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Long Covid- An Introduction
Current statistics emerging from COVID-19 pandemic tends to show that it’s just like any other viral infection. >90% of infected people remain asymptomatic or suffer from extremely mild symptoms. <1% of the infected actually die. And this rate is not higher than what we see with common viral infections such as flu.
But looking at the absolute numbers we feel scared.
Since this virus spreads rapidly and infects at a lightening fast pace, millions are getting infected globally and number of people dying just looks exceedingly disastrous (1% of a million is 10 times more than 1% of a lakh!). Also, due to heightened panic and efforts from government we are able to identify way larger number of people getting infected with COVID-19 as compared to flu. If we do a similar exercise for flu, maybe we will find equally high number of flu cases- it’s just a thought though and we will never know the truth.
I have been writing a lot on COVID-19 since quite some time. As a student of immunobiology most of my viewpoints, like above, have been quite optimistic. Having seen and treated so many patients during the second wave of pandemic, I know that my optimism is not blind. If you understand what the virus does to your body biologically, it’s fairly easy to see that management of COVID-19 is not the toughest of all medical problems out there.
So COVID-19 doesn’t scare me. What really scares me is something that happens much after infection is gone. This is a delayed phenomenon called “Long- Covid”.
Long Covid Can Be Dangerous- A True Story
In Aug 2021 the number of patients infected with COVID-19 in India was declining from its peak in May. Raj Verma was a happy man. He thanked God for his good luck. Couple of months back Raj became infected with COVID-19 and things were looking really hopeless. He had to be hospitalized for 2 weeks, and death didn’t seem to be an uncommon phenomenon amongst those infected. But Raj had fought his way to life successfully. He had fully recovered from COVID-19. It was an early Tuesday morning. Raj, for some reason, couldn’t sleep comfortably and woke up tired at around 4:30 am. This was not new for Raj- since past two months he had been having difficulty in getting a good satisfactory night sleep. Raj got up and walked to the kitchen to get a bottle of drinking water from the fridge. Suddenly he felt a sharp pain in the left part of his chest. The pain felt as if someone was stabbing a knife on his chest. His left arm felt heavy. And he could now hardly breathe. Soon, he lost his consciousness and fell on the floor like a log of wood. The smashing sound woke up his family members, who came rushing to help Raj. But it was too late- Raj wasn’t breathing. Nevertheless, ambulance was called. Doctors at the hospital declared myocardial infarction as the cause of death.
Raj had died due to a massive heart attack. Everybody was surprised hearing this. Raj was just 31 years old. He was slim, and extremely health conscious. He was a non-smoker and didn’t drink alcohol. He would regularly work out in gym and eat healthy. How did he die of heart attack?
(The name “Raj Verma” is not real to respect confidentiality, but it refers to a real person)
While I personally knew of several such cases where heart attacks would happen in apparently young and healthy people, it was definitely uncommon. Somehow, such occurrences were becoming more and more common during the COVID-19 pandemic. It soon became apparent that the real scare with COVID-19 is not about the infection, but it’s something else, and something we all are ignoring.
What is Long COVID?
Most cases of COVID-19 infection remain asymptomatic. Even if symptoms appear, they are mild and might include little fever, runny nose, headache etc. We expect these symptoms to disappear once the virus is eliminated. As per WHO, the median time from onset to clinical recovery for mild cases is approximately 2 weeks and is 3–6 weeks for patients with severe or critical disease.
Unfortunately, in many, the symptoms continue for several months. Often new distressing symptoms start appearing which are quite troublesome. >50% patients continue experiencing fatigue for more than 2 months. In more than 10% patients, this fatigue continues well beyond 6 months. When the symptoms continue for > 1 month, we call it as Long Covid.
Long Covid is defined as symptoms persisting for more than 4 weeks after the first suspected acute COVID-19 that cannot be attributed to an alternative diagnosis.
Long Covid has been called by various names including long haul COVID-19, post COVID-19 syndrome, chronic COVID-19, post acute COVID-19 etc. The most commonly reported long COVID symptoms include fatigue, headache, attention disorder, hair loss, breathlessness joint pains, sleep disturbance and muscle pain.
