusions and pseudodementia
  • Neuropsychological sequelae: Due to critical illness stressors (lengthy hospitalization, and intensive care interventions).

Post viral fatigue syndromes

  • Postviral fatigue syndromes include: Cognitive alterations, unrefreshing sleep, and postexertional malaise. Recognized since 1980s.
  • Fatigue syndromes: Evans’ 1934 description of chronic brucellosis.
  • Gilliam: first report of fatiguing symptoms occurring during acute epidemic. “Atypical poliomyelitis” at the Los Angeles County Hospital
  • Premorbid lifestyle factors have also been related to prolonged recoveries.

Post viral syndromes and COVID-19

  • 181SARS: Survivors followed for 41.3 months.Reported somatic pain disorder: 15.5%
  • Similar reports expected in COVID-19: sufficient to trigger a postviral syndrome.
  • Common: fatigue, headache, chest pain, musculoskeletal pain, shortness of breath, chronic cough, cognitive alterations, sleep disturbances, anxiety, exercise intolerance, and autonomic symptoms.

Sociocultural impact

  • Unprecedented sociocultural stresses.
  • Topics: health, social, and financial uncertainties. Resulting in moderate to severe anxiety, depression, and insomnia
  • Consequences :impact on neurologic, endocrine, and immune functioning, even in people untouched by the virus.

Clinical Summary

Follow Up

What to do?

  • Bedside vitamin C levels If low, 3 infusions of 3 grams of intravenous vitamin C 48 hours apart Daily Vitamin C po (2 grams daily)
  • Daily Thiamine (200 mg PO)
  • Melatonin 6 mg PO q hs
  • Elemental Zinc (220 mg daily)
  • Follow the visitation protocol 100%