With more than 30 million documented infections and 1 million deaths worldwide, the coronavirus disease 2019 (COVID-19) pandemic continues unabated. The clinical spectrum of severe acute respiratory syndrome coronavirus (SARS-CoV) 2 infection ranges from asymptomatic infection to fatal and life-threatening disease.
Current estimates are that approximately 20 million people worldwide have "recovered" ; However, clinicians are seeing and reading reports of patients with persistent severe symptoms and even substantial end-organ dysfunction following SARS-CoV-2 infection. Because COVID-19 is a new disease, much of the clinical course remains uncertain, in particular the potential long-term health consequences, if any.
Epidemiology
Currently, there is no consensus definition of post-acute COVID-19 . According to the COVID Symptom Study, in which more than 4 million people in the US, UK and Sweden have entered their symptoms after a COVID-19 diagnosis, post-acute COVID-19 is defined as the presence of symptoms that extend beyond 3 weeks from the onset of symptoms and chronic COVID-19 extends beyond 12 weeks. It is possible that people with symptoms were more likely to participate in this study than those without symptoms.
Described above, a post-acute syndrome is well recognized in patients who are recovering from a serious illness, particularly an illness that required hospitalization and admission to the intensive care unit.
In a 2016 study among 43 patients who had been discharged after their intensive care unit stay (46% required mechanical ventilation), 36 (84%) reported deterioration in cognition, mental health, or physical function that persisted. for 6 to 12 months after hospital discharge, known collectively as post-intensive care syndrome .
In a study from Italy that assessed the persistence of COVID-19 symptoms among 143 patients discharged from hospital, only 18 patients (12.6%) were completely free of COVID-19-related symptoms after a median of 60 days. after the onset of initial symptoms3.
However, post-acute COVID-19 syndrome is not only seen in patients who had severe illness and were hospitalized. In a telephone survey conducted by the Centers for Disease Control and Prevention among a random sample of 292 adults (≥18 years) who tested positive for SARS-CoV-2 outpatient chain reaction reverse transcriptase polymerase, 35% of 274 symptomatic respondents reported not having returned to their usual health 2 weeks or more after testing, including 26% among those aged 18 to 34 years (n = 85), 32% among those aged 35 to 49 years (n = 96), and 47% among those aged 50 years or older (n = 89).
Those older than 50 years and the presence of 3 or more chronic medical conditions were associated with not returning to usual health within 14 to 21 days of receiving a positive test result. However, 1 in 5 people ages 18 to 34 without chronic medical conditions had not yet reached baseline health when interviewed a median of 16 days from the date of testing.
Demonstrations
The most frequently reported symptoms after acute COVID-19 are fatigue and dyspnea.
Other common symptoms include joint pain and chest pain. In addition to these general symptoms, specific organ dysfunction has been reported, primarily affecting the heart, lungs, and brain.
From the point of view of pathogenesis , these complications could be a consequence of direct tissue invasion by the virus (possibly mediated by the presence of the angiotensin-converting enzyme 2 receptor), deep inflammation and cytokine storm, damage to the immune system. related, hypercoagulable state described in association with severe COVID-19 or a combination of these factors.
Cardiovascular
Myocardial injury, defined by an elevated troponin level, has been described in patients with severe acute COVID-19, along with thromboembolic disease.
Inflammation and myocarditis , as well as cardiac arrhythmias, have been described after SARS-CoV-2 infection. In a German study of 100 patients who recently recovered from COVID-19, cardiac MRI (performed a median of 71 days after COVID-19 diagnosis) revealed cardiac involvement in 78% and ongoing myocardial inflammation in 60%.
The presence of chronic comorbidities, duration and severity of acute COVID-19 illness, and time since original diagnosis did not correlate with these findings. However, the sample was not random and probably biased toward patients with cardiac findings.
