Open Access
Focus on COVID-19

Recovery after COVID-19. Persistent symptoms beyond acute infection

Open Access
Focus on COVID-19

Recovery after COVID-19. Persistent symptoms beyond acute infection

David R. Darley, Gregory J. Dore, Gail V. Matthews, EMILY STONE

Figures

© onurdongel/istockphoto.com
© onurdongel/istockphoto.com
Dr Darley is a Staff Specialist in the Department of Thoracic Medicine, St Vincent’s Hospital Darlinghurst, Sydney; and a PhD candidate at St Vincent’s Clinical School, UNSW Sydney. Professor Dore is a Clinical Academic in the Department of Infectious Diseases, St Vincent’s Hospital Darlinghurst, Sydney; and Head of the Viral Hepatitis Clinical Research Program at the Kirby Institute, UNSW Sydney. Professor Matthews is a Clinical Academic in the Department of Infectious Diseases, St Vincent’s Hospital Darlinghurst, Sydney; and Associate Professor at the Kirby Institute, UNSW Sydney. Dr Stone is a Staff Specialist in the Department of Thoracic Medicine, St Vincent’s Hospital Darlinghurst; and Conjoint Lecturer at St Vincent’s Clinical School, UNSW Sydney, Sydney, NSW.

Abstract

Severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) has caused a global pandemic with over 29,000 confirmed infections in Australia to date. A high rate of persistent symptoms several months after SARS-CoV-2 has been observed and represents a novel health concern that requires careful assessment and multidisciplinary follow up.

Key Points

  • A considerable proportion of patients experience persistent symptoms beyond acute phase of severe acute respiratory distress syndrome coronavirus (SARS-CoV-2) infection, known as the ‘long COVID’ syndrome, or post-acute sequelae of SARS-CoV-2 (PASC).
  • These symptoms may impact physical function, mental health and quality of life of patients recovering from COVID-19 and other SARS infections.
  • Systematic assessment is recommended to monitor recovery, assess the need for rehabilitation and detect complications.
  • GPs are recommended to undertake a clinical review of patients with COVID-19 four weeks after infection.

A high rate of persistent and multiorgan symptoms, beyond the acute phase of severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2), has been observed. Given the large number of confirmed cases of acute coronavirus disease 2019 (COVID-19) in Australia (over 29,000 confirmed infections to date)1 being followed in the community by GPs, this represents a novel disease and health concern for which we recommend careful assessment and multidisciplinary follow up. 

How and why does the patient present with this problem?

COVID-19 is characterised by symptoms such as fever, dry cough, myalgias, anosmia and gastrointestinal disturbance.2-4 Persistent symptoms, affecting multiple organ systems and lasting for months after resolution of acute infection, have been reported in a number of studies. This syndrome has been termed ‘long COVID’ or the ‘post-COVID-19 syndrome’ and refers to the long-term effects of COVID-19; however, a precise consensus definition is lacking. 

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As part of the ADAPT study, a prospective Australian cohort of adult patients at St Vincent’s Hospital Sydney, is being followed to characterise the long-term effects of COVID-19. At two to three months after COVID-19 infection, a considerable proportion of patients (39.7%) reported persistent symptoms including fatigue, shortness of breath and chest tightness.5 The proportion of patients with symptoms at initial infection and follow up are summarised in Figure 1. The proportion of individuals with persistent symptoms was highest in those hospitalised for initial infection, but a third of patients with community-managed COVID-19 reported persistent symptoms; this is of particular relevance to GPs. 

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In other international cohorts, fatigue is a commonly reported persistent symptom but multiple other symptoms are also described, in particular referrable to the pulmonary, cardiovascular and neuropsychiatric systems.6-8 Ongoing research priorities include the identification of predictive factors for ‘long COVID’, defining its natural history and identifying clinically-effective interventions.9 Additional work is needed to understand whether long-term symptoms represent persistence of initial COVID-19 infection or a post-viral complication. 

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What are the likely causes of 'long COVID' syndrome?

Residual pulmonary radiological changes (ground-glass opacities and parenchymal bands) and abnormalities in pulmonary function testing during recovery have been reported and may explain persistent cardiothoracic symptoms in patients recovered from COVID-19.10 Figure 2 demonstrates post-viral parenchymal bands and volume loss in coronal slices of a chest CT of a recovering patient in the ADAPT study. Patients in this study showed reduced total lung capacity and abnormalities in the diffusion capacity for carbon monoxide (DLCO) on complex lung function testing, especially those requiring hospitalisation for viral pneumonia.5 Long-term abnormalities were also reported after severe acute respiratory distress syndrome (SARS) including reduced DLCO and exercise capacity, chronic fatigue and psychiatric morbidity.11-15 Long-term illness has also been reported after Middle-East Respiratory Syndrome (MERS) and other viral infections including infectious mononucleosis and influenza.16-18