An interesting comment in The Lancet published January 8, 2021, long term follow up of recovered patients with COVID-19.
By early January 2021, COVID-19, caused by SARS-CoV-2, has resulted in more than 83 million confirmed cases and more than 1.8 million deaths worldwide. The clinical spectrum of SARS-CoV-2 infection is wide, encompassing asymptomatic infection, fever, fatigue, myalgias, mild upper respiratory tract illness, severe life threatening viral pneumonia requiring admission to hospital, and death.
Physicians are observing persisting symptoms and unexpected, substantial organ dysfunction after SARS-CoV-2 infection in an increasing number of patients who have recovered. This was previously observed in the SARS outbreak.
However, COVID-19 is a new disease and uncertainty remains regarding the possible long term health sequelae. This is particularly relevant for patients with severe symptoms, including those who required mechanical ventilation during the hospital stay, for whom long term complications and incomplete recovery after discharge will be expected.
Unfortunately, few reports exist on the clinical picture of the aftermath of COVID-19.
The study by Chaolin Huang and colleagues in The Lancet is relevant. They describe the clinical follow up of a cohort of 1,733 adult patients, 48% women, 52% men with a median age of 57 years with COVID-19 who were discharged from Jin Yan-Tan Hospital in Wuhan.
Six months after the illness onset 76%, that is 1,265 of the 1,655 patients, reported at least one symptom persisted, with fatigue or muscle weakness being the most frequently reported symptom. 63% out of 10,038 of 1,655 reported fatigue or muscle weakness.
More than 50% of patients presented with residual chest imaging abnormalities.
Disease severity during the acute phase was independently associated with extensive lung diffusion impairment at follow up. These findings are consistent with those from earlier small studies that reported lingering radiological and pulmonary diffusion abnormalities in a sizeable proportion of COVID-19 patients up to three months after hospital discharge.
Evidence from previous Coronavirus outbreaks suggests that some degree of lung damage could persist, as shown in patients who recovered from SARS, 38% of whom had reduced lung diffusion capacity 15 years after infection.
Although SARS-CoV-2 primarily affects the lungs, several other organs, including the kidneys, can also be affected. Therefore, Huang and colleagues assess the sequelae of extra pulmonary manifestations of COVID-19.
Unexpectedly 13% 107 of 822 of the patients who did not develop acute kidney injury during their hospital stay and presented with normal renal function, based on estimated glomerular filtration rate, eGFR, during the acute phase, exhibited a decline in eGFR at follow up.
Deep venous thrombosis was not diagnosed in any of the patients who underwent ultrasound at follow up – this is an encouraging finding, in light of the frequent development of venous thromboembolism in patients with COVID-19 who are critically ill whilst in hospital.
This study offers a comprehensive clinical picture of the aftermath of COVID-19 in patients who have been admitted to hospital. However, only 4%, that is 76 of 1733, were admitted to an intensive care unit and therefore the information from the study about long term consequences for most patients admitted to ICU is inconclusive. However, previous research on patient outcomes after ICU stay suggests that several patients with COVID-19 who are critically ill during their hospital stay will subsequently face impairments regarding their cognitive and mental health or physical function far beyond their hospital discharge.
Clearly, these further studies are important to understand and mitigate the long term consequences of COVID-19 on multiple organs and tissues.
The London General Practice has worked with many physicians involved with COVID 19 patients to develop a care pathway for patients who are suffering long COVID.
Dr Paul Ettlinger
BM, DRCOG, FRCGP, FRIPH, DOccMed