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Long COVID pathophysiology
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A number of research studies have investigated '''[[long COVID]]''' or '''Post-Acute Sequelae of COVID-19''' '''(PASC)''', the long term health problems that occur in a significant minority of people who remained ill for an extended time after developing [[COVID-19]]. {{Quote2|source=The Guardian | author=Hannah Davis | date = Aug 12, 2021 | title = When it comes to breakthrough cases, are we ignoring long Covid once again?|1=Research has found ongoing endothelial dysfunction, hypometabolism in the brains of long Covid patients, microclots in long Covid blood samples, reduced aerobic capacity and impaired systemic oxygen extraction in non-hospitalized patients without cardiopulmonary disease, disrupted gut microbiota that persists over time, damage to corneal nerves, immunologic dysfunction persisting for at least eight months, numerous findings of dysautonomia (a common post-viral disorder of the autonomic nervous system), and countless other conditions.<ref name="Guardian12Aug2021">{{Cite news | url=https://www.theguardian.com/commentisfree/2021/aug/12/when-it-comes-to-breakthrough-cases-are-we-ignoring-long-covid-once-again | title = When it comes to breakthrough cases, are we ignoring long Covid once again? | date = 2021-08-12|publisher=The Guardian|last = Davis | first = Hannah}}</ref>}} == Overview == {{Main article|page_name=Long COVID}} == Diagnosis == A blood test to identify Long COVID patients by (IFN-gamma + [[interleukin 2|IL-2]])/CCL4 > 0.4) could identify Long COVID patients with 100% sensitivity and 88% specificity in a cohort of 144 individuals among them 64 individuals with Long COVID.<ref name="Patterson2020" /> == Pathophysiology == === Infection and immunity === A range of [[:Category:Antibodies|antibodies]] have been found in patients with persistent post-acute COVID symptoms. Elevated [[G-protein coupled receptor]] autoantibodies have been found.<ref>{{Cite journal | date = 2021-01-01 | title = Functional autoantibodies against G-protein coupled receptors in patients with persistent Long-COVID-19 symptoms|url=https://www.sciencedirect.com/science/article/pii/S2589909021000204|journal=Journal of Translational Autoimmunity|language=en|volume=4|pages=100100|doi=10.1016/j.jtauto.2021.100100|issn=2589-9090}}</ref> One study founded elevated antinuclear antibody (ANA) titles in 43.6% of long COVID patients twelve months after symptom onset.<ref name="See2021">{{Cite journal|last = Seeßle | first = Jessica | last2 = Waterboer | first2 = Tim | last3 = Hippchen | first3 = Theresa | last4 = Simon | first4 = Julia | last5 = Kirchner | first5 = Marietta | last6 = Lim | first6 = Adeline | last7 = Müller | first7 = Barbara | last8 = Merle | first8 = Uta | date = 2021-07-05 | title = Persistent symptoms in adult patients one year after COVID-19: a prospective cohort study|url=https://doi.org/10.1093/cid/ciab611|journal=Clinical Infectious Diseases|issue=ciab611|doi=10.1093/cid/ciab611|issn=1058-4838|pages=|pmc=|pmid=|quote=|access-date=|via=|volume=}}</ref> Long COVID may be associated [[herpesvirus]] reactivation such as [[Epstein-Barr virus|Epstein-Barr Virus]],<ref name="Gold2021">{{Cite journal|last = Gold | first = Jeffrey E. | last2 = Okyay | first2 = Ramazan A. | last3 = Licht | first3 = Warren E. | last4 = Hurley | first4 = David J. | date = Jun 2021 | title = Investigation of Long COVID Prevalence and Its Relationship to Epstein-Barr Virus Reactivation | url =https://www.mdpi.com/2076-0817/10/6/763|journal=Pathogens|language=en|volume=10|issue=6 | pages = 763|doi=10.3390/pathogens10060763|pmc=|pmid=|quote=|via=}}</ref> which has been shown to cause elevations of certain G-protein coupled receptor autoantibody types.