Care of patients with new, persistent or recurrent symptoms after acute SARS-CoV-2 infection

As the pandemic of acute SARS-CoV-2 infection continues, another pandemic accompanies it: the growing population of people who experience new, persistent, or recurring symptoms long after the initial infection. Many refer to this condition as “long COVID,” and the official National Institutes of Health (NIH) name for the condition is postacute sequelae of SARS-CoV-2 (PASC). Whatever we call it, the current limited understanding of the pathophysiology, epidemiology and course of this disease makes the management of these patients a thorny challenge.

In order to provide practical guidance to clinicians based on current knowledge, the Annals of Internal Medicine and the American College of Physicians held their ninth COVID-19 Forum on May 24, 2022. The focus of this program was the evaluation and management of patients with persistent symptoms after acute SARS-CoV- infection. 2. Panelists included Dr. H. Clifford Lane, director of clinical research and special projects at the National Institute of Allergy and Infectious Diseases; Dr. Carlos del Rio, Professor Emeritus of Medicine in the Division of Infectious Diseases at Emory University School of Medicine and Associate Executive Dean for Emory in Grady; Dr. Aluko Hope, associate professor of pulmonary and critical care and medical director of the Long COVID-19 Program at Oregon Health & Science University; and Dr. Lindsay Lief, associate professor of medicine at Weill Cornell Medicine/New York Presbyterian Hospital and director of the Weill Cornell Post-ICU Recovery Clinic. Dr. Elisa Choi, Chair of the CPA Board of Governors and a practicing physician and certified educator in internal medicine and infectious diseases, facilitated the program. The video of this program and the 8 previous ones is available on Annals.org.

Video. ACP/Annals COVID-19 Forum IX: Caring for patients with persistent symptoms after COVID-19
The ACP/Annals COVID-19 Forum IX, held May 24, 2022, features speakers Carlos del Rio, MD; Aluko Hope, MD, MSCE; H. Clifford Lane, MD; Lindsay Lief, MD; and Elisa I. Choi, MD. (Duration 1:29:11)

The program began with Dr Lane summarizing the results of a study he and his colleagues have just published in Annals who attempted to characterize sequelae after recovery from COVID-19 in a cohort of survivors and controls. All participants underwent the same assessments regardless of the presence or absence of symptoms, including a physical exam, laboratory tests and questionnaires, cognitive function tests, and cardiopulmonary assessment (1). A subset also had exploratory immunological and virological evaluations. The study documented a high burden of persistent symptoms in people after COVID-19, but found no specific cause for the symptoms reported in most cases and highly variable antibody levels after COVID-19. The study is ongoing and continues to recruit participants (ClinicalTrials.gov: NCT04411147).

Following the presentation of this recent study, Dr. Choi presented 3 clinical scenarios involving patients concerned about long COVID, with participants completing a survey indicating what they would do in these situations. The panelists then reviewed these responses and discussed what they would do and why. This exercise has highlighted large gaps in the available evidence and the current lack of an accepted and definitive best strategy when caring for patients with persistent symptoms after COVID-19. Recurring themes included the need to rule out other causes of symptoms; avoiding potentially harmful therapies, such as systemic corticosteroids, unless there is a specific indication to try them; recognizing that non-targeted test batteries were unlikely to be clinically useful; and affirm that vaccination is the most effective strategy to reduce the risk of acute infection and therefore the risk of persistent sequelae.

Next, the panelists answered questions that participants submitted when registering for the program. Similar themes emerged in the responses to these questions as in the discussion of the clinical vignettes. Other points that came up repeatedly during the discussion were the importance of validating patient symptoms; exploring the social context of patients’ symptoms; combat misinformation about long COVID that patients may receive; and aimed at avoiding harm from testing, referral to a specialty, or treatment not specifically targeted to the patient’s individual presentation. Panelists also noted the potential value of vocational, cognitive and physical rehabilitation to help alleviate symptoms. All expressed hope that the NIH’s RECOVER initiative, created to learn more about the long-term effects of COVID, will help answer many unanswered questions about PASC and, where possible, encouraged participants to consider referring patients to RECOVER sites to help with this knowledge generation.

Panelists mentioned the following resources as reliable sources of information to help manage patients with PASC:

Resources from the Centers for Disease Control and Prevention on the long COVID: www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html

RECOVER Initiative information on sites and ongoing studies: https://recovercovid.org/

General information about dysautonomia, which can occur after COVID-19, from Dysautonomia International: www.dysautonomiainternational.org/index.php

Information from the US Department of Health and Human Services on Disability and Long COVID: www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/guidance-long-covid-disability/index.html

As Dr. Hope eloquently stated in an op-ed he wrote to accompany the NIH report that Dr. Lane summarized at the start of the program, we must thoroughly study and care for COVID-19 survivors who continue to suffer (2). As we wait for high-quality evidence to guide our clinical decisions, we must recognize the many ways patients suffer and do our best to help alleviate their symptoms while preventing harm.

References

  • 1. Sneller MC, Liang C.J., AR brands, et al. A longitudinal study of the sequelae and immunity of COVID-19: basic results. Ann Medical Intern. May 24, 2022. [Epub ahead of print]. [PMID: 35605238] do I:10.7326/M21-4905 LinkGoogle Scholar
  • 2. I hope AA. Understanding and improving recovery after COVID-19. Ann Medical Intern. May 24, 2022. [Epub ahead of print]. [PMID: 35605242] do I:10.7326/M22-1492 LinkGoogle Scholar

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