Not Just An Acute Infection: The Prolonged Onslaught Of Coronavirus
Time and time again, this novel coronavirus has shown us that it does not cause your garden-variety respiratory infection. Over the past several months, we’ve learned that SARS-CoV-2 has been associated with strokes, myocarditis, leg clots, pediatric inflammatory syndromes and much more. But we’re also uncovering that, unlike most respiratory illnesses, Covid-19 can keep people sick for a long time. Several case reports describe patients experiencing waves of symptoms for well over 60 days.
“Little attention, until recently, has been given to the more long-term effects that a certain subset of patients, a.k.a. ‘long-haulers,’ are experiencing,” observes infectious disease physician, Geeta Karnik Mantravadi MD, MS, and assistant professor of clinical medicine at Indiana University School of Medicine.
Most Cases Are Still Mild
According to the World Health Organization, around 80% of cases are mild or asymptomatic, and most people recover within two weeks. The most common symptoms are fever, dry cough and fatigue; less common symptoms include headache, nasal congestion, sore throat, conjunctivitis, body aches, rash, loss of taste or smell and discoloration of fingers or toes. About 1 out of 5 people develop severe illness including difficulty breathing; among them are people with chronic underlying conditions such as diabetes, high blood pressure, obesity and COPD.
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Risk Factors for Prolonged Viral Shedding
A Wuhan study revealed that the following factors related to late viral clearance (>15 days) – male sex, delayed hospital admission after illness onset, and invasive mechanical ventilation – were associated with prolonged SARS-CoV-2 RNA shedding. The authors recommended that hospital admission and general treatments should be started as soon as possible in symptomatic COVID-19 patients.
Some people infected with Covid-19 who require hospitalization simply experience one complication after another. Take the case of Fred Szoch, a 69-year-old gentleman who was hospitalized for 75 days at the University of Pittsburgh Medical Center. With a history of non-Hodgkin’s lymphoma and lung cancer, Mr. Szoch was already considered a high-risk patient. Upon arriving in the emergency department, he developed respiratory failure and was subsequently transferred to the ICU where he was intubated and placed on a ventilator for the next 21 days. Long-term consequences of prolonged ventilation will be discussed later. Mr. Szoch’s hospitalization was further complicated by C. difficile, a bacterium that causes diarrhea and colitis (colon inflammation) more commonly among people over 65 in healthcare settings.
Most Symptoms Linger While at Home
Unlike Mr. Szoch, Vonny LeClerc was a young, healthy, 32-year-old woman who wrestled with coronavirus symptoms at home. Her symptoms lasted for 80 days. Thousands of people have shared their experiences with Covid-19 on Facebook, describing agonizing symptoms lasting one to three months, if not longer. Their symptoms did not warrant hospitalization or intubation and were thus classified as mild, but they were no less debilitating to their quality of life.
Dr. Karnik has seen many patients like Ms. LeClerc. “Although the majority of people with Covid-19 recover within two weeks, we are seeing many patients complaining of chronic fatigue, muscle aches and persistent intermittent fevers.” She adds that some patients have headaches, difficulty concentrating and other neurologically debilitating symptoms. Several individuals are classified as “FUO” or fever of unknown origin. By the time they’re tested, Dr. Karnik explains, the results are negative for coronavirus because their viral load is so low.
Many people with prolonged symptoms complain of profound exhaustion. This can have work-related ramifications, according to some medical experts.
“This post-infectious, long-term fatigue is similar to myalgic encephalomyelitis or chronic fatigue syndrome,” describes Divya Bappanad, MD, a pulmonary and critical care physician at PeaceHealth Medical Group in Washington state. She underscores the magnitude of the problem: “With the sheer number of people we expect will ultimately be infected with coronavirus, we may be seeing a whole new group of people unable to return to the workforce, with a chronic disability unrelated to their lung function.”
Because this is a novel virus, we simply do not have data on long-term sequela from Covid-19 infection.
“There is unfortunately much unknown about the varying effects of Covid-19 and its trajectory,” reflects Dr. Mantravadi. “Some form of an ongoing inflammatory response is lingering in certain patients whose symptoms never warranted hospitalization but are having a long road to recovery.”
Some patients, like Mr. Szoch, experience adverse consequences associated with long-term ventilation, typically defined as vent use for over 21 days. According to Dr. Bappanad, “Patients who survive COVID but end up requiring mechanical ventilation typically stay intubated much longer than other causes of respiratory failure.” She points out that individuals with acute respiratory distress syndrome (ARDS) – a life-threatening lung disease where air sacs fill with fluid – often require prolonged ventilation, on the order of weeks, but many ventilated patients with Covid-19, even without ARDS, require several weeks to recover. Some studies show that among these patients, less than 50% will be able to perform activities of daily living, like dressing and feeding, in a year.
We clearly need more research on clinical findings as well as on antibodies, inflammatory markers and the potential role of anti-inflammatory therapies, including the well-known steroid, dexamethasone, which is showing some promise in treating Covid-19. In the meantime, the medical community needs to listen to patients’ stories and support their healing journey. We need to recognize that there’s very little that’s “typical” about this novel coronavirus, and we need to keep on learning.