Experts estimate that 30% of patients with COVID-19 infection will end up developing Long Covid.
Understanding Long Covid- Why it happens?
To understand why Long COVID happens, you have to imagine our body to be like a wooden mansion with several floors and each floor with several rooms. Each room can be visualized as an organ. In this mansion, there is a big fireplace at the basement that supplies heat to all the rooms. The heat not only keeps all the rooms warm, but always serves as energy that can be utilized by the appliances in each room to function. The level of flame of the fireplace is normally at Level 1. It can go up to Level 5.
When COVID-19 invades the “room called lungs”, the defense system of that room starts demanding for more heat so that it can fight the virus. So, the fireplace at the basement starts burning more wood more vigorously so that the required additional head reaches the room under attack.
Five scenarios are possible now depending on how efficient the fireplace and its apparatus are:
- Scenario 1- Flame at Level 0 or 1 (Subnormal Response): This the least likely scenario where very little amount of heat is produced. The room under attack won’t have enough energy to kill the invaders. In biological world, this scenario is almost never possible, except in dead bodies or maybe in some theoretical scenarios where body is undergoing extreme starvation.
- Scenario 2- Flame at Level 2 (The Ideal Scenario): In ideal scenario, the additional heat would reach only the room the requires more heat. Similarly, the amount of heat generated would be exactly equal to what is required. Also, once the invaders have been killed, immediately the fireplace lowers its flame intensity and brings the temperature back to original level. This indicates that the fireplace and its systems are all working in the best possible manner and there are no faults. In this scenario the patient remains asymptomatic, virus is optimally destroyed and there is no Long Covid.
- Scenario 3- Flame at Level 3 (Little hyper response): In this situation, the fireplace is a bit over- reactive. It produces heat a little more than what is required, and for a time little longer than needed. And this extra heat is the problem. Here it ends up causing some minor damage to all the rooms. In this scenario the patient remains asymptomatic, virus is optimally destroyed; but there are some manifestations of Long Covid.
- Scenario 4- Flame at Level 4 (Moderate hyper response): In this situation, the fireplace is quite over- reactive. It produces heat a much more than what is required, and for a time quite longer than needed. The extra heat keeps causing moderate damage to all the rooms. In this scenario the patient is symptomatic. Virus is optimally destroyed. But Long Covid is definite.
- Scenario 5- Flame at Level 5 (Extreme hyper response): In this situation, the fireplace is over- reactive beyond control. The valves are old and have worn down. This fireplace produces an engulfing fire that is highly destructive. The flames end up damaging all the rooms significantly. In real world, this patient will develop complications and will require hospitalization. Some will die. The ones who survive will definitely develop Long Covid and the suffering will continue for a significant amount of time. Here too, virus is optimally destroyed.
In all the above scenarios, you will see that virus is always destroyed and it is not the one that’s really contributing to Long Covid. It’s the reaction to this virus from the body that determines whether the patient will develop Long Covid or not. We call this reaction- this fire- as inflammation.
As long as the fire produced is in excess of what is required and burns longer than the required time, it will lead to Long Covid.
Why Am I afraid of Long Covid?
If you have been following my posts, you would have noticed that I am generally not too much afraid about COVID-19 infection. To me it’s like any other viral respiratory infection like flu and can be easily managed if we keep in mind the basic concepts of immunobiology.
But, Long Covid scares me. Long Covid happens if we haven’t managed the initial infection in a correct way. If Long Covid sets it, it just means that a lot of damage has already happened. Can we reverse all these damages remains a tricky question.
For the earlier analogy I described, it should be clear that Long Covid is a result of the excess unnecessary heat from the fireplace that causes damage to all the rooms (organs were imagined as rooms). The extent of damage will directly correlate with the amount of excess heat and the time of exposure to such heat.
The rooms, in this analogy, include vital organs like heart, brain, kidneys and others. Scientists have already shown that lung damage persists in around 90% patients even after 12 months post their discharge from hospital post-COVID-19. Similarly, around 80% of patients show evidence of heart damage even after 2 months post recovery from COVID-19.
