COVID-19 is a new disease whose clinical manifestations can be mild, moderate or severe, requiring hospitalization in an intensive care unit. It is estimated that about 10% of the 20 million survivors, in the acute phase of COVID-19, maintain persistent and even severe cardiovascular, pulmonary or neuropsychiatric dysfunction symptoms. However, it is still unknown what will be the long-term result of the approximately 4 millions of survivors in the United States of America, the United Kingdom and Sweden, who remain with symptoms three weeks after the onset of the disease, or even those who continue to have them 12 weeks later. Although rare, sequelae associated with other viral diseases have been described, such as infectious mononucleosis and measles, and this syndrome is also recognized in patients who have recovered from serious illness, requiring hospitalization and admission to an intensive care unit.
It should also be noted that this post-COVID-19 syndrome is not limited to critically ill patients who have been hospitalized or, just to elderly adults. This situation occurs, more frequently, in individuals over 50 years old and with three or more chronic diseases. However, it has also been observed in young adults with a positive test for SARS-CoV-2, without the need for hospitalization.
The most common symptoms are extreme fatigue and difficulty breathing, in addition to joint and chest pains. Cardiac (myocardial inflammation, myocarditis and arrhythmia), pulmonary (interstitial thickening and fibrosis) or cerebral dysfunction (SARS-CoV-2 can penetrate brain tissue through viremia and, also, by direct invasion via the olfactory nerve) has been observed, in association with the general symptoms referred to above, and is correlated with: a) invasion by the virus itself (through the presence in the tissues of those organs of the angiotensive-2 converting enzyme receptors; b) inflammation and cytokine storm; c) damage to the immune system; d) hypercoagulation state.
The increased incidence of myocardial infarction, as a result of COVID-19, has implications for older people with multiple comorbidities, but also for previously healthy younger people. The persistent changes observed in radiological studies of the lung, such as interstitial thickening and fibrosis, with pulmonary dysfunction, have serious cardiopulmonary consequences. The neurological consequences, more common in the long term, after CODIV-19, are headache, vertigo and sensory dysfunction (anosmia and ageusia), with stroke, encephalitis and convulsions being rarer, in addition to mood changes and brain fog.
The neuropsychiatric sequelae of COVID-19 can persist for months (as has been reported for infections with SARS-CoV-1, MERS and influenza viruses), with cognitive and life quality implications for survivors of COVID-19. Patients who have recovered from COVID-19 are at high risk for depression, anxiety, post-traumatic stress and disorders associated with substance abuse (such as alcohol, tobacco and drugs). A curious case of psychosis, as a consequence of COVID-19, was described in a woman, in her fifties, with no psychiatric history, who started seeing lions and monkeys at home, became disoriented and aggressive and convinced that her husband was an impostor.
Some of these symptoms are reminiscent of chronic fatigue syndrome, also known as myalgic encephalomyelitis, whose etiology and pathogenesis are unknown and for which biomarkers are not available, so the diagnosis is based on the symptoms.
A comprehensive multidisciplinary intervention is imperative to better understand the long-term consequences of the effects on the physical and mental health of the millions of patients who have recovered from COVID-19.
Francisco Antunes
Infecciologist and retired professor at the Faculty of Medicine of the University of Lisbon