How does Post-Covid Syndrome manifest

Post-Covid syndrome manifests with a number of features, symptoms and sequelae that have been studied (and discovered) in recent months.

What are the most characteristic clinical manifestations of Post-Covid syndrome?

The clinical manifestations of Post-Covid Syndrome, by category, are:

  1. Sequelae, which are a consequence of the organ damage established after the acute illness. The most frequent are thrombotic events, as well as psychiatric, neurological, pulmonary, renal, cardiac and also reproductive problems.
  2. Manifestations of the hospitalization itself, which would be common with other pathologies, such as post-ICU syndrome, or secondary to prolonged hospitalization. The latter include neuromuscular involvement, fatigue, psychiatric and/or cognitive alterations.
  3. Decompensation of previous chronic diseases.
  4. Onset of new disease. Covid-19 infection could act as a trigger for other diseases, whether autoimmune, metabolic or psychiatric.
  5. Pharmacological toxicity. Although little referenced in the literature, it is important to consider the effects of treatments administered during hospitalization.

Clinical manifestations, both physical and mental, which cannot be grouped into these categories and which persist over the time described, would constitute the “post-COVID syndrome” as a post-infectious syndrome per se. Any patient can present persistent COVID, regardless of the severity of the initial infection, even asymptomatic patients, with predominant involvement in women.

Based on the current data, it appears that the duration of symptoms is longer the more severe the COVID infection was, especially in patients who required hospitalization. Of these, 33% had symptoms limiting their usual activity 60 days after discharge. Previous diseases (comorbidity) have been described as risk factors for severe COVID, such as cancer, stroke, chronic kidney disease, liver disease, COPD, diabetes mellitus, heart disease, dementia, chronic anemia, transplanted patients or patients undergoing immunosuppressive treatment.

Patients with outpatient (out-of-hospital) management should have a follow-up of several months to check for the appearance of problems. Young people have fewer later symptoms. But the occurrence of these increases with comorbidity, especially in non-hospitalized patients with a Covid-19 picture of moderate severity. Of these, 39% have persistent symptoms up to nine months after having had COVID, with fatigue (or asthenia) accounting for 71%.

What are the most frequent persistent symptoms in Post-Covid syndrome?

The most frequent persistent symptoms are:

  1. Asthenia (tiredness). The most frequent symptomatology, collected by WHO and CDC, includes fatigue as the most characteristic symptom (present in 15-70%), defined as intense tiredness that interferes with activities of daily living. It usually improves in an average of 3 months.
  2. Dyspnea (shortness of breath), present in 10-71% of patients. With normal oximetry, radiological and functional respiratory examination, and with a frequency associated with cough of 34%, it is characteristic and is prolonged in time until 2-3 months later, even in some patients. In many patients dyspnea is a consequence of the sustained tachycardia they present, being more frequent in women. Patients with previous heart disease should always be evaluated.
  3. Nonspecific chest pain between 12 and 44%, with a duration of 2 to 3 months.
  4. Cough between 17 and 34% of patients, lasting 2-3 months.
  5. Psychic symptoms, which are frequent, and in greater proportion than in other diseases. Most of them are secondary to the physical symptoms. 90% of patients admitted to the ICU present psychological symptoms after discharge.
  6. Neurological symptoms, which are becoming very frequent and varied, of which new forms are appearing every day. In the neurocognitive area, the decrease in the ability to concentrate or brain fog (in 16%), memory alterations (18%) which can last up to 12 months, stand out. Other patients also suffer from headache and persistent ageusia and anosmia (alterations of taste and smell). It is very important the regular study of patients with neurological symptoms, given the sensitivity of the Central Nervous System (CNS) and its relationship with the blood alterations expressed at that level (both thrombosis and bleeding, in some cases). The advice would be to consult whenever there is a symptom, however slight, with the specialist (vertigo, headache…).
  7. Anxious-depressive symptoms, with 23% of patients with anxiety and 18% of patients with depression, as well as sleep disturbances, are very frequent.
  8. Less frequent symptoms (less than 10%): rhinitis, arthralgias, hyporexia (decreased appetite), vertigo, myalgias (muscle pain), sweating, alopecia and alterations of the intestinal rhythm (diarrhea and nausea, which persist over time). Also, in some cases, weight loss occurs and specific tests are necessary to study it.