<ref name="Albani2002">{{cite book | last2 = Albani | first2 = Salvatore | title = Immune-mediated Disorders of the Central Nervous System in Children | url =https://books.google.com/books?id=5trQOK8hcZUC&pg=PA7&lpg=PA7&dq=coxsackie&hl=en&sa=X&ved=0ahUKEwjflpmqg9fOAhWBeSYKHSR4Dh0Q6AEIMTAD#v=onepage&q=coxsackie%20b%20acetylcholine&f=false | pages = 7|isbn=0861966317|edition=|volume=10|language=|title-link=|access-date= | date = 2002|publisher=John Libbey Eurotext|last = Giannoni|first = Francesca | authorlink3 = |veditors=|others=|doi=|oclc=|quote=|archive-url=|archive-date=|location=|editor-last = Angelini|editor-first = Lucia|editor1-link=|editor-last2 = Bardare|editor-first2 = Maria|series=Mariani Foundation paediatric neurology|editor-last3 = Martini|editor-first3 = Alberto|editor-last4 = Pierfranco|editor-first4 = Fondazione|editor-last5 = Mariani|editor-first5 = Luisa|chapter=Molecular mimicry and autoimmunity}}</ref><ref name="Gebhardt2000">{{Cite journal|last = Gebhardt | first = B.M. | date = 2000-06-26 | title = Evidence for antigenic cross-reactivity between herpesvirus and the acetylcholine receptor |url =http://www.ncbi.nlm.nih.gov/pubmed/10742556|journal=Journal of Neuroimmunology|volume=105|issue=2|pages=145–153|issn=0165-5728|pmid=10742556}}</ref><ref name="Brenner1989">{{Cite journal|last = Brenner | first = T. | last2 = Timore | first2 = Y. | last3 = Wirguin | first3 = I. | last4 = Abramsky | first4 = O. | last5 = Steinitz | first5 = M. | date = Oct 1989 | title = In vitro synthesis of antibodies to acetylcholine receptor by Epstein-Barr virus-stimulated B-lymphocytes derived from patients with myasthenia gravis|url=http://www.ncbi.nlm.nih.gov/pubmed/2553772|journal=Journal of Neuroimmunology|volume=24|issue=3|pages=217–222|issn=0165-5728|pmid=2553772}}</ref><ref name="Kaminski">{{Cite journal | last = Kaminski|first = Henry J. | last2 = Janos | first2 = Minarovits | title = Epstein-barr virus: Trigger for autoimmunity?|volume=67|issue=6 | pages = 697-8 | date = Jun 2010|pmid=20517931|doi=10.1002/ana.22031|url=http://www.academia.edu/20258853/Epstein-barr_virus_Trigger_for_autoimmunity/|journal=Annals of Neurology|language=en|issn=0364-5134}}</ref> Non-classical [[monocyte]]s (CD14low, CD16+) have been found in the blood of Long COVID patients up to 15 months after infection.<ref name="Patterson2021">{{Cite journal | last = Patterson | first = Bruce K. | last2 = Francisco | first2 = Edgar B. | last3 = Yogendra | first3 = Ram | last4 = Long | first4 = Emily | last5 = Pise | first5 = Amruta | last6 = Rodrigues | first6 = Hallison | last7 = Hall | first7 = Eric | last8 = Herrara | first8 = Monica | last9 = Parikh | first9 = Purvi | date = 2021-07-26 | title = Persistence of SARS CoV-2 S1 Protein in CD16+ Monocytes in Post-Acute Sequelae of COVID-19 (PASC) Up to 15 Months Post-Infection | url =https://www.biorxiv.org/content/10.1101/2021.06.25.449905v3|journal=bioRxiv|language=en|pages=2021.06.25.449905|doi=10.1101/2021.06.25.449905}}</ref> It has been determined that these particular non-classical monocytes express the fractalkine receptor and the CCR5 receptor.<ref name="Patterson2021" /> Since [[TNF-alpha]] and [[IFN-gamma]], which is elevated in Long COVID patients<ref name="Patterson2020">{{Cite journal | last = Patterson | first = Bruce K. | last2 = Guevara-Coto | first2 = Jose | last3 = Yogendra | first3 = Ram | last4 = Francisco | first4 = Edgar | last5 = Long | first5 = Emily | last6 = Pise | first6 = Amruta | last7 = Rodrigues | first7 = Hallison | last8 = Parikh | first8 = Purvi | last9 = Mora | first9 = Javier | date = 2020-12-22 | title = Immune-Based Prediction of COVID-19 Severity and Chronicity Decoded Using Machine Learning | url =https://www.biorxiv.org/content/10.1101/2020.12.16.423122v1|journal=bioRxiv|language=en|pages=2020.12.16.423122|doi=10.1101/2020.12.16.423122}}</ref>, cause