Post-COVID-19 illness

There have been some reports of long term illness in survivors of COVID-19; it is unclear how many people are affected at this stage. One small study from Wuhan, China, found that survivors of COVID-19 who tested negative twice before discharge from hospital still had some abnormalities in metabolism and liver function markers when discharged.

Relapse or reinfection
Some patients have described feeling fully recovered, then experiencing COVID-19 symptoms again, and feeling like their lungs were "on fire" for some weeks afterwards. There is uncertainty about whether this is a relapse due to the virus remaining at low levels in the body and bring reactivated, or if this is a reinfection.

Post-SARS illness
COVID-19 is caused by the SARS-CoV-2 virus; the similar SARS-CoV coronavirus causes SARS, and SARS is known to have caused long term illness in some survivors, including chronic fatigue syndrome and a post-SARS syndrome similar to fibromyalgia involving chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep.

ICU survivors




Long term physical, cognitive and mental health problems have also been found to be relatively common in patients discharged from intensive care from illnesses other than COVID-19, with the length of time in intensive care influencing the long term health impacts. Post Intensive Care Syndrome (PICS) is one of several conditions that can result, including Critical Illness Polyneuropathy (CIP) and Critical Illness Myopathy (CIM), and requires both short and medium term rehabilitation treatments.

COVID-19 pneumonia and SARI
Moderately ill patients with COVID-19 may develop mild viral pneumonia. Severe acute respiratory infection (SARI) is known to develop in some people severely ill with COVID-19. SARI resulting from other illnesses has been studied.

Acute respiratory distress syndrome
Acute respiratory distress syndrome (ARDS) is a life-threatening condition that involves the patient's lungs becoming inflamed, and being unable to produce enough oxygen for the body's vital organs. ARDS develops in 17-29% of hospitalized COVID-19 patients and is known to have long term effects. ARDS can cause nerve and muscle damage, which causes pain and weakness.

Mechanical ventilator effects
Invasive ventilation using a mechanical ventilator was needed by 47-71% of patients admitted to Intensive Care Units.

COVID-19 complications
These include:
 * Anecdotal reports of DVT and PE in critically ill patients
 * Central nervous system encephalitis and encephalomyelitis
 * anecdotal evidence of pulmonary aspergillosis
 * pneumonia
 * hypoxemic respiratory failure/ARDS
 * sepsis and septic shock
 * cardiomyopathy and arrhythmia
 * acute kidney injury
 * complications from prolonged hospitalization including:
 * secondary infections including bacterial and fungal infections
 * thromboembolism
 * gastrointestinal bleeding
 * critical illness polyneuropathy/myopathy.

Fatigue after COVID-19
COVID-19 can cause severe fatigue, however experiencing fatigue after recovering from the virus should not be the considered the same as the illness chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME), a neurological disease involving multiple bodily systems and sustained symptoms over an extended period of time. Post-viral fatigue which does not meet the criteria for CFS or ME and lasts at least 6 months is known as chronic fatigue (without the "syndrome"), or idiopathic chronic fatigue if the cause is unknown.

Potential brain damage
Scientists warn of a potential wave of coronavirus-related brain damage as new evidence suggests COVID-19 can lead to severe neurological complications, including brain inflammation, psychosis and delirium. "“Whether we will see an epidemic on a large scale of brain damage linked to the pandemic – perhaps similar to the encephalitis lethargica outbreak in the 1920s and 1930s after the 1918 influenza pandemic – remains to be seen,” said Michael Zandi, from UCL’s Institute of Neurology, who co-led the study."

