Helping COVID 'Long Haulers' in Primary Care

Charles P. Vega, MD


February 26, 2021

This transcript has been edited for clarity.

Hi. I'm Chuck Vega from the University of California, Irvine, Department of Family Medicine. I am here to talk to you today about long-hauler syndrome in COVID-19.

Like many of you, I've been seeing more and more cases of COVID-19 in my practice. Now we have experience with these patients who are recovering from COVID-19 over many months, and a minority of them will develop symptoms that are more chronic in nature, extending beyond the subacute period. Long-haul syndrome is a patient-derived diagnosis. It started with patients coming together online in groups like the Body Politic COVID-19 Support Group, which is an excellent support group for folks who are recovering from COVID-19.

It's clear that many patients have had symptoms lasting longer than 2 weeks, a month, or even 3 months. What symptoms do we see with long-haul syndrome? We are seeing fatigue and dyspnea with exertion. Patients can experience difficulty with basic activities of daily living, such as going out to check the mail or preparing a meal. They have persistent cough, and some have chest pain. We know about the loss of smell and taste — the anosmia and dysgeusia — which, although reversible, can take several months to improve.

There's a mental health aspect as well. Many patients have difficulty with cognitive function that affects their concentration. Patients may start to develop symptoms of depression and/or anxiety, particularly when they can't overcome these persistent symptoms.

How common is long-haul syndrome? In the largest available database, the COVID Symptom Study out of the UK, they found that 10% of the patients still had lingering symptoms of COVID-19 after 1 month and 1.5%-2% had symptoms lasting more than 3 months.

Some prospective studies have followed patients who were hospitalized with COVID-19, a cohort with more severe COVID-19 infection. They found much higher rates of persistent symptoms. Only 13% were symptom free at 2 months, whereas 55% had three or more symptoms 2 months after diagnosis. Generally, we see more long-haul symptoms among women vs men. Also, it seems to affect adults in the working-age group vs younger (≤ 18 years) or older (≥ 65 years), even though the latter are at higher risk for complications of COVID-19.

When I see a symptomatic patient who has tested positive for COVID-19, I have to consider whether this is a subacute or long-haul symptom of infection, or some other entity entirely, I typically initiate a workup with basic lab tests such as a CBC and a TSH. I screen for depression and anxiety. I'm also concerned about the possibility of a secondary infection. If the patient's primary symptoms are cough and dyspnea, for example, I'm worried about a secondary pneumonia, such as aspergillosis.

For patients with pulmonary symptoms, I order a chest x-ray — perhaps even a CT scan — and spirometry. If pulmonary function is still compromised a couple of months after active COVID-19 infection, I also think about an echocardiogram, because they may have a form of pericarditis related to COVID-19. These are folks who might have some chest pain, dyspnea, and myalgias as well.

The key here is to begin by validating their symptoms and making sure patients are heard. We don't have a lot of great objective tools in common clinical practice to measure these symptoms. Most post-COVID-19 patients do improve, but they have to be patient, because there are going to be some setbacks and days when they can't function as well. They have to take this day by day; that's the best advice you can give. I usually initiate mental health support early by suggesting a mindfulness app (which are very easy to use); or if I want something a bit more formal, I arrange for a social worker to counsel the patient. Addressing these issues early is really important to getting the physical symptoms and ability to function under control.

It's best to develop a care team that includes neurology, pulmonary medicine, and perhaps physical medicine and rehabilitation. Try to develop the team with the patient in mind. And sometimes it's just different with different levels of support. We don't have an exact therapeutic regimen, nor do we have an exact diagnosis or way to classify long-haul COVID-19; it's such an emerging science. But there is research being done that is looking at the inflammatory pathways. And I think that more information is forthcoming about how best to take care of this condition. For now, just being there for our patients and enlisting that team to provide support for our patients across different domains of their illness is really important. That's the best we have right now. I look forward to the future.

Thank you for your attention, and please stay well.

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