endothelial cells to produce fractalkine (CX3CL1) ligands<ref>{{Cite journal | last = Matsumiya | first = Tomoh | last2 = Ota | first2 = Ken | last3 = Imaizumi | first3 = Tadaatsu | last4 = Yoshida | first4 = Hidemi | last5 = Kimura | first5 = Hiroto | last6 = Satoh | first6 = Kei | date = 2010-04-15 | title = Characterization of Synergistic Induction of CX3CL1/Fractalkine by TNF-α and IFN-γ in Vascular Endothelial Cells: An Essential Role for TNF-α in Post-Transcriptional Regulation of CX3CL1|url=https://www.jimmunol.org/content/184/8/4205|journal=The Journal of Immunology|language=en|volume=184|issue=8 | pages = 4205–4214|doi=10.4049/jimmunol.0903212|issn=0022-1767|pmid=20231691}}</ref>, said monocytes bind to endothelial cells and cause inflammation. The presence of fractalkine (CX3CL1) and TNF-alpha inhibits apoptosis<ref>{{Cite journal|last = Narasimhan | first = Prakash Babu | last2 = Marcovecchio | first2 = Paola | last3 = Hamers | first3 = Anouk A.J. | last4 = Hedrick | first4 = Catherine C. | date = 2019-04-26 | title = Nonclassical Monocytes in Health and Disease|url=https://pubmed.ncbi.nlm.nih.gov/31026415/|journal=Annual Review of Immunology|volume=37 | pages = 439–456|doi=10.1146/annurev-immunol-042617-053119|issn=1545-3278|pmid=31026415}}</ref> and thereby allows these non-classical monocytes to survive for a long time. === Neurological and neuropsychiatric === === Cardiovascular === === Pulmonary === In a single [[cardiopulmonary exercise test]], Post-COVID-19 patients exhibited markedly reduced peak exercise aerobic capacity (VO2) compared to controls and impaired oxygen extraction, even in those without cardiopulmonary disease.<ref name="Singh2021" /> == Prevention == The only way to prevent Long COVID is by preventing an infection with [[SARS-CoV-2]]. Antibodies from vaccination can protect against an infection in case of exposure to the virus.<ref name="Antonelli2021">{{Cite journal | last = Antonelli|first = Michela | last2 = Penfold | first2 = Rose S. | last3 = Merino | first3 = Jordi | last4 = Sudre | first4 = Carole H. | last5 = Molteni | first5 = Erika | last6 = Berry | first6 = Sarah | last7 = Canas | first7 = Liane S. | last8 = Graham | first8 = Mark S. | last9 = Klaser | first9 = Kerstin | date = 2021-05-27 | title = Post-vaccination SARS-CoV-2 infection: risk factors and illness profile in a prospective, observational community-based case-control study|url=https://www.medrxiv.org/content/10.1101/2021.05.24.21257738v2|journal=medRxiv|language=en|pages=2021.05.24.21257738|doi=10.1101/2021.05.24.21257738}}</ref> == Comparison to other conditions == {| class="wikitable" !Findings !Long COVID !Post-acute SARS !ME/CFS !POTS !MCAS !Chronic Lyme disease |- |G-protein coupled receptor autoantibodies |β2- and α1-adrenoceptors, angiotensin II AT1-, muscarinic M2-, MAS-, nociceptin- and ETA-receptors | |M3 and M4 [[Muscarinic acetylcholine receptor|muscarinic acetylcholine receptors]], as well as ß2 [[Adrenergic receptor|adrenergic receptors]] |α1, β1 and β2 adrenergic receptor autoantibodies | | |- | | | | | | | |} === Post-SARS syndrome === {{Main|page_name=Post-SARS syndrome}} === ME/CFS === {{Main article|page_name=Myalgic encephalomyelitis}} === Postviral fatigue syndrome === {{Main|page_name=Postviral fatigue syndrome}} === Chronic fatigue and Idiopathic chronic fatigue === {{Main|page_name=Idiopathic chronic fatigue}} === POTS === {{Main|page_name=Postural orthostatic tachycardia syndrome}} === MCAS === {{Main|page_name=Mast cell activation syndrome}} === Post-Ebola syndrome === {{Main|page_name=Post-Ebola syndrome}} === Chronic Epstein-Barr virus === {{Main|page_name=Chronic Epstein-Barr virus}} === Post-Treatment Lyme disease syndrome === Post-treatment Lyme disease syndrome (PTLDS) is hypothesized