No organ is spared from the damaging impact of Long Covid.
Remember the example of Raj I discussed. He was an extremely young and a fit guy who died from heart attack just couple of months post COVID-19 infection. Several such cases of unexpected heart attacks, strokes etc have started emerging in patients who reportedly fully recovered from COVID-19.
COVID-19 is an intelligent virus and follows rules of survival. The faster it infects, the wider it infects, better will be its survival. Similarly, killing host is detrimental to its survival. These rules are actually true for any parasite. COVID-19 will eventually become extremely efficient in infecting everyone rapidly again and again without killing many.
So, COVID-19 virus is not the real killer here. In fact it would try its best not to harm the us, because the survival of this virus is linked to our survival. But issue is our body’s reaction to this virus.
Any level of over- reaction will lead to excessive inflammation. The flame of excessive inflammation will continuously keep damaging all the organs. Some of these damages will be reversible. But many will be irreversible. Long standing inflammation accelerates aging leading to diabetes, hypertension, stroke, autoimmune diseases, cancer etc. The fire of inflammation slowly keeps boiling the arteries carrying blood to heart, brain and other organs. If the damage is serious enough it will interrupt this blood flow and leading to heart attack, stroke etc that we can see months after COVID-19 infection is gone.
My fear is potentially we could be seeing a tremendous, unprecedented increase in patients suffering from the diseases of increased aging in young adults. Soon you will see increase in number of deaths due to stroke, heart attack and similar organ failures if my fear is true. Even if we assume around 10% of symptomatic COVID-19 patients will suffer significantly due to Long Covid (experts claim that this number is a severe underestimation, and can be around 30%), we are looking at millions every year being treated additionally for diabetes, heart diseases, hypertension etc. We will soon see an explosion in number of cancer cases.
How to predict who will develop Long Covid?
It has been reported that females have higher chances of developing Long Covid compared to males. But I have a different opinion on this. Females are biochemically different from males. I believe Long Covid equally effects both genders- but the manifestations are different in both. Females are more expressive and symptoms of Long Covid such as prolonged headache, muscle pain, breathlessness would be more commonly reported in females. However, serious complications such as heart attacks, stroke etc should be more common with males. I will await for further studies to check if this thought process is accurate.
What is known with great accuracy is that all the factors that lead to severe COVID-19 infection also lead to Long Covid. We know that high age, diabetes, hypertension, obesity are risk factors that increase chances of severe COVID-19 infection. Same is true with Long Covid. Higher the age, higher is the chance of developing Long Covid. Children rarely get Long Covid. Diseases such as diabetes, hypertension etc also increase the chance of developing Long Covid. An important observation that has been made by experts is that if you get infected with COVID-19 and suffer with >5 symptoms within the first week of infection, there is a high chance that you will develop Long Covid.
But all these are mere probabilities. I have seen young fit individuals developing Long Covid after infection. I have seen patients with very mild COVID-19 infection suffering for months from Long Covid. We need a robust way of predicting who will develop Long Covid.
One way to do that is to measure if the efficiency of immune system to react to any invader such as a virus. A test called CD4/CD8 ratio is a very economical and easy way to evaluate our immune system. I have written in great lengths about this in a different article. You may click here to read more. The same idea has been submitted as a paper to leading journals. If CD4/CD8 ratio is >1, it indicates you have a very healthy immune system.
If CD4/CD8 ratio is >1 most probably you will have asymptomatic/ mild COID-19 and may not develop Long Covid. If CD4/CD8 ratio is <1, you need to be careful- if you get COVID-19 infection it may worsen into something serious, and you have very high likelihood of developing Long Covid.
I would highly recommend you read about this test.
CD4/CD8 ratio as a test is very simple and very cheap. It is available nearly in every healthcare facility and has been used since decades in HIV +ve patients to predict who might require additional medical support. It’s still extremely surprising why we have just forgotten about this test in our fight against COVID-19.