Notable studies
"A study by researchers at University College London (UCL) described 43 cases of patients with COVID-19 who suffered either temporary brain dysfunction, strokes, nerve damage or other serious brain effects.""The research adds to recent studies which also found the disease can damage the brain."
 * Jul 8, 2020, The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings

Post-viral syndrome
Post-viral syndrome or post-viral state is sometimes used to refer to symptoms that occur as a result of a virus, which take longer than a few weeks to resolve. The older term Post-infective fatigue is no longer in use. Post-viral syndrome may include shortness of breath, fatigue, difficulty thinking, aches and pains, or other symptoms, and typically improves gradually over time. People who remain ill after 6 months may meet the criteria for postviral fatigue syndrome (PVFS), which is more commonly diagnosed as chronic fatigue syndrome or myalgic encephalomyelitis, although it may be possible to diagnose this sooner using the international consensus criteria. For most people, this is a very disabling, long-term (chronic) illness.

Dr. Anthony Fauci, the United States top infectious disease expert, acknowledged that many unrecovered COVID-19 patients may have ME, also known as chronic fatigue syndrome, or ME/CFS. Dr. Fauci stated: “There may well be a post-viral syndrome associated with Covid-19,...If you look anecdotally, there is no question that there are a considerable number of individuals who have a post-viral syndrome that in many respects incapacitates them for weeks and weeks following so-called recovery,” At the International AIDS conference, he stated: "Brain fog, fatigue, and difficulty in concentrating. So this is something we really need to seriously look at because it very well might be a post-viral syndrome associated with COVID-19.

An internist at Texas Health Presbyterian Hospital, Dr. Donna Casey, said “We can now see documented abnormalities in your nervous, immune, and metabolic systems. So we’re seeing abnormalities in all three that create myalgic encephalomyelitis.” Dr. Casey did say that we are not at the six month mark for COVID, but she does see ongoing improvement in her hospitalized patients. Dr. Amir K. Ghiassi, a pulmonologist with St. Joseph Hospital in Orange County, California said of the ongoing symptoms they were uncertain if it had to do with the virus or “because of the immune system reacting the way it does that causes symptoms.”

Postviral fatigue syndrome and ME/CFS
Myalgic encephalomyelitis, better known as ME, is a neurological disease that commonly begins after a virus, although other possible triggers include bacterial infections, injuries, surgery and other events. Some researchers and some patients use the term chronic fatigue syndrome (CFS), or ME/CFS to refer to ME, although CFS has different diagnostic criteria. The older term Postviral fatigue syndrome (PVFS) is rarely used, although the World Health Organization recognize PVFS, ME, and CFS using the same diagnostic code. Some countries including the United States, deviate from this.

Moldofsky et al. (2011) conducted a long term follow up of 21 SARS survivors in Toronto, Canada, all of who remained too ill to return to work, and concluded that that chronic post-SARS was similar to fibromyalgia. Lam et al. (2009) conducted a much larger long term follow-up of SARS survivors in Hong Kong, and reported that 27% had chronic fatigue syndrome, 40% had chronic fatigue, and 40% has depression. A number of the SARS survivors unable to return to work were previously healthy health-care workers. The high rates of chronic fatigue could not be accounted got by depression or psychiatric illness.

Treatment
No treatment studies have yet been published, despite this and the uncertainty over long term physical and psychological health consequences of coronavirus disease 19 (COVID-19), some self-help advice has already been published.

A group of over 20 ME and chronic fatigue syndrome specialists and patient groups have recommended fatigue following COVID-19 should be treated/managed using:
 * activity pacing
 * nutrition and
 * sleep hygiene, stating that should help reduce the risk of developing ME/CFS after COVID-19.

Pacing
Less controversially, the self-help leaflet mentions pacing, a symptom-management approach also without evidence for COVID-19 survivors, but which is used by many people with chronic fatigue, chronic pain, and/or persistent illness that limits their everyday activities. ME patient associations surveys have found pacing helped most, but not all, patients.

CBT and GET not recommended for fatigue
The Oxford Health NHS Foundation Trust published a Coping with Coronavirus: Fatigue leaflet referring to chronic fatigue syndrome, a neurological disease, as a possible mental health consequence of COVID-19, and confusing fatigue after COVID-19 illness with chronic fatigue syndrome. The leaflet recommenddations included the highly controversial use of cognitive behavioral therapy (CBT) and graded exercise therapy (GET) to address the physical symptoms of chronic fatigue syndrome. The leaflet was withdrawn after public health expert David Tuller asked for the evidence based used by it, details of its authorship, and strongly criticised the advice given in it. An open letter opposing the leaflet was signed by a large number of medical professionals and UK patient groups at around the same time.

