The Increasing Need for Post COVID-19 Clinics

While most people who become ill with COVID-19 recover after a few days or weeks, an estimated 10% to 15% experience symptoms at least 4 weeks after the infection itself has resolved. So-called Long COVID, or Long-Haul COVID, is prevalent enough that clinics focusing on Covid’s aftermath are springing up around the U.S. and other nations. The Infectious Diseases Society of America (IDSA) held a press briefing during which experts discussed who they’re seeing at these clinics, why patients are having lingering symptoms, and the kinds of treatment they receive.

Technically, Long COVID is defined as the persistence of symptoms at least 4 weeks after the initial infection has resolved, according to Allison Navis, MD, assistant professor in the Division of Neuro-Infectious Diseases and neurology clinic director at New York’s Icahn School of Medicine at Mount Sinai. However, she noted that symptoms often continue for months; some patients have had symptoms for close to a year. These may be the same symptoms that plagued them during their infection or entirely new ones.

“Fatigue seems to be the most common thing,” Navis said. “It’s a little unclear as to what’s causing the fatigue because that can have many different etiologies. It can be cardiac, or pulmonary, and then for many others we’re not finding a specific cause.” Dyspnea and pulmonary issues are the second most common complaints. Chest pain is frequent, too, as are neurological changes and “brain fog.” Other symptoms include headaches, numbness and tingling, and manifestations of dysautonomia such as lightheadedness, dizziness, heart, palpitations, and gastrointestinal disturbances. Navis has also received reports of joint pain, rashes, and anosmia persistence.

A major focus at post COVID-19 clinics is figuring out whether symptoms are caused by COVID-19 itself or whether they’ve sprung up as part of a post viral syndrome. According to Navis, post viral problems can last up to a year or longer and then resolve.

At Mt. Sinai, Navis orders cognitive testing for all post COVID patients, and sometimes does imaging studies in older patients to look for vascular issues. For her patients with neuropathy, Navis checks for vitamin and hormone deficiencies. She might prescribe antidepressants or antiseizure medications, depending on the individual and any other problems they might be having. Treatment for most issues is supportive care, so managing depression, anxiety, and sleep disruptions is key. She acknowledged that it’s difficult to determine whether a symptom like depression is a direct result of COVID-19 or is secondary, but “[w]e still need to address the depression, because maybe that’s something we can do something about,” she said.

Dallas-based Kathleen Bell, MD agreed that determining whether patients’ prior health conditions are contributing to their post COVID symptoms can be tricky. Many of the people at highest risk for severe illness, such as those with diabetes or hypertension, have physiological abnormalities before they ever contract COVID-19. In a patient with hypertension, for example, “you may have a little bit of chronic microvascular disease in your brain [that sets you] up for having brain problems later,” said Bell, the Kimberly Clark Distinguished Chair in Mobility Research and chair of the Department of Physical Medicine and Rehabilitation at UT Southwestern Medical Center. “If you’re diabetic, you already may have some nerves that are affected by the chronic diabetes in your arms or legs.”

When COVID-19 hits people with pre-existing conditions like these, vulnerable areas of the body can be impacted. “People may find that they may have been compensating very well for problems that they had beforehand—maybe some minor cognitive impairment they had from the hypertension or the microvascular disease—but when you put a trauma like this and a stress [like this] on the body, it may actually bleed over into becoming symptomatic for them,” Bell said. In these cases, it can be difficult to distinguish exacerbations of preexisting problems from new problems caused solely by COVID-19, which can include inflammation of the brain, heart, nerves, and muscles.

People who were hospitalized with COVID-19, as opposed to dealing with it at home, suffer from particular aftereffects, Bell noted. Many of the sickest patients had to be turned over onto their stomachs, or proned, which puts a lot of pressure on certain nerves. These patients are now experiencing weakness and paralysis in their arms and legs, an outcome that can be particularly troublesome for people with diabetes.

But post COVID symptoms aren’t only physical. “For a large percentage of these people, we’re actually seeing mental health reactions to this,” Bell said. People who were in the hospital for weeks and months without the comfort of loved ones nearby may struggle with post-traumatic stress disorder, anxiety, and depression. Navis agreed: “A lot of our patients who were sick in March or April, even if they had a milder infection, it was a very scary time here in the city and they might have been alone in their apartments.”

Recognizing the increasing need for post COVID clinics, the National Institutes of Health (NIH) and the US Centers for Disease Control and Prevention (CDC) are developing protocols for these centers, while established centers such as Mt. Sinai’s are offering guidance to those just getting up and running. For hospitals figuring out who should staff these clinics and who they should partner with, Navis and Bell emphasized that specialists who can address physical weakness, cardiopulmonary issues, muscle conditioning, and cognitive issues are key. Patients also benefit from access to neuropsychological therapy and autonomic nervous system testing.

The demographics of patients at these clinics may surprise some. Men are likelier than women to die from Covid-19, but they don’t seem to be hit as hard by lingering symptoms; Navis noted that while the gender balance at Mt. Sinai is fairly even, Long-Haul COVID sufferers tend to skew female. Although older people clearly are at higher risk and have been prioritized for vaccination, the people showing up at post-COVID clinics are surprisingly young: The average age of patients at Mt. Sinai is roughly 40. And while many Long Haulers were severely ill, some had decidedly milder illnesses. Navis even has 1 or 2 patients who had what she feels were asymptomatic cases of COVID-19, only to experience symptoms after the infection resolved—a reminder that there is still much to learn about this virus.