How to treat Long Covid?
While Long Covid does appear scary and implications are quite daunting, we need to understand Long Covid is not a new phenomenon seen only with COVID-19. Long Covid actually what we medically call as post viral syndrome that has been always seen with other viral pandemics such as SARS, MERS, avian flu etc. And this shouldn’t be surprising if you carefully read the analogy I described in an earlier section. The phenomenon of inflammation remains similar whether the invader is COVID-19 or SARS or MERS or common flu.
However, we hardly have figured out how to deal with post viral syndromes. So, we don’t have clear cut guidance on how to deal with Long Covid.
But that doesn’t change the fact that Long Covid is a result of excessive inflammation. The fire of inflammation needs to be douched. And that is the hint towards treating Long Covid. I would generally treat Long Covid as a rheumatologist would treat an early case of autoimmune disease. Hopefully a short course of high dose steroids followed by long term administration of anti- inflammatory drugs such as Aspirin + Clopidogrel + Atorvastatin should help. There might be a need to administer IVIG to treat serious complications.
From patient’s side, apart from drugs, body and mind would need holistic relaxation. The patient needs to be genuinely happy and relaxed to calm down the inflammatory process. Any form of stressful exercise must be completely avoided. Please don’t start hitting gym and resort to any weight lifting or excessive running immediately after COVID-19 infection. Actually, any form of stress- either physical or mental- must be completely avoided. Each stress event acts as fuel to the ongoing fire. Yogasanas, pranayamas and meditation will help. Unfortunately, many experts do not see this aspect as important to treat Long Covid since it’s difficult to measure the impact of these using current statistical methods. But, in my opinion, holistic relaxation is the key.
But you also need to understand that some of the damage caused by the flames of inflammation might take a long time to repair. Treating Long Covid is far more difficult than its prevention.
How to prevent Long Covid?
As we saw, Long Covid is result of damage caused by the fire of ongoing excessive inflammation generated by our immune system as a response to COVID-19 infection. If we are able to control the flame level of this fire, maybe we can prevent that fire from damaging the rooms of our metaphorical mansion.
Following are two critical observations from various studies done globally on Long Covid:
- Observation 1: Magnitude of Long Covid is directly related to severity of COVID-19 infection. How body reacts during the first 7 days to infection decides how bad Long Covid will be.
- Observation 2: Mild infection doesn’t mean one will not develop long Covid. But severity of Long Covid should be much milder
I used these two observations while treating patients with COVID-19. I have written extensively with minute details on how to keep severity of COVID-19 infection under control in two separate blog (links here- Blog 1, Blog 2). Once you have successfully managed the infection, its important not to forget Observation 2. I would generally recommend my patients to take a combination of Aspirin + Clopidogrel + Atorvastatin once daily for 45- 60 days post treatment of COVID-19 infection (unless if there are any contra- indications). Also, COVID-19 infection tends to shoot up the blood sugar- that needs to be kept under strict vigil and control all the time.
Of course, whatever I discussed here needs to be tested and verified via clinical trials. But my experience with treating 49 patients makes me quite confident that this is valid way of preventing Long Covid.
Vaccines might play a major role in preventing Long Covid, or at least should help decrease the impact of Long Covid. Vaccination helps train the immune system to fight against the virus. Such training leads immune system to react in a calm and mature fashion while fighting against the virus. Vaccination acts as an additional valve to control the level of our metaphorical flame from the fireplace! However, if the immune system is extremely weak and defective, vaccine itself can trigger mild form of Long Covid. The logic is very similar to why rarely some patients develop blood clotting complications post vaccination. We will hopefully discuss this in detail in another article.
Long Covid is a scary outcome of Covid-19 infection. People can suffer for several months. Some may die due to heart attack, stroke and other such fatal complications. Long Covid is a result of damage caused by more than necessary “heat” generated by our immune system while combating COVID-19 infection. So, the prevention and treatment both revolves around taming this “heat”. Using a simple cheap readily available test like CD4/CD8 ratio, one may predict the likelihood of developing Long Covid.