to be caused by the presence of residual bacterial debris (possibly bacterial cell envelope fragments) stimulating the immune system. The relapsing character and the symptoms of this syndrome are very similar to the symptom presentation of Long COVID. The discovery of antigen-presenting non-classical monocytes in Long COVID<ref name="Patterson2021" /> supports the theory that both syndromes are similarly caused by residual debris of pathogens after the infection is cleared. === Alzheimer's disease === === Traumatic Brain Injury === ==Notable studies == *2021, <sup>18</sup>F-FDG brain PET hypometabolism in patients with long COVID<ref name="Guedj2021">{{Cite journal|last = Guedj|first = E. | last2 = Campion | first2 = J.Y. | last3 = Dudouet | first3 = P. | last4 = Kaphan | first4 = E. | last5 = Bregeon | first5 = F. | last6 = Tissot-Dupont | first6 = H. | last7 = Guis | first7 = S. | last8 = Barthelemy | first8 = F. | last9 = Habert | first9 = P. | date = 2021-08-01 | title = 18F-FDG brain PET hypometabolism in patients with long COVID|url=https://doi.org/10.1007/s00259-021-05215-4|journal=European Journal of Nuclear Medicine and Molecular Imaging|language=en|volume=48|issue=9|pages=2823–2833|doi=10.1007/s00259-021-05215-4|issn=1619-7089|pmc=PMC7837643|pmid=33501506}}</ref> [https://link.springer.com/article/10.1007/s00259-021-05215-4 (Full text)] *2021, Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients<ref name="Blitshteyn2021">{{Cite journal|last = Blitshteyn | first = Svetlana | last2 = Whitelaw | first2 = Sera | date = 2021-04-01 | title = Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients|url=https://doi.org/10.1007/s12026-021-09185-5|journal=Immunologic Research|language=en|volume=69|issue=2|pages=205–211|doi=10.1007/s12026-021-09185-5|issn=1559-0755|pmc=PMC8009458|pmid=33786700}}</ref> [https://link.springer.com/article/10.1007%2Fs12026-021-09185-5 (Full text)] *2021, Corneal confocal microscopy identifies corneal nerve fibre loss and increased dendritic cells in patients with long COVID<ref name="Bitirgen2021">{{Cite journal|last = Bitirgen | first = Gulfidan | last2 = Korkmaz | first2 = Celalettin | last3 = Zamani | first3 = Adil | last4 = Ozkagnici | first4 = Ahmet | last5 = Zengin | first5 = Nazmi | last6 = Ponirakis | first6 = Georgios | last7 = Malik | first7 = Rayaz A. | date = 2021-07-08 | title = Corneal confocal microscopy identifies corneal nerve fibre loss and increased dendritic cells in patients with long COVID|url=https://bjo.bmj.com/content/early/2021/07/08/bjophthalmol-2021-319450|journal=British Journal of Ophthalmology|language=en|doi=10.1136/bjophthalmol-2021-319450|issn=0007-1161|pmid=34312122}}</ref> [https://bjo.bmj.com/content/early/2021/07/08/bjophthalmol-2021-319450 (Full text)] *2021, Gut microbiota composition reflects disease severity and dysfunctional immune responses in patients with COVID-19<ref name="Yeoh2021">{{Cite journal|last = Yeoh|first = Yun Kit | last2 = Zuo | first2 = Tao | last3 = Lui | first3 = Grace Chung-Yan | last4 = Zhang | first4 = Fen | last5 = Liu | first5 = Qin | last6 = Li | first6 = Amy YL | last7 = Chung | first7 = Arthur CK | last8 = Cheung | first8 = Chun Pan | last9 = Tso | first9 = Eugene YK | date = 2021-04-01 | title = Gut microbiota composition reflects disease severity and dysfunctional immune responses in patients with COVID-19|url=https://gut.bmj.com/content/70/4/698|journal=Gut|language=en|volume=70|issue=4 | pages = 698–706|doi=10.1136/gutjnl-2020-323020|issn=0017-5749|pmid=33431578}}</ref> [https://gut.bmj.com/content/70/4/698 (Full text)] - Pre-print *2021, Persistent clotting protein pathology in Long COVID/ Post-Acute Sequelae of COVID-19 (PASC) is accompanied by increased levels of antiplasmin<ref name="Pretorius2021">{{Cite journal | last = Pretorius | first = Etheresia | last2 = Vlok | first2 = Mare | last3 = Venter | first3 = Chantelle | last4 = Bezuidenhout | first4 = Johannes A. | last5 = Laubscher | first5 = Gert Jacobus | last6 = Steenkamp | first6 = Janami | last7 = Kell | first7 = Douglas B. | date = 2021-05-24 | title = Persistent clotting protein pathology in Long COVID/ Post-Acute Sequelae of COVID-19 (PASC) is accompanied by increased levels of antiplasmin | url =https://www.medrxiv.org/content/10.1101/2021.05.21.21257578v2|journal=medRxiv|language=en|pages=2021.05.21.21257578|doi=10.1101/2021.05.21.21257578}}</ref> [https://www.medrxiv.org/content/10.1101/2021.05.21.21257578v2 (Full text)] - Pre-print *2021, Immunological dysfunction persists for 8 months following initial mild-moderate SARS-CoV-2 infection<ref name="Phetsouphanh">{{Cite journal | last = Phetsouphanh|first = Chansavath | last2 = Darley | first2 = David | last3 = Howe | first3 = Anette | last4 = Munier | first4 = C. Mee Ling | last5 = Patel | first5 = Sheila K. | last6 = Juno | first6 = Jenifer A. | last7 = Burrell | first7 = Louise M. | last8 = Kent | first8 = Stephen J. | last9 = Dore | first9 = Gregory J. | date = 2021-06-03 | title = Immunological dysfunction persists for 8 months following initial mild-moderate SARS-CoV-2 infection | url =https://www.medrxiv.org/content/10.1101/2021.06.01.21257759v1|journal=medRxiv|language=en|pages=2021.06.01.21257759|doi=10.1101/2021.06.01.21257759}}</ref> [https://www.medrxiv.org/content/10.1101/2021.06.01.21257759v1 (Full text)] - Pre-print *2021, Clinical characterization of dysautonomia in long COVID-19 patients<ref name="Barizien2021">{{Cite journal|last = Barizien | first = Nicolas | last2 = Le Guen | first2 = Morgan | last3 = Russel | first3 = Stéphanie | last4 = Touche | first4 = Pauline | last5 = Huang | first5 = Florent | last6 = Vallée | first6 = Alexandre | date = 2021-07-07 | title = Clinical characterization of dysautonomia in long COVID-19 patients|url=https://www.nature.com/articles/s41598-021-93546-5|journal=Scientific Reports|language=en|volume=11|issue=1|pages=14042|doi=10.1038/s41598-021-93546-5|issn=2045-2322}}</ref> [https://www.nature.com/articles/s41598-021-93546-5 (Full text)] *2021, Persistent Exertional Intolerance after COVID-19: Insights from Invasive Cardiopulmonary Exercise Testing<ref name="Singh2021">{{Cite journal|last = Singh|first = Inderjit | authorlink = | last2 = Joseph | first2 = Phillip | authorlink2 = | last3 = Heerdt | first3 = Paul M. | authorlink3 = | last4 = Cullinan | first4 = Marjorie | authorlink4 = | last5 = Lutchmansingh | first5 = Denyse D. | authorlink5 = | last6 = Gulati | first6 = Mridu | authorlink6 = | last7 = Possick | first7 = Jennifer D. | last8 = Systrom | first8 = David M. | authorlink8 = David Systrom | last9 = Waxman | first9 = Aaron B. | date = 2021-08-10 | title = Persistent Exertional Intolerance after COVID-19: Insights from Invasive Cardiopulmonary Exercise Testing.|url=https://journal.chestnet.org/article/S0012-3692(21)03635-7/abstract|journal=CHEST|language=English|volume=|issue=|pages=|doi=10.1016/j.chest.2021.08.010|issn=0012-3692|pmc=|pmid=|access-date=|quote=|via=}}</ref> [https://journal.chestnet.org/article/S0012-3692(21)03635-7/fulltext (Full text)] *2021, Persistent Endotheliopathy in the Pathogenesis of Long COVID Syndrome<ref name="Fogarty2021">{{Cite journal | last = Fogarty|first = Helen | authorlink = | last2 = Townsend | first2 = Liam | authorlink2 = | last3 = Morrin | first3 = Hannah | authorlink3 = | last4 = Ahmad | first4 = Azaz | authorlink4 = | last5 = Comerford | first5 = Claire | authorlink5 = | last6 = Karampini | first6 = Ellie | authorlink6 = | last7 = Englert | first7 = Hanna | last8 = Byrne | first8 = Mary | last9 = Bergin | first9 = Colm | date = | title = Persistent Endotheliopathy in the Pathogenesis of Long COVID