While there is no agreed upon definition, Long COVID refers to a heterogenous group of symptoms persisting for 12 or more wk after the initial infection with SARS-COV-2 that cannot be explained by an alternative diagnosis.

Post-Acute Sequelae of COVID-19 (PASC)

Post COVID-19 Condition

Long-Haul COVID

Manifestations of Long COVID may be multisystemic, though one system may predominate, mild to severe in their presentation, and may persist 12 wk or more and up to 2 yr. Symptoms and exam findings may include but are not limited to:

• Pulmonary findings such as cough, wheeze, tachypnea, altered or increased work of breathing, breathing pattern disorder, and shortness of breath, which may continue following the acute viral infection
• Cardiovascular symptoms such as chest pain, chest pressure, and palpitations
• Neurologic symptoms such as headache, memory and concentration difficulties, cognitive impairment, “brain fog”, anosmia, ageusia or dysgeusia, and neuropathy; mental health changes like depression and anxiety, poor sleep
• Autonomic dysregulation resulting in orthostatic hypotension, dizziness, frequent nausea and gastrointestinal disturbance, and hyperalgesia
• Allergic symptoms such as conjunctivitis, rash, pruritus
• Functional impairment in tasks of daily living, generalized fatigue, exercise intolerance (as determined by chronotropic incompetence, for example), or post-exertional symptom exacerbation (PESE) or malaise (PEM)

Given the heterogenous presentation of Long COVID, the pathophysiology, while unknown, is likely multifactorial and may differ among patients with different comorbidities or risk factors. Possible mechanisms include cellular injury, immune dysfunction due to autoimmunity or chronic inflammation, viral persistence, and unmasking or exacerbation of other comorbidities, such as primary pulmonary disease or heart failure.

Diagnosis relies upon a multisystemic appraisal. Long COVID should be considered in those with new or newly worsened features of pulmonary, cardiovascular, neurologic, autonomic, rheumatologic, or psychiatric disease following the acute period of SARS-COV-2 infection. However, Long COVID is a diagnosis of exclusion, and alternative etiologies of presenting symptoms should be ruled out prior to diagnosis. Additionally, providers should be careful of anchoring bias given the prevalence of prior COVID-19 infections.

• Workup should be tailored to individual and predominant symptoms, accounting for the identification of alternative, treatable etiologies, such as asthma, for example
• Obtaining a full history and physical exam, including full neurologic, cognitive, and psychiatric assessment is essential to characterizing disease onset, frequency, intensity and impact on daily functions
• Other initial assessments may include obtaining an EKG, rest and ambulatory pulse oximetry, PFTs, ambulatory cardiac monitoring, and tilt table testing

Consider CBC, CMP, TFT, B12, ANA, ESR, CRP, and D-dimer when clinically appropriate if concerned for VTE

Consider chest x-ray, high-resolution chest CT, transthoracic echocardiogram

• Those experiencing new pulmonary, cardiac, autonomic, and functional impairments may benefit from cardiac, pulmonary, and general physical rehabilitation.
• Other symptom specific forms of rehabilitation, such as olfactory training, may be available to those with anosmia and other sensory deficits.
• Autonomic symptoms, like orthostatic hypotension, may improve with compression stockings, as well as lifestyle management to avoid and manage triggers.
• Behavioral health measures, such as counseling for mood disorders and sleep, should also play a role in the treatment of Long COVID when indicated.

• There are no known treatments for Long COVID.
• Acute treatment is symptom dependent; no one specific pharmacologic therapy is indicated for those suspected to have Long COVID.
• Vaccination against SARS-COV-2 may have a modest to no effect on symptom intensity. Vaccination has not been shown to worsen symptoms in those with Long COVID.

Similar to acute treatment, there are no disease-specific therapy recommendations for the management of Long COVID.

There are no reliable predictors of duration of symptoms, though most patients may expect to improve or recover within 3 to 12 mo. Symptoms may plateau for long periods, fluctuate, or be retriggered by emotional or physical stress, but time could potentially be shortened via engagement with pulmonary, cardiac, and physical rehabilitation.

Specialty referral should be tailored to specific concerns regarding symptom management. Primary care providers should serve as coordinators of a multidisciplinary approach to management, although some health care networks have also developed dedicated Long COVID clinics that may also serve as entry points for coordination of care. Physical Medicine and Rehabilitation (PM&R) providers have served at the forefront of providing support and care of those patients with functional impairments due to Long COVID.

Vaccination against SARS-COV-2 should be recommended for those without contraindications to prevent COVID-19 and its sequelae, such as long COVID.

https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html