“Will I ever lead a normal life again?” A question on the mind of every COVID-19 affected patient. With the ongoing pandemic, the suffering continues, a person even after being tested negative for the virus has to endure several other complications. It is a long road to recovery and takes time for normalcy to return. There is much to be explored and understood about the lasting effects of severe viral respiratory infection and treatment and prevention of post-infection complications, especially in the context of COVID-19.
Post-COVID conditions are a wide range of new, returning, or ongoing health problems people can experience more than four weeks after first being infected with the virus that causes COVID-19. Even people who did not have symptoms when they were infected can have post-COVID conditions.
Long COVID
Long COVID is a range of symptoms that can last weeks or months after first being infected with the virus that causes COVID-19 or can appear weeks after infection. People with long COVID report experiencing different combinations of symptoms like tiredness or fatigue, difficulty thinking or concentrating (sometimes referred to as “brain fog”), headache, loss of smell or taste , dizziness on standing , fast-beating or pounding heart (also known as heart palpitations), chest pain, difficulty breathing or shortness of breath , cough ,joint or muscle pain, depression or anxiety ,fever. Long COVID can happen to anyone who has had COVID-19, even if the illness was mild, or they had no symptoms.
Multi-organ effects can affect most, if not all, body systems including heart, lung, kidney, skin, and brain functions. Multi-organ effects can also include conditions that occur after COVID-19, like multisystem inflammatory syndrome (MIS) and autoimmune conditions. It is unknown how long multiorgan system effects might last and whether the effects could lead to chronic health conditions.
Some of these complications that have risen post recovery include:-
Poor exercise tolerance
This is mainly a complication caused due to the corona virus infection and reduced physical movement. This can be due to the affect or the damage done by the virus on lungs, heart, blood vessels or muscle changes.
Lung or respiratory complications
The most common long-term complication of COVID-19 is lung disease . Most of the COVID-19 patients recover completely except for some minor complications such as cough and shortness of breath. However, a certain proportion of patients have excessive lung damage, and some of them develop pulmonary fibrosis. Patients can also present with post viral bronchial hyperresponsiveness symptoms of which resemble asthma. Secondary infections like bacterial, fungal (mucormycosis, aspergillosis), tuberculosis are seen.
Mucormycosis
Mucormycosis is a fungal infection that is seen in an immunocompromised host. It presents itself as a respiratory or a skin infection and is mainly caused due to exposure to mucormycetes molds by breathing in the affected mold spores in air also referred to as a sinus (pulmonary) exposure. When the infection spreads to the brain through the nasal route it is called as rhino cerebral mucormycosis, when it spreads to the lungs it is called as pulmonary mucormycosis, on the skin it is called cutaneous mucormycosis and it when spreads through the bloodstream it is called disseminated mucormycosis.
The predisposing factors for mucormycosis can be uncontrolled diabetes mellitus, immunosuppression by steroids, prolonged ICU stay, Comorbidities – post transplant/malignancy, Voriconazole therapy. For a patient affected with mucormycosis it is advised to control hyperglycemia, monitor blood glucose level post COVID-19 discharge and also in diabetics, use steroids judiciously, use clean and sterile water for humidifiers during oxygen therapy, and antibiotics/antifungals must be taken judiciously. It is always better to pay attention to the warning signs and symptoms.
Do not consider all the cases with blocked nose as cases of bacterial sinusitis, particularly in the context of immunosuppression and/or COVID-19 patients on immunomodulators. Do not lose crucial time to initiate treatment for mucormycosis, if left untreated, it can lead to death.
Cardiac complications
Recent studies reported an increased risk of heart failure in COVID-19 patients. Post-COVID cardiac complications like acute coronary syndrome (ACS), Acute MI (stroke), dysrhythmias, persistent hypotension, infective myocarditis have been reported.
Cardiac muscle Injury
Heart damage or cardiac muscle injury complication is seen after several days or weeks of recovery. The infection from COVID-19 can lead to inflammation in various parts of the body resulting in the weakening of the heart muscle, abnormal heart rhythm and could even cause blood clots in blood vessels. Complications like Myocarditis or an inflammation of the heart leads to it not pumping blood properly, causing the narrowing of the arteries, triggering high BP, and thus leaving one susceptible to a heart attack.
