You have either heard of or experienced first hand the “brain fog” associated with COVID-19 infection.  This disordered operation of thought and memory occurs during an active COVID-19 infection.  But what about later, down the road?  Do these issues persist? Is this Long COVID Brain?

The most comprehensive investigation of brain issues weeks after recovery from active COVID-19 was published in Nature (Douaud et al.)

These investigators performed brain scans on a 785 patients on two occasions.  Sometime after the first scan, 401 patients in this group tested positive for COVID-19.  The scientists compared the brain images before and after COVID-19 infection and compared these images with those obtained in 384 COVID-19-negative controls.  They reported structural changes in three main areas:

1. A decrease in the outer layer of brain (grey matter) densely filled with nerves most noticeable in the front of the brain and in a layer called the parahippocampal gyrus;
2. Signs of brain damage in the part of the brain connected to the olfactory nerve which is responsible for the sense of smell; and,
3. An overall decrease in the size of the brain.

In addition, they found a decrease in cognitive skills like computation, judgement and memory in those patients who tested positive and showed the changes in brain structure.

These cognitive changes have been reported previously (Taquet et al, Taquet et. al.).

How Does

Long COVID Brain

Affect

Brain Function?

In the Douaud et al. study, the investigators used a neuropsychological measure called the Trail Making test, which reflects a number of complex brain functions that together comprise Executive Functioning.  Executive functioning is essential for planning, organizing and executing tasks.  We don’t know yet how long these brain disorders last.

Wellivery and Long COVID Brain.

I will track and update this section of Wellivery.com to give you the best information about this topic.

What Causes

Long COVID Brain?

At least 2 major theories that have been proposed to explain the brain effects of Long COVID.  So far, the mechanisms that have been proposed have not been proven.  Getting the answer to this question will be a key component of understanding how to treat, prevent, and possible reverse Long COVID brain.

Wellivery and Long COVID

I have created a dedicated page about Long COVID as a launching point for exploring what we know about Long COVID, its cause, treatment, and longterm affects.

Infection with COVID-19 has shown us many unique medical problems caused by the virus.  Once you as a patient get out of the danger zone with your initial infection, you may not be out of the woods.  Many patients COVID-19 are reporting new problems beginning many weeks later.  A number of body systems seem to be injured by this virus.  The heart and blood vessels is one we are learning more about.

Long COVID Heart

The most interesting source of this information comes from a recent study published in Nature Medicine by Xie et. al. showing that COVID-19 produces a number a serious disorders that become evident weeks after recovery from the initial infection.  They include:

• Strokes (due to blood clots in the blood vessels of the brain);
• Heart Rhythm problems;
• Heart attacks (ischemic heart disease);
• Inflammation around the heart (pericarditis);
• Inflammation of the heart muscle (myocarditis);
• Heart failure; and
• Blood clots in vessels throughout the body.

Even minor symptoms from COVID-19 have been assciated with these disorders!

What To Do About It?

Be on the lookout for symptoms. Long COVID has a broad set of symptoms that appears at least four weeks after the initial COVID-19 infection.  Symptoms in this list related to the heart and blood vessels should alert your doctor to the possibility that more serious disorders exist.  More testing will be needed in each case to make sure you are ok.

Treating Long COVID Heart

So far, the disorders of the heart and blood vessels from COVID-19 are treated using standard, well established medicines or procedures.  Whether we can prevent the development of these disorders is not yet known.

My Job?

My job as a physician is to evaluate your symptoms, get a diagnosis of the underlying disorder, and launch treatment and/or intervention.  Perhaps in time, there will be specific treatments and interventions for heart and blood vessel problems caused by COVID-19.  For now, you keep an eye on your health and I’ll watch the scientific and medical literature for new information.

I’ll post new scientific discoveries on this page, so BookMark it now!

Long COVID treatment is becoming a serious topic as doctors and scientists come to appreciate just how many COVID-19 survivors are likely to experience this disorder.  Both the CDC and the WHO are working establish more knowledge about it.  But first, what are we talking about?

The definition of Long COVID is evolving and this evolution is occurring faster than almost any other area of medicine.  Consequently, we will know dramatically more about Long COVID in 6 months. 

For now, Long COVID is a broad set of symptoms that appears at least four weeks after the initial COVID-19 infection.  None of these symptoms are unique to COVID-19 and are seen in other disorders.  

Treating It

In some of these other disorders, well defined treatments have been established. My job as a physician is to evaluate these symptoms, determine if they are part of a non-COVID disorder and launch treatment.  

For example, after recovery from COVID-19, many patients complain of shortness of breath. Shortness of breath is also a symptom seen in poorly controlled asthma. If the shortness of breath these patients report is from asthma, and we make the diagnosis of asthma, then asthma medicine can be prescribed with good relief of the symptoms.

