Post-acute covid-19 (“long covid”) seems to be a multisystem disease, sometimes occurring after a relatively mild acute illness.Clinical management requires a whole-patient perspective.This article, intended for primary care clinicians, relates to the patient who has a delayed recovery from an episode of covid-19 that was managed in the community or in a standard hospital ward. Broadly, such patients can be divided into those who may have serious sequelae (such as thromboembolic complications) and those with a non-specific clinical picture, often dominated by fatigue and breathlessness. The specialist rehabilitation needs of a third group, covid-19 patients whose acute illness required intensive care, have been covered elsewhere.
Defining post-acute covid-19 In the absence of agreed definitions, for the purposes of this article we define post-acute covid-19 as extending beyond three weeks from the onset of first symptoms and chronic covid-19 as extending beyond 12 weeks. Since many people were not tested, and false negative tests are common,we suggest that a positive test for covid-19 is not a prerequisite for diagnosis.
How common is it? Around 10% of patients who have tested positive for SARS-CoV-2 virus remain unwell beyond three weeks, and a smaller proportion for months .This is based on the UK COVID Symptom Study, in which people enter their ongoing symptoms on a smartphone app. This percentage is lower than that cited in many published observational studies, whose denominator populations were those admitted to hospital or attending specialist clinics. A recent US study found that only 65% of people had returned to their previous level of health 14-21 days after a positive test.
Why are some people affected? It is not known why some people’s recovery is prolonged. Persistent viraemia due to weak or absent antibody response, relapse or reinfection,inflammatory and other immune reactions, reconditioning, and mental factors such as post-traumatic stress may all contribute. Long term respiratory, musculoskeletal, and neuropsychiatric sequelae have been described for other coronaviruses (SARS and MERS),and these have pathophysiological parallels with post-acute covid-19.
What are the symptoms? Post-acute covid-19 symptoms vary widely. Even so-called mild covid-19 may be associated with long term symptoms, most commonly cough, low grade fever, and fatigue, all of which may relapse and remit.Other reported symptoms include shortness of breath, chest pain, headaches, neurocognitive difficulties, muscle pains and weakness, gastrointestinal upset, rashes, metabolic disruption (such as poor control of diabetes), thromboembolic conditions, and depression and other mental health conditions.Skin rashes can take many forms including vesicular, maculopapular, urticarial, or chilblain-like lesions on the extremities (so called covid toe). There seems to be no need to refer or investigate these if the patient is otherwise well.
What tests are required? Blood tests should be ordered selectively and for specific clinical indications after a careful history and examination (see infographic); the patient may not need any. Anaemia should be excluded in the breathless patient. Lymphopenia is a feature of severe, acute covid-19. Elevated biomarkers may include C reactive protein (for example, acute infection), white cell count (infection or inflammatory response), natriuretic peptides (for example, heart failure), ferritin (inflammation and continuing prothrombotic state), troponin (acute coronary syndrome or myocarditis) and D-dimer (thromboembolic disease). Troponin and D-dimer tests may be falsely positive, but a negative result can reduce clinical uncertainty. Further research is likely to refine the indications for, and interpretation of, diagnostic and monitoring tests in follow-up of covid-19.
For patients who were not admitted to intensive care, British Thoracic Society guidance on follow-up of covid-19 patients who have had a significant respiratory illness proposes community follow-up with a chest x ray at 12 weeks and referral for new, persistent, or progressive symptoms.For those with evidence of lung damage (such as persistent abnormal chest x ray and oximeter readings), referral to a respiratory service is recommended; subsequent early referral to pulmonary rehabilitation probably aids recovery.
Reference & Source information: https://www.bmj.com/
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