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

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© 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.

Persistent morbidity is well established after sepsis and intensive care admission.19,20 A wide range of cardiac complications has been observed in people with COVID-19 including fulminant myocarditis, acute heart failure and arrhythmias.21,22 Assessment for myocardial damage is an area for ongoing evaluation in those with persistent cardiothoracic symptoms.

Given the systemic effects of SARS-CoV-2, including reports of neurological manifestations such as large vessel stroke, encephalitis and delirium, neurocognitive impairment remains a concern.23-25 Abnormalities have been observed in the quality of life of people recovering from COVID-19 and include new problems in mobility, self-care and activities of daily living.26 Mental health disturbances may include post-traumatic stress disorder, anxiety and depression.27 Several factors could be driving these abnormalities including the experience of recent illness, uncertainty of recovery, general concerns over COVID-19 and its global effects and exacerbation of pre-existing conditions. Increased mental health disturbance in the Australian community in the immediate post-COVID period has been reported, and issues around stigma and discrimination of people with or recovering from COVID-19 may also be factors contributing psychological decline.28-31 

Some cohorts have reported persistently elevated D-dimer, C-reactive protein, interleukin 6 (IL-6), ferritin and brain natriuretic peptide concentrations in recovering patients.32 In relation to the specific symptom of fatigue after COVID-19, there is no established association with routine laboratory markers of inflammation and cell turnover or pro-inflammatory molecules.6 

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What initial investigations should be considered if you suspect 'long COVID' in your patient?

A variety of health resources may be required to adequately manage persistent symptoms after COVID-19. We recommend a clinical review by a GP at four weeks after COVID-19 infection and we urge that GPs be aware of the potential long-term symptoms (Box). Full lung function testing and pulmonary imaging should be considered to investigate thoracic symptoms, especially in patients with oxygen desaturation or physical signs of respiratory disease by 12 weeks after acute infection. Cardiology investigations such as an echocardiogram may be required to investigate those with persistent cardiothoracic symptoms or physical signs of cardiac disease. Blood tests, including a full blood count and kidney, liver function and C-reactive protein tests, may be offered. Pulmonary rehabilitation may assist to improve exercise capacity and breathlessness.33 Neurocognitive testing and imaging may be required to investigate cognitive symptoms. Mental health symptoms should be specifically asked about and early referral for liaison psychiatry specialist support may be required. Shared care by GPs and specialists is likely required to care for patients with persistent symptoms after COVID-19. 

Does 'long COVID' differ from other post-viral syndromes and if so, how?

A number of viral infections have been associated with longer term symptoms after the resolution of an initial infection. SARS-CoV-1, a novel coronavirus that caused a pandemic outbreak in 2002, results in SARS illness and has been associated with pain, fatigue, psychological symptoms and disturbed sleep up to three years after infection.34 Viral infection has been considered a possible causal factor for chronic fatigue/myalgic encephalomyelitis and Guillain-Barré syndrome, the neurological illness mediated by an aberrant immune response to prior infection, including viral infections.35,36 It is too early in the pandemic to fully establish the nature of ‘long COVID’. A better understanding of this syndrome will depend on further careful clinical and research evaluation of patients after infection. 

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Conclusion

A considerable proportion of patients experience persistent symptoms beyond acute SARS-CoV-2 infection that may impact physical function, mental health and quality of life. Systematic assessment is recommended to monitor recovery, assess the need for rehabilitation and to detect complications. This is particularly relevant for GPs, given the significant number of patients undergoing follow up in the community.    RMT

 

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COMPETING INTERESTS: The authors’ research is supported by funding from  St Vincent’s Curran Foundation and St Vincent’s Clinic Foundation.