Syndrome|url=https://onlinelibrary.wiley.com/doi/abs/10.1111/jth.15490|journal=Journal of Thrombosis and Haemostasis|language=en|volume=|issue=|pages=|doi=10.1111/jth.15490|issn=1538-7836|pmc=|pmid=|access-date=|quote=|via=}}</ref> [https://onlinelibrary.wiley.com/doi/epdf/10.1111/jth.15490 (Full text)] *2021, Long COVID or Post-acute Sequelae of COVID-19 (PASC): An Overview of Biological Factors That May Contribute to Persistent Symptoms<ref name="Proal2021">{{Cite journal | last = Proal|first = Amy D. | authorlink = Amy Proal | last2 = VanElzakker | first2 = Michael B. | authorlink2 = Michael VanElzakker | date = 2021 | title=Long COVID or Post-acute Sequelae of COVID-19 (PASC): An Overview of Biological Factors That May Contribute to Persistent Symptoms|url=https://www.frontiersin.org/articles/10.3389/fmicb.2021.698169/full|journal=Frontiers in Microbiology|language=English|volume=12|issue= | pages = 698169|doi=10.3389/fmicb.2021.698169|issn=1664-302X|pmc=8260991|pmid=34248921|access-date=|quote=|via=}}</ref> [https://doi.org/10.1101/2020.12.24.20248802 (Full text)] *2020, Long COVID-19: Challenges in the diagnosis and proposed diagnostic criteria<ref name="PMC7737559">{{Cite journal|last = Raveendran | first = A.V. | date = 2021 | title=Long COVID-19: Challenges in the diagnosis and proposed diagnostic criteria|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737559/|journal=Diabetes & Metabolic Syndrome|volume=15|issue=1|pages=145–146|doi=10.1016/j.dsx.2020.12.025|issn=1871-4021|pmc=7737559|pmid=33341598}}</ref> [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737559/ (Full text)] *2020, Multi-organ impairment in low-risk individuals with long COVID<ref name="Dennis2020">{{Cite journal|last = Dennis | first = Andrea | authorlink = | last2 = Wamil | first2 = Malgorzata | authorlink2 = | last3 = Kapur | first3 = Sandeep | authorlink3 = | last4 = Alberts | first4 = Johann | authorlink4 = | last5 = Badley | first5 = Andrew D. | authorlink5 = | last6 = Decker | first6 = Gustav Anton | authorlink6 = | last7 = Rizza | first7 = Stacey A. | last8 = Banerjee | first8 = Rajarshi | last9 = Banerjee | first9 = Amitava | authorlink9 = | date = 2020-10-16 | title = Multi-organ impairment in low-risk individuals with long COVID|url=https://www.medrxiv.org/content/10.1101/2020.10.14.20212555v1|journal=medRxiv|language=en|volume=|issue=|pages=2020.10.14.20212555|doi=10.1101/2020.10.14.20212555|pmc=|pmid=|access-date=|quote=|via=}}</ref> [https://doi.org/10.1101/2020.10.14.20212555 (Full text)] - Pre-print *2020, Living with covid-19. A dynamic review of the evidence around ongoing covid-19 symptoms (often called long covid)<ref name="NIHR15Oct2020">{{Cite web|url=https://evidence.nihr.ac.uk/themedreview/living-with-covid19 | title = Living with covid-19. A dynamic review of the evidence around ongoing covid-19 symptoms (often called long covid). | last = National Institute for Health Research|first = | authorlink = National Institute for Health Research | date = Oct 2020|doi=10.3310/themedreview_41169 |website=National Institute for Health Research|language=en-GB|archive-url=|archive-date=|url-status=|access-date=2020-10-15}}</ref> [https://evidence.nihr.ac.uk/themedreview/living-with-covid19 (Full text)] == News and articles == * Aug 2021, [https://www.theguardian.com/commentisfree/2021/aug/12/when-it-comes-to-breakthrough-cases-are-we-ignoring-long-covid-once-again When it comes to breakthrough cases, are we ignoring long Covid once again?] - Hannah Davis, The Guardian == Learn more == * [https://docs.google.com/spreadsheets/d/1gF-kMUxJWNrwxbmoMW2wGKTMlksRUAROjh7b97G9IE8/edit Long COVID Resource Hub] (database of Long COVID research) == See also == * [[Long COVID]] == References == {{Reflist}} [[Category:Long COVID]]
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