More than 50 different symptoms have been described. The multiple studies currently in progress are observing new and different symptoms, according to patient profiles, so it is a dynamic problem that is occurring in real time and it is important to maintain an observant and open attitude to delve into it, both on the part of patients and on the part of professionals.

Percentage of patients with Post-Covid symptoms

Half of the almost 300 patients hospitalized for Covid-19 and systematically evaluated 12-14 weeks after infection, with analytical, clinical and radiological evaluation and respiratory functional tests, had some of these symptoms, usually mild but interfering significantly with their quality of life.

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On the other hand, it is estimated that 20% of patients required readmission after 30 days, and 10% of patients after 60 days.

The incidence of post-Covid symptoms published in the scientific literature is highly variable and highly conditioned by the great heterogeneity of the series, as well as the different times at which the studies were carried out during the pandemic, which is why we must be cautious with the value of the data. Thus, according to published meta-analyses (questionable), post Covid symptoms have been reported from 60 to 80% at 8 weeks after infection, and from 40 to 50% after 10-14 weeks. Recently, however, a prospective cohort of more than 1200 patients describes the presence of some symptoms in more than 68% and 49% of patients, at 6 and 12 months, respectively.

Importance of studying patients with post-Covid symptoms and how to act in consultation

Post-Covid symptoms are an obvious problem that Internal Medicine specialists encounter in daily medical practice. Patients should be consulted early to avoid that these symptoms are left without treatment to limit their evolution, or that other previously healthy systems are involved.

Thus, it is important to avoid trivialization by professionals (medical gaslighting) of these symptoms, which leads to frustration on the part of patients. A comprehensive clinical evaluation and correct information to patients can help to manage this problem, which is often desperate for them.

Young patients with mild infection require little further follow-up. Recently, symptoms of long Covid are being observed in mild cases, regardless of age, so attention should be paid to each individual’s symptoms in order to consider being evaluated.

In patients with comorbidity and mild Covid, a review three weeks after infection is recommended. The in-depth study of these cases has sometimes been minimized, since they are patients who have not required hospitalization and “apparently” have overcome the disease well.

In patients who have required hospitalization, it would be desirable to be evaluated one week after discharge, in ideal conditions, which could be postponed up to 3 weeks maximum, if they are stable. This group of patients is perhaps the one that usually receives more health control, with better control of the evolution, but they have more burden of previous disease, which makes an orderly follow-up necessary. Of special importance in this group are coagulation disorders, previous heart disease and metabolic disorders (diabetes mellitus, osteoporosis and adrenal pathology) which tend to worsen after Covid.

All patients presenting symptoms for more than three months should be evaluated in Internal Medicine.

The evaluation of these patients should include a complete clinical history, laboratory tests and complementary explorations aimed at objectifying the changes that have occurred and the different potential complications per device, taking into account the previous pathology, with a regulated study that relates the impact on the different organs and allows the necessary treatment to be adjusted in each case. This is essential in patients with multiple pathologies (suffering from several previous chronic diseases). Likewise, functional limitation scoring scales (Borg scale, Montreal Cognitive Assessment: MoCA) are included in the different problems that are impacting on quality of life, with a setback in personal capacity. This allows the treatment to be calibrated, since in many cases they require rehabilitation to recover their pre-infection baseline.

As Covid affects multiple internal systems simultaneously but in different combination and intensity in each patient, it is up to the internal medicine specialist to individualize the study in each case. There are always internal changes following infection. Many of these symptoms and disorders are known to the general population, and are mild, but there are many others that must be evaluated by an expert professional and studied objectively to quantify their extent and subsequent impact. For all these reasons it is advisable to consult, in case of doubt, since the sooner the patient is evaluated, the better the disorder will be measured and the treatment will be designed.

We must remember that we are still in a pandemic. There are cases of unvaccinated patients and we must strive to minimize the impact of the disease as much as possible, since we still do not know the course or the end of the disease. As it cannot be otherwise, we strongly encourage vaccination, which is the safest and only way for everyone. We, the health professionals, are also there to help in case of doubts about the vaccine, fear or limitations in making decisions on medical issues. We encourage patients to rely on their doctors in this regard, who, with technical criteria, will be happy to help them make the best decision in each case.

These are hard times for healthcare professionals and patients, but our work is of service to others. Internal Medicine includes the management of serious and complex infections with similar behavior, let’s move forward together in this battle that we are all fighting.