In this photograph taken on July 8, 2020, British forensic psychiatrist Jenny Judge who is a long ... [+]
Close to 50% of people who develop mild Covid-19 may still suffer with persistent symptoms up to 6 months later, based on results of a new study in the Journal of Clinical Microbiology and Infection.
The small study from Israel looked at 103 people, older than 18 years of age, who were diagnosed with Covid-19 between April and October of 2020. The participants had mild symptoms and were not sick enough to be hospitalized. The study participants completed interviews up to 4 times over the duration of the study.
The study found that at 6 months, 46% of patients had at least one lingering symptom, most commonly fatigue (22%), followed by changes in taste and smell (15%), and difficulty breathing (8%).
Researchers further noted that 44% of people experienced headaches, 41% fever, 39% muscle aches, and 38% dry cough as their initial Covid-19 symptom, typically at the second day of onset of the disease. However, many of these symptoms quickly resolved, based on the data in the study. But loss of smell and taste, which typically developed around the fourth day after onset of disease, were some of the most enduring symptoms noted among the study participants.
Study participants displayed 12 of 14 symptoms contained in the list of the CDC’s defining symptoms of Covid-19 originally created in December, 2020. Participant symptoms included fever, dry cough, productive cough, changes in taste and smell, productive cough, muscle aches, headache, sore throat, runny nose, breathing difficulty, nausea and vomiting. More than 50% of study participants also had loss of appetite, a symptom not included by the CDC’s 2020 list of symptoms defining Covid-19.
Fatigue, which the CDC now recognizes as a Covid-19 symptom, was not included among the choices in the original questionnaire provided to participants, but was self- reported by 18% of patients in the study. Hair loss, depression and memory difficulties were other symptoms also reported. The study found that the majority of patients were healthy before developing Covid-19, but there were specific medical conditions identified among study participants, with 16 obese participants were obese, 2 with hypertension, 6 with lung disease and 2 having cardiac disease.
Limitations of the study included data collection by questionnaire, and intermittent sampling at particular intervals, potentially introducing recall bias. Moreover, patients were recruited by through social media and word of mouth. This may have resulted in many participants who were younger, with higher incomes and more advanced educational levels, as opposed to a random sample of patients in a medical center or clinic with mild symptoms.
This study, and other prior research, demonstrates how previously young and healthy people continue to struggle with bothersome symptoms for many months on end, (e.g. fatigue, loss of taste and smell, shortness of breath, memory issues, brain fog) preventing many from doing simple activities such as cooking, cleaning one’s home, or even just walking to the mailbox.
But loss of smell or even taste, can have dangerous or even deadly consequences. Inability to smell a gas leak or smoke in your apartment or home, or taste spoiled food could be life altering or even fatal. These are the consequences of living with such a symptom which might seem relatively minor on face value. Beyond this, mental health experts recognize that loss of smell places one at risk for anxiety and depression, making this a significant issue with widespread implications.
Dr. Scott Krakower, a child and adolescent psychiatrist, and Associate Professor of Psychiatry, Zucker School of Medicine at Hofstra/Northwell, ending up developing long Covid after initially developing chills and fever for close to 2 weeks in April of 2020 before testing positive for Covid-19. After experiencing fevers and chills during the early days of his illness, he then lost his sense of taste and smell a week later. He told WBUR.org in a radio interview, that losing these senses was a “very usual and bizarre feeling”, which he will never forget. He continued to experience symptoms until October of 2020, with shortness of breath on short walks, along with difficulty swallowing and speaking.
Overall, Krakower says it was “less fatigue than the coughing” that was most debilitating to him over the the last several months. But he emphasized that “my longest symptom is the chills, which still occur and worsen if I pick up another infection,” adding that “I may also have cardiac sequelae, and potential inflammation in that area—so this of course complicates things. It’s a strange illness to say the least.”
I also reported on a recent study which found that some patients had symptoms up to 9 months later, with fatigue and loss of smell and taste also representing the most common lingering symptoms. These ongoing symptoms suggest that post viral inflammation, as seen in patients with ME/CFS, may be the underlying mechanism in Covid-19 patients. The finding of POTS (postural orthostatic tachycardia syndrome), in long Covid patients, another syndrome associated with ongoing inflammation, also adds ongoing support to post viral inflammation as an etiology of this disease.
POTS is characterized by a sustained heart rate increase of greater than 30 beats per minute within 10 minutes of standing or a head-up tilt, with symptoms of chest pain, palpitations, and exercise intolerance. A recent study evaluated the heart failure drug, ivrabadine (Corlanor), which was found to effectively blunt the increase in heart rate associated in patients with hyperadrenergic POTS, with significantly fewer side effects compared to midrodine, a drug commonly used to treat this syndrome.
“I think it's becoming clear that some subset of patients do have lingering symptoms even after mild illness, said Amesh Adalja, MD, an Infectious Disease physician, and Senior Scholar Johns Hopkins Center for Health Security. “Fatigue appears to be common post-Covid and is also something seen after other infections such as mononucleosis.”
Adalja also explained that “it will be important to get an idea of the prevalence of these symptoms as this study may overestimate the prevalence given it used social media to recruit participants and was thus not a random sample of mild cases.”
Another expert, Dr. Thomas Gut, Associate Chair, Department of Medicine, and Director of the Post Covid Recovery Center at Staten Island University Hospital in New York City agreed with Adalja, offering that the meticulous process of screening patients in a medical center or recovery clinic would be more useful.
“A lot of what we identify in a recovery center is often times through a screening process, especially memory issues—and not necessarily something that patients will come in and complain with. But fatigue is something people notice pretty quickly after the acute infection has passed—you’ll have it during the acute infection but afterwards it really persists, so I think a lot of it may be more of a recall bias because of the way that they chose to collect the data.”
While Gut believes that the Israeli study is “in line” with other recent studies looking at long Covid symptoms, he noted that “it’s interesting that the [Israeli researchers] have more of a fatigue presentation in their study, compared to other studies that split more fatigue vs. memory [and brain fog] issues.”
“I think that much of their follow-up was a bit more in the acute phase after Covid, compared to other studies that have longer followup where memory issues and brain fog come about. I think that there is probably more information to be gathered if these patients were to be followed for a longer period of time,” Gut explained.
The most common presentation of long Covid symptoms Gut sees in his practice is “fatigue and brain fog, probably split 50-50. In our population, approximately 25-50% patients present in this typical manner with these two symptoms.”
Gut explains that some of his patients have experienced “resolution of symptoms within 2-3 months, while others have not had any benefit or improvement up to 9 months or a year out” at this point.
Another question is whether most patients who experience long Covid symptoms should be enrolled in a program to monitor recovery and address long Covid symptoms. In this regard, Gut feels that patients should be carefully evaluated, and based on a referral process.
“I think in general, it’s best done as a referral basis, where if some patients still feel that they are having symptoms after the virus has cleared, they should be referred.” offered Gut.
“The vast overwhelming majority of patients that had Covid will not develop this type of syndrome [long Covid], but it’s just unfortunate that there is still a very large portion that will.” said Gut.
