Understanding Long COVID, or not !

Even though the World Health Organization (WHO) has declared that COVID-19 is no longer a global health emergency, the mess it left behind is still very much with us and manifesting itself with continuously unpleasant memories and ongoing symptoms. 

“Long COVID” is now a part of our lexicon and discussion of this terrible infection that has wrought pain and suffering for so many people around the world, and we are still trying to define just what it is, how we recognize it, and most importantly, how we treat it. It appears that many of the symptoms people are experiencing mimic myriad other recognizable conditions that have been around for decades, such as chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis, which represents a constellation of symptoms including profound tiredness despite prolonged bed rest, headaches, muscle and joint pain, insomnia, forgetfulness, mood swings, confusion, depression, and low-grade fever. These symptoms can represent any number of possible diagnoses, which I suppose is why chronic fatigue syndrome is called a syndrome. The severity and duration are highly individualized, but symptoms can last more than six months, and there is no specific treatment to shorten the effects of CFS.

Likewise with long COVID, but we are still in the early stages of trying to learn what we can about this disease process. From my review of the literature, we don’t seem to be closing in on how to effectively treat the symptoms. In fact, some might conclude that the coronavirus caused by the SARS-CoV-2 virus and long COVID [CL1]might be two different, although closely related, illnesses. There just seems to be a patchwork of data on long COVID, just as in the early days of COVID, in which health care providers worldwide were just trying to compare notes and observations to sort out what was going on.

The research seems to point to a few observations that have been gleaned to help better identify when long COVID might be suspect, including:

  • The key systems and organs impacted by the disease
  • The most commonly identified symptoms
  • Useful therapeutic options for managing symptoms
  • The best healthy lifestyle choices that providers can recommend to help their patients
  • The most commonly identified symptoms 

The article I’m referencing notes a study showing that more than 10% of people infected with COVID-19 go on to have symptoms associated with long COVID. COVID-19 is a ubiquitous virus that can and does affect multiple organ systems in the body. There can be many symptoms across the body that mimic other physiologic insults that could lead to a totally different diagnosis. The complexity of the disease presentations compounds the difficulty physicians have in relating different symptoms to COVID versus some other illness, further complicating a diagnosis and treatment plan.

Another study in the article divided symptoms into four categories to assist with diagnosis:

  • Cardiac and renal complications (heart palpitations, chest pain, and kidney function)
  • Sleep and anxiety such as insomnia and waking up in the middle of the night
  • Nervous system and musculoskeletal (muscle and bone pain, osteoarthritis, and cognitive skills)
  • Digestive and respiratory systems (trouble breathing, asthma, stomach pain, nausea, and vomiting)

Also interesting is that there were specific patterns in each of the groups. In the first group, the cardiac and renal group, older males had other preexisting conditions and were infected during the first wave of the COVID pandemic. The second group was more than 60% female and had a higher incidence of previous allergies or asthma. The third group, again, mostly female with autoimmune conditions including rheumatoid arthritis. The fourth group, also 60% female, were the least likely of the groups to have another condition.

This study provides researchers some idea of what preexisting conditions might trigger a patient to contract long COVID, and to identify specific symptoms to be on the lookout for. But it also presents the challenge of recognizing that not everyone falls into one of the four categories. It seems that researchers can be on the right track of something valuable, only to hit a dead end somewhere along the way and the trail just vanishes.

Health care providers do note some consistency in patients who are suspect for long COVID and have identified symptoms that could point to the diagnosis.

Post-exertional malaise (PEM) “is often conflated with fatigue, but it’s very different,” according to Dr. David Putrino at Mount Sinai Health System in New York City. PEM worsens symptoms after physical or mental exertion, usually a day or two after the activity, and it can last for days and sometimes much longer. “It’s very different from fatigue, which is just a generalized tiredness, and exercise intolerance, where someone complains of not being able to do their usual workout on the treadmill,” he noted. “People with PEM are able to push through and do what they need to do, and then are hit with symptoms anywhere from 12 to 72 hours later.”

Another impressive-sounding clinical term, dysautonomia, refers to a dysfunction of the autonomic nervous system that regulates bodily functions that we don’t control, such as blood pressure, heart rate, and respirations. The symptoms can be heart palpitations as noted in the first group above, and feeling dizzy or faint while standing upright for long periods. Several studies suggest that these symptoms are present in many long COVID patients.

Exercise intolerance also popped up in numerous studies and suggested that patients with long COVID had a more difficult time doing physical exercise than before they developed symptoms. Exercise capacity was reduced to levels that would be expected about 10 years later in life! I have noticed that complaint among members I speak with who are post-COVID, who are demonstrating possible long COVID symptoms, and who are undergoing exercise stress tests for issuance of a medical certificate as a result of reporting long COVID symptoms on the FAA medXpress medical application.

The article concludes with a list of the most common symptoms present with suspect long COVID, and it’s an impressively diverse list! Chest pain, heart palpitations, coughing, shortness of breath, belly pain, nausea, impaired cognitive (mental) skills, fatigue, sleep disturbances, memory loss, ringing in the ears (tinnitus), erectile dysfunction, and irregular menstruation. That list crosses numerous organ systems and clearly demonstrates the breadth and depth of complications long COVID can present.

Bringing the issue home to pilots and medical certification, the FAA has a disposition table for COVID-19 as well as long or post-COVID that requires deferral by the aviation medical examiner. The table emphasizes the scope of COVID and post-COVID effects on multiple organ systems that can significantly complicate the aeromedical disposition and decision making.

Hopefully you are well and looking forward to the flying season now upon us!

Portrait of Gary Crump, AOPA's director of medical certification with a Cessna 182 Skylane at the National Aviation Community Center.
Frederick, MD USA

Gary Crump

Gary is the Director of AOPA’s Pilot Information Center Medical Certification Section and has spent the last 32 years assisting AOPA members. He is also a former Operating Room Technician, Professional Firefighter/Emergency Medical Technician, and has been a pilot since 1973.
Topics: COVID19

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