Long COVID: Learning as We Go

Matthew F. Watto, MD; Paul N. Williams, MD


March 08, 2022

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto here with my two fantastic co-hosts, the great Dr Paul Nelson Williams and the great soon-to-be-doctor Beth "Garbs" Garbatelli. In this video, we're going to tell you a couple of our favorite pearls about long COVID from a recent podcast with Dr Monica Verduzco-Gutierrez. Paul, will you start us off? How do we define long COVID? Because I've been confused, seeing multiple conflicting definitions.

Paul N. Williams, MD: It's a great question. There's all kinds of confusing terminology: post-acute COVID, long COVID, long-haul COVID. But let's go with "long COVID" for the purposes of this video. It's anything where the symptoms persist after the initial COVID infection. Dr Gutierrez says any symptoms that persist more than a few weeks probably qualify. That's our expert's opinion. We are typically used to a COVID course lasting a couple of weeks. But if symptoms last for weeks beyond that, I think we're now in the range of long COVID.

Watto: But the good news is that we completely understand the pathophysiology, correct?

Williams: This is my favorite educational framework. As a matter of fact, that is not correct, Matthew. There's a lot of hand-wavy stuff. We're still trying to figure it out. It's inflammatory — sure, that's easy to say. There may be an autoimmune component. We're seeing a lot of autonomic stuff happening after the fact, and we talked a little bit about this in the podcast.

It's not uncommon to have post-viral illness. That's actually something that the virologists have known about for a long time. But we have not seen a virus impact this many people all at the same time. So we're just seeing a lot more of this type of post-viral illness. In terms of the mechanisms, we're still trying to figure it out, unfortunately. But the manifestations are myriad. We'll talk through some of the symptoms that patients are experiencing.

Watto: We wanted to just highlight two main symptoms.


The first, fatigue, is probably the biggest one that most patients experience. Fatigue can actually cause disability, and long COVID is covered under the Americans with Disabilities Act, so you might need to fill out FMLA or disability forms for these folks.

It's sort of looking like chronic fatigue syndrome or myalgic encephalomyelitis, which we have seen in the past even before COVID. We knew it existed and we thought maybe it was some sort of a post-viral syndrome. The main way you combat this is with a lot of patient education. Tell patients to follow the "3 P's": Pace yourself, plan out your activities, and prioritize them so you don't try to do everything in one day. I counsel patients that it might take a while for you to get back to where you were before. A lot of the focus here is not necessarily on diagnosis as much as on expectation management and helping them through this phase.

Williams: Yes, and to a large extent, it's validation, right? That's another point that we made during the episode. It's believing that the patients are having symptoms, and telling them, "I know that you're having these symptoms and we'll try to figure out how we can best help you." It's setting realistic expectations and having plans in place. The validation is almost as important as some of the management stuff.

Watto: Beth, tell us a little bit about what Dr Gutierrez told us about loss of smell.

Beth Garbatelli: Yes, and this one has always been scary for me, because taste and smell are so important to our day-to-day lives. I can see how this can be so impactful and distressful to people. We've seen people have a weird continuance of an inability to smell, and some are experiencing new things they've never smelled before.

Dr Gutierrez went through some really good patient safety education tips, which were very practical. Make sure your smoke alarms have batteries. Make sure you're keeping your appetite up, even if food doesn't quite taste the same. Monitor your weight to make sure that you are eating enough. Consider having someone smell your food if you think it might be bad, so you don't get food poisoning. Get a smell check if you need deodorant.

She also mentioned that you could suggest a steroid nasal spray. These are some nice tips for people who are suffering from that symptom, which would be very frustrating. Even though it's not a major systemic issue, it's definitely a frustrating one for a patient.

Watto: This has come up for me a couple of times. Friends and neighbors have asked me about the loss of smell. It's known that this can last for months to years. You can give a trial of steroid nasal spray. Dr Gutierrez also mentioned smell training with essential oils and sending these patients to a specific therapist who can work with them on smell training. But we just don't have a lot of information yet on what's going to work in this area. It could be really devastating to not be able to smell or taste. Food odor is such a big part of taste.

Paul, is there anything we're missing here?

Williams: Whole worlds of stuff — the episode is jam-packed. We talked a lot about the autonomic instability and the management of that, but that's probably a topic best reserved for another day. But if any of this stuff sounds interesting, I'd really encourage viewers to listen to the entire episode because it was just jam-packed full of practical tips.

Watto: And one last plug for vaccination. Our guest, Dr Gutierrez, said that you should still vaccinate patients even if they have long COVID. Many of them will either feel no worse or they will feel better. It's unusual for patients to feel worse after getting vaccinated, and you want to protect them because we know reinfection happens. Remember a year or two ago we thought that reinfection wasn't going to happen?

Williams: You said many dumb things. It's good that we have a permanent record of being wrong so often.

Garbatelli: If we've learned anything from the past 2 years, it's been a continual lesson in humility. Long COVID is just one more example of how we're learning as we go.

Watto: All right. So if you want to hear the full episode, click on Long COVID with Dr Monica Verduzco-Gutierrez. You can check out our show notes and infographics as well.

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