However, among 26 competitive collegiate athletes who were diagnosed with COVID-19 by reverse transcriptase-polymerase chain reaction, none of whom required hospitalization and most with no reported symptoms, 12 (46%) had evidence of myocarditis. or previous myocardial injury due to heart problems.
MRI is routinely performed for positive results (range, 12 to 53 days later). The durability and consequences of such imaging findings are not yet known and longer follow-up is needed. However, an increased incidence of heart failure as a major sequela of COVID-19 is concerning, with considerable potential implications for the general population of older adults with multimorbidity, as well as for previously healthy younger patients, including athletes.
Pulmonary
In a study of 55 patients with COVID-19, 3 months after discharge, 35 (64%) had persistent symptoms and 39 (71%) had radiological abnormalities consistent with pulmonary dysfunction, such as interstitial thickening and evidence of fibrosis. Three months after discharge, 25% of the patients showed a decrease in the diffusing capacity of carbon monoxide.
In another study of 57 patients, abnormalities in pulmonary function test results obtained 30 days after discharge, including decreased diffusing capacity for carbon monoxide and decreased respiratory muscle strength, were common. and occurred in 30 patients (53%) and 28 patients (49%), respectively.
If coupled with cardiovascular comorbidity, whether pre-existing or as a consequence of COVID-19, persistent decline in lung function could have important adverse cardiopulmonary consequences.
Neurological
SARS-CoV-2 can penetrate brain tissue through viremia and also by direct invasion of the olfactory nerve, leading to anosmia . To date, the most common long-term neurological symptoms after COVID-19 are headache, vertigo, and chemosensory dysfunction (e.g., anosmia and ageusia).
Although stroke is a serious, though rare, consequence of acute COVID-19, cases of encephalitis, seizures, and other conditions such as significant mood swings and "mental confusion" have been reported up to 2 to 3 months after the onset of the initial illness.
Past pandemics involving pathogenic viruses (such as SARS-CoV-1, Middle East Respiratory Syndrome [MERS] coronavirus, and influenza) have involved neuropsychiatric sequelae that could persist for months in "recovered" patients , potentially seriously threatening survival. cognitive health, general well-being and day-to-day functional status.
Health and Emotional Wellbeing
In addition to the persistence of symptoms and clinical sequelae that may last well beyond the initial COVID-19 illness, the extent of emotional and behavioral concerns and general distress of those affected remains to be determined. A COVID-19 diagnosis and the resulting need for physical distancing has been associated with feelings of isolation and loneliness.
Stigma related to COVID-19 has also become widespread and can result in a feeling of hopelessness . Increased reports of persistent malaise and exhaustion similar to chronic fatigue syndrome can leave patients with physical weakness and emotional disturbances. Compounded by the psychological toll of the pandemic experienced across the population, people recovering from COVID-19 may be at even greater risk of depression, anxiety, post-traumatic stress disorder, and substance use disorder . These combined effects have the potential to result in a global health crisis, considering the large number of COVID-19 cases around the world.
Conclusions Admitting that there are no long-term data from a substantial number of patients with various presenting symptoms and comparison groups, and that it is still early in the COVID-19 pandemic, it is possible that a large number of patients will experience long-term sequelae. term. Post-COVID-19 outpatient clinics are opening in many localities where large outbreaks have occurred, and the term “long-distance runners” has been suggested to refer to these patients. It is imperative that the care of this vulnerable patient population adopts a multidisciplinary approach , with a carefully integrated research agenda, to avoid fragmentation of the health system and allow for the comprehensive study of the long-term health consequences of COVID-19 in multiple organic systems and in general in health and well-being. Furthermore, such an approach will provide the opportunity to efficiently and systematically conduct studies of therapeutic interventions to mitigate the adverse effects on the physical and mental health of hundreds of thousands, if not millions, of people recovering from COVID-19. Larger observational studies and longitudinal clinical trials will be critical to elucidate the durability and depth of health consequences attributable to COVID-19 and how they may compare to other serious diseases. |