What if asthma is not diagnosed in these patients? Would asthma medicine still provide them relief? These are valid and very important questions that doctors and patients will be discovering the answers to as we move forward.

 

Moving Ahead!

I believe there are a few main points to remember:

1. At this time, it is believed that most post-Covid symptoms will resolve in a period of six months to one year.
2. The medication or interventions that improve the long COVID symptoms are already well known.
3. Most Long COVID patients can be managed by a primary care physician.
4. As a physician, the most important task is to keep Long COVID patients hopeful while being vigilant for treatable serious underlying diseases. 
5. Just as with all chronic health problems, building an expert, accessible, healing relationship between the patient and physician is be the best way to move through the Long COVID recovery process.

Long COVID will present some treatment challenges.

There is much that we don’t know about this disorder.  But, we know a lot about helping patients overcome the limitations of a chronic disease.  We can apply that knowlege and those approaches to help patients overcome Long COVID for life!

First, we need clarify what is meant by Long COVID.  The definition of long COVID is being perfected but for now, it refers to new mental or physical symptoms that are present four or more weeks after your acute COVID infection.  We know the SARS-CoV-2 virus causes COVID-19 and we are getting better understanding about why infection with SARS-CoV-2 creates so much lung damage.  How this virus causes the symptoms of Long COVID in other body systems is still being worked out but, we have some clues.

Yep!  Hamsters get COVID-19 and they suffer the same complications as human, including LONG COVID!

This means they can be studied for clues to how COVID-19 induces Long COVID in humans.

The first symptom of long COVID explored in hamsters was loss of smell.  Hamsters loose their sense of smell with COVID-19 just like humans and this effect can be long lasting.  The study describing these observations performed by Zazhytska et al. was published in the journal Cell.

In hamsters that suffered lasting loss of smell, evaluation of the olfactory nerve showed damage to a particular structural cell in the olfactory (smell) bulb connected to the nose.  The damage to these cells results in a large amount of inflammation which impairs the normal functions of olfactory nerve cells in the same tissue.  The nerve cells are not damaged but cannot maintain their normal smell-functions resulting in loss of the sense of smell.

The normal immune response eventually gets control of this inflammation, allowing the olfactory nerve cells to resume their normal smell-related functions and the sense of smell returns.

The same inflammation-related malfunction was found in other areas of the hamster brain.   If true in humans, this may explain neurological and mental changes that have been reported in Long COVID.

Fixing it.

Studies are currently looking to see if shutting down the inflammation response with medication will allow more rapid recovery of these neurological functions including smell and other mental health functions.

Until we have a more detailed understanding of the cause of lasting changes in the brain and other body systems in Long COVID, we will focus on assisting patients with a wide variety of symptoms. Our overall goal is to improve functional capacity and quality of life in these patients.

Many patients ask me about steroids early in the treatment of long COVID-19. While it’s true that steroids are often used in hospitalized patients with active COVID-19, the evidence for their effectiveness in patients who are recovering is not strong.

In fact, in animal studies of how COVID affects the brain, it appears that the non-judicious use of steroids in COVID-19 infection can make things worse.  That’s because early in COVID-19 infection, the immune system needs to be fully functional and at full speed.  Steroids like prednisone and dexamethasone shut down immune defense systems, which gives the virus an unchecked advantage in spreading inside the body.

When COVID-19 patients land in the hospital, its usually because their lungs are failing.  The current evidence indicates that in some people, due to underlying disease or genetic factors, COVID-19 infection triggers a hyper-reaction in their immune system.  The lungs are at ground zero of this reaction and are damaged in the cross-fire.  In this setting, steroids are used to tone-down the immune response to lessen lung damage.

How Would Steroids Help in Long COVID?

We are at the very edge of understanding this question. The first studies that will answer this will be conducted in hamsters, a species that remarkably mimics COVID-19 infection in humans.

It will be sometime before we know how applicable these findings are to humans. Nonetheless, these studies are encouraging and provide additional insight into COVID-19 and long Covid symptoms.

Long COVID is a fascinating medical challenge!  Helping patients navigate to recovery from Long COVID is a top priority at Wellivery.  Keep track of Long COVID developments by bookmarking the Wellivery Long COVID page.

Long COVID (also called Postacute Sequelae of SARS-CoV-2 Infection or PASC) is a new clinical diagnosis and as such, the diagnostic criteria for this disorder have not been settled.

What we can say is that survivors of COVID-19 infection are frequently reporting  new mental and physical problems that last weeks to months after their acute COVID-19 symptoms passed.

 

Does everybody with COVID-19 get long COVID?