CBT for fatigue is a psychological therapy focused on treating a presumed illness beliefs such as a fear of activity and GET is exercise/activity based, both treatments rely on the assumption that there is no lasting physical damage or underlying illness process that could prevent full recovery. GET is particularly controversial and has been found to cause most patients with chronic fatigue syndrome (not resulting from COVID-19) to deteriorate, sometimes permanently. CBT and GET are no longer recommended by the CDC, and their use within the UK's National Health Service is currently under review, with many concerns having been raised about high rates of patient harm resulting from these treatments, and a lack of effectiveness. CBT and GET they are not recommended by the UK's ME Association, Action for ME, Invest in ME Research, MEAction, or The 25% ME Group. CBT may be useful for depression or generalized anxiety.

Recovery advice

 * MEA Information on Post-viral fatigue (PVF) and Post-viral fatigue syndrome (PVFS) following coronovirus infection - ME Association (May 2020)
 * Post Covid-19 Rehabilitation - Physios for ME, Workwell Foundation, and ME Association (May 2020)

Notable studies
No studies have yet been completed on the impact of COVID-19 on the long term health of survivors, or on treatment approaches.

News articles and blogs

 * Aug 20, 2020, Coronavirus patients still suffering from complications three months later, study finds - The Independent
 * Jul 9 2020, Coronavirus may cause fatigue syndrome, Fauci says
 * Jul 1, 2020, Three Months In, These Patients Are Still Ravaged by Covid’s Fallout - Wall Street Journal
 * May 18, 2020, Paul Garner: Covid-19 and fatigue—a game of snakes and ladders - The BMJ
 * May 4, 2020, Fever, fatigue, fear: For some recovering COVID-19 patients, weeks of illness, uncertainty - Erika Edwards, NBC News
 * Apr 17, 2020, Coronavirus survivors say they fear long-term effects - Melissa Malamut, New York Post
 * Apr 17, 2020, What we know about coronavirus' long-term effects - Erin Shumaker, ABC news
 * Apr 16, 2020, Trial By Error: Oxford-NHS Recommends GET/CBT for Post-COVID “CFS” Patients
 * Apr 16, 2020, Those Who Get COVID-19 and Get Healed Can Face Another Disease After A Few Years - Daniel Kucher - SOMAG news
 * Apr 15, 2020, Could the coronavirus trigger post-viral fatigue syndromes? - Clare Wilson, New Scientist
 * Apr 15, 2020, Coronavirus destroys lungs. But doctors are finding its damage in kidneys, hearts and elsewhere - Lenny Bernstein, Carolyn Y. Johnson, Sarah Kaplan and Laurie McGinley, Washington Post
 * Apr 13, 2020, We Need to Talk About What Coronavirus Recoveries Look Like - Fiona Lowenstein, New York Times Opinion
 * Apr 2, 2020, Will COVID-19 -19 leave an explosion of ME/CFS cases in its wake? - blog by Cort Johnson
 * Mar 28, 2020, 'Post intensive-care syndrome': Why some COVID-19 patients may face problems even after recovery - Erika Edwards, NBC News

Learn more

 * May 2020, MEA Information on Post-viral fatigue (PVF) and Post-viral fatigue syndrome (PVFS) following coronovirus infection - ME Association
 * May 2020, Post Covid-19 Rehabilitation - Physios for ME, Workwell Foundation, and ME Association
 * May 2020, Patients at higher risk of developing ME after COVID-19 diagnosis - University of Leicester
 * Apr 30, 2020, Covid-19 and Post-viral Fatigue Syndrome - Charles Shepherd, ME Association
 * Coronavirus disease 19 (SARS-CoV-2) - John Hopkins University