Dr Arvind Kohli
The Coronavirus disease 2019 (COVID-19) is an infectious disease caused by SARS-CoV-2 This virus does not seem to behave epidemiologically like influenza virus and continues to resurge in clusters or outbreaks, not always in waves with rapid widespread community transmission. Presently it has caused a pandemic in world
For survivors of severe COVID-19 disease, having defeated the virus is just the beginning of an uncharted recovery path. What follows after the acute phase of SARS-CoV-2 infection depends on the extension and severity of viral attacks in different cell types and organs.
Even though the number of COVID-19 cases worldwide now approaches 19crore we are still amazed how little we know about this very complex disease. The clinical spectrum varies widely. Up to 40% of people infected with SARS-CoV-2 never develop symptoms. About 81% of those who do become symptomatic have a mild illness that does not require hospitalization. Common symptoms include cough, fever, dyspnea, musculoskeletal symptoms (myalgia, joint pain, fatigue), gastrointestinal symptoms, and anosmia/dysgeusia.(Loss of smell and distortion of taste)
About 14% are sick enough to require hospitalization;because of impaired oxygenation levels but only 5% require care in an intensive care unit, usually for mechanical ventilation to treat respiratory insufficiency. The long-term consequences of COVID-19 infection are not well understood. In addition, prolonged recovery from symptoms has been described even in patients who had mild symptoms and did not require hospitalization. This entity is known as Post Covid Syndromes.
Pathogenesis
It has been suggested that the presence of symptoms beyond 8 to 12 weeks from the onset of illness as a description of post-acute COVID-19 syndrome. these patients have been divided into three groups: those who had severe manifestations such as acute respiratory distress syndrome (ARDS), requiring intensive care unit (ICU) admission; those who were not admitted during the acute illness but later presented with symptoms and signs of end-organ damage, such as cardiac or respiratory disease; and those who did not require hospitalization but presented with prolonged symptoms without evidence of end-organ damage
Many studies have documented lingering damage to many organs or systems, including lungs, heart, brain, kidneys, and vascular system, in patients infected with SARS-CoV-2. The damage seems to be caused by severe inflammatory responses, thrombotic microangiopathy, venous thromboembolism, and oxygen deprivation. Low blood oxygen saturation has been found even in asymptomatic and presymptomatic patients with COVID-19 pneumonia, where it has been called “silent hypoxia.” The most important open question to be answered is as follows: “Once recovered from COVID-19 what happens to patients, and how has the virus impacted their body
Presentation
There is a marked variation in the presentation of post-acute COVID-19 syndrome. Patients may present with non-specific symptoms such as fatigue, muscle aches and pains, poor sleep, cough, and breathlessness, to more specific organ related symptoms, such as orthopnea, leg swelling, and exercise intolerance due to COVID-19 induced heart failure. Furthermore, chest pain and significant breathlessness might be due to pulmonary embolism. Autonomic symptoms such as palpitations with mild exertion, night sweats,variation in heart rate and poor temperature controlhave also described
A group of symptoms that sometimes occur in people who were patients in an intensive care unit and that involves muscle weakness, balancing problems, cognitive decline, and mental health disturbances observed after discharge from critical care that usually involved a prolonged period of mechanical ventilation
Post-Covid lung fibrosis
Radiologically, most patients infected by SARS-COV-2 present with bilateral ground glass opacities with or without consolidation,. Pulmonary fibrosis is a recognised sequelae of ARDS developing out of SARS-COV-2 infection Abnormal immune mechanisms initiate and promote pulmonary fibrosis, possibly as a consequence of a cytokine storm. Importantly, it has been shown that progressive pulmonary fibrosis can be a cause of mortality in a substantial proportion of patients while a considerable proportion of survivors will experience long-term impairment of lung function The extent of reticulation on computed tomography correlates with quality of life and pulmonary function such as forced vital capacity (FVC) and DLCO which is a measurement to assess the lungs’ ability to transfer gas from inspired air to the bloodstream called as the Diffusion capacityare measures that indicate a restriction pattern,along with Impaired 6minutes walk Test 6MWT
Taking into consideration these data, even a relatively small degree of residual fibrosis could result in considerable morbidity and mortality in older patients who suffer from COVID-19, many of whom may already have lung disorders Management of post-COVID-19 pulmonary fibrosis is also unclear systemic steroids have been used in some patients with good results. The role of the antifibrotic drugs, pirfenidone and nintedanib, is awaiting clinical trial evidence.However Pulmonary rehabilitation programs are important support in this subset of patients
Cardiovascular assessment
SARS-CoV-2 impacts the cardiovascular system in multiple ways. Many cardiac conditions have been described in Post COVID-19 patients, including heart failure and cardiomyopathy. Heart failure is especially highly prevalent even in hospitalized patients. Cardiomyopathy was also reported and is thought to develop direct effects of the virus and/or toxic effects of the cytokines that are released during the infection. In many patients, a prothrombotic state develops during the acute phase, which may lead to pulmonary embolism, intracardiac thrombus, and exacerbation of coronary artery disease. . For these reasons, a complete trans-thoracic echocardiography is performed during the post-acute phase to explore the effects of SARS-CoV-2 infection and its after effects on the heart and cardiovascular system
COVID-19 is also recognized as a cause of severe vascular complications, mainly secondary to the inflammatory cytokine storm and rapidly progressing systemic inflammation and they show significant abnormalities in the coagulation pathway and are at increased risk of venous thromboembolic events(VTE). Evaluation of the risk of VTE before hospital discharge using the IMPROVE-D-dimer score and prolonged post-discharge thromboprophylaxis with rivaroxaban, apixaban, or LMWH.is important to prevent disastrous Pulmonary embolism.
Covid 19 and Mucormycosis SARS-CoV-2 has been associated with a wide range of opportunistic bacterial and fungal infections.Several cases of mucormycosis in people with COVID-19 have been increasingly reported from India. The primary reason that appears to be facilitating Mucorales spores to germinate in people with COVID-19 is an ideal environment of low oxygen (hypoxia), high glucose (diabetes, new-onset hyperglycemia, steroid-induced hyperglycemia), acidic medium (metabolic acidosis, diabetic ketoacidosis [DKA] high iron levels (increased ferritins) and decreased phagocytic activity of white blood cells (WBC) due to immunosuppression Mucormycosis can involve nose, sinuses, orbit, central nervous system (CNS), lung (pulmonary), gastrointestinal tract (GIT), skin, jaw bones, joints, heart, kidney, and mediastinum (invasive type)however nose and sinuses involvement was most common followed by rhino-orbital .If not treated early with appropriate antifungal drugs and surgical intervention Mortality has been high in these subset of patient.
Conclusion
As there is a exponential increase in number of patients who have been affected by COVID-19 we are going to face many patients with symptoms suggestive of Post COVID syndromes. For most patients, the goal of medical management of post-COVID conditions is to optimize function and quality of life. Ideally, healthcare professionals, in consultation with the appropriate specialists, should develop a comprehensive management plan based on their patients’ presenting symptoms, set up treatment goals so as to minimize problems arising out of these postcovid syndromes
(The author is Senior Consultant CTVS GMC Jammu)
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