This is very important question and is a moving target, like so many other aspects of COVID-19.  Only a few studies have been performed that can shed any light on this question.  In 2021, a systematic review of 57 published studies from around the world, covering 250,351 patients diagnosed with COVID-19 found that long covid symptoms occurred in 54% of survivors at 1 month, 55% at 2-5 months, and 54% at 6+ months (Groff et al, 2021).

Ok, so if 50% of COVID-19 survivors get long COVID, how many is that, in the U.S. and the world?  To get that number, we need to know how many people have gotten COVID19 and survived.

 

How Many People Have Survived COVID-19??

In the U.S. the current data from the CDC says 78M have survived COVID19 (as of 2/8/2022).  This number is currently increasing by 243K cases per day.

World-wide, WHO data indicate 397M cases, increasing at 1.8M cases per day;

On this point, we run into an ugly truth about how many people have had documented COVID19.  You see, I was there in early 2020, working in the ER when health systems said: “don’t come in unless you are really sick”, and, ‘we don’t have enough COVID tests to offer it to patients that aren’t being admitted”.  Then, throughout 2021, patients were instructed to assume they had COVID19 if they developed typical symptoms and had been exposed to a person known to be positive. We have all witnessed the widespread failure of COVID testing access.

 

The result: A lot of people that had, and currently have COVID19 didn’t get and aren’t getting counted.

 

So, you wouldn’t be shocked if I suggested the numbers offered above are a large under-representation of the true number of people infected with COVID19.  But, how far off is that number?  Why do I care?  Well, if ~50% of people surviving COVID19 are getting long COVID, it is important to know the size of that group so we can organize a clinical response that can reasonably deliver the needed care.

Estimating the ‘true’ Numbers

Though not often discussed in the media, epidemiologists appreciate that undercounting of COVID19 cases has occured.  In an effort to derive the real case counts, Reese et al considered the reasons for “underdetection” and derived a correction factor.  For every hospitalized patient,  2.5  patients weren’t counted. For every COVID19-positive patient that wasn’t hospitalized, 7.1 were not counted.  Let’s just consider the non-hospitilized scenario: To find the actual number of non-hospitalized COVID19 cases in the U.S., we need to multiply the CDC number by ‘7’.  That yields 546M, more than the population of the U.S., which suggests, as we know, that many people have gotten COVID19 more than once.

How Many Long COVID Patients Should We Prepare to Treat?

Given the currently reported undercounts, along with daily increases and the non-hospitalized correction factor (7. 1), it becomes clear that the current incidence of long COVID could easily be 273M.  As a frame of reference, the incidence of other chronic diseases is:

• Diabetes: 34 M
• Pre-diabetes: 88 M
• Heart Disease: 30 M
• Mental Health: 52 M
• Obesity: 119 M

This means long COVID is already the #1 chronic disease in the U.S.

How is the U.S. health system going to respond to the needs of 273M patients with a new chronic disease?

We’ll get into that next.

If you believe you have long COVID, schedule an appointment on Wellivery to get an assessment.

Long COVID is a fascinating medical challenge!  Helping patients navigate to recovery from Long COVID is a top priority at Wellivery.  Keep track of Long COVID developments by bookmarking the Wellivery Long COVID page.

You’ve heard a lot about COVID-19 but now you are wondering: What is Long COVID?

Long COVID is a new clinical diagnosis, emerging from the COVID-19 pandemic.

Survivors of COVID-19 reported new mental and physical problems that persisted for weeks or months after their acute COVID-19 symptoms passed.  The current working definition of long COVID is:

What kinds of problems?

• Shortness of Breath
• Poor endurance
• “Brain fog”
• Cough
• Chest pain
• Headache
• Palpitations and/or tachycardia
• Joint pain
• Muscle aches
• Tingling and numbness
• Abdominal pain
• Diarrhea
• Sleep difficulties
• Fever
• Lightheadedness
• Unable to function daily
• Pain
• Rash (e.g., urticaria)
• Mood changes
• Loss of smell and taste
• Menstrual cycle irregularities

As you can see, these symptoms are not unique to COVID-19 and are often seen in other medical conditions.  The observation that they occur as new problems after COVID-19 is likely related to the body systems involved in the acute infection phase.  Both the CDC and the WHO are actively considering this disorder and though their definitions are different, they are unified in emphasizing both the large number of patients experiencing it and the need to develop a health system response to care for sufferers.

If you believe you have long COVID, schedule an appointment on Wellivery to get an assessment.

Long COVID is a fascinating medical challenge!  Helping patients navigate to recovery from Long COVID is a top priority at Wellivery.  Keep track of Long COVID developments by bookmarking the Wellivery Long COVID page.