Renal injury or failure complications
Elevated levels of protein in the urine and abnormal blood work confirm kidney problems in patients, even in those who did not have renal issues before COVID-19. Hypertensive and diabetic COVID-19 patients are at a higher risk of kidney complication post COVID-19. Some complications may even require dialysis. This organ acts like a filter for the body by flushing out the extra water, toxins and waste products from the body. Thus, its proper functioning plays a vital role. Blood clots can stifle the tiny blood vessels in the kidneys leading to its damage.
Diabetes
Though a common ailment, it is seen as a complication even post COVID. It is a chronic disease in which the blood glucose or the blood sugar gets very high. Insulin, the hormone which is produced by the pancreas, helps glucose to get into the cells. But when the body does not make enough glucose, it stays in the blood causing various health issues.
Central nervous system complications
Reported complications include acute strokes, encephalopathy, Guillain-Barre syndrome, taste impairment, smell impairment, vision impairment and neuropathy.
Brain disease - Acute necrotizing encephalopathy
Acute necrotizing encephalopathy(ANE) is an immune mediated disease which is usually seen after infection with mycoplasma, influenza A and herpes simplex virus. However, it was recently reported in post-COVID patients and seen in children rarely . Coronavirus binds to ACE receptors which are abundant in glial cells and arterial smooth cells in the brain , that is why neurological manifestations are seen in COVID-19 and also post-COVID complications. Mechanism of entry to CNS would be a cribriform plate of ethmoid bone or hematogenous dissemination. COVID-19 with Cytokine storm leads to immune mediated damage with predilection to Central nervous system however exact pathophysiology is not known ANE in children presents with focal seizure, hemiparesis, irritability, fluctuating consciousness.
MIS-C (Multisystem inflammatory syndrome in children)
This can also present with seizure , irritability and intolerance to feeds and shortness of breath and hypotension. As both are immune mediated and are due to post-COVID complications they tend to be similar. However, MRI findings in ANE are T2 AND FLAIR hyperintensities in basal ganglia, internal capsule, thalamus, cerebellum and rarely in occipital and parietal lobes. MIS -C presents with fever, rash, breathing difficulty, hypotension, vomiting and coagulation abnormalities. It occurs due persistent elevation of IgG which activates monocytes, greater activation of T lymphocytes. A high number of ANE is seen in children.
Multiple cases of MIS-C are being reported in the pediatric population. As COVID is a pro-inflammatory condition we tend to see these complications with direct injury to the central nervous system. Direct invasion of virus is also another possibility. ANE is a life threatening condition. It needs immediate ICU admission, MRI to look for abnormalities in the brain, EEG to look for subclinical seizures and CSF analysis to rule out CNS infection.
Vascular complications
COVID-19 is an infectious disease that leads to a proinflammatory and prothrombotic state, resulting in both micro and macrovascular thrombosis, and both arterial and venous thrombotic events. One-third of patients hospitalized due to severe COVID-19 develops macrovascular thrombotic complications, including venous thromboembolism, myocardial injury/infarction and stroke. Complications like acute pulmonary thromboembolism, deep vein thrombosis, acute limb ischemia/ gangrene, mesenteric ischaemia are seen.
Psychiatric complications
Anxiety, depression, sleep disturbances, lack of concentration, anhedonia and suicidal tendencies have also been reported.
Anxiety and fepression
This can be seen in patients as a result of stress induced by the pandemic and battling the disease itself. COVID-19 isn't just an infection that affects the respiratory system, but has a huge impact on the mental state of a person.
Insomnia
This is a sleep disorder which affects the central nervous system where the sleep cycle of the person gets affected, leading to slower recovery. Various factors can trigger this state which includes anxiety, stress and loneliness. This is more so for patients who stay alone for weeks in hospitalization or isolation, thus making insomnia a post COVID-19complication.
While the list of complications keeps increasing by the day, the uncertainty faced during the pandemic has become a part of our lives. In order to avoid such complications, it is wise to avoid exposure to the infection by ensuring precautions.
Other Organs Complications
★ Acute liver failure, gastrointestinal complications like acute bowel ischaemia and gangrenes.
★ Skin complications such as hemorrhagic bullae with intra-bullae blood clots and dissecting hematomas, Isolated herpetiform lesions, petechial rash.
Effects of COVID-19 treatment and hospitalization can also include post-intensive care syndrome (PICS), which refers to health effects that remain after a critical illness. These effects can include severe weakness and post-traumatic stress disorder (PTSD). PTSD involves long-term reactions to a very stressful events.
Immunosuppressive drugs (tocilizumab, itolizumab) can lead to fulminant secondary infections and opportunistic infections. Prolonged steroid usage can lead to hyperglycemia, secondary infections.
