Clinical Implications of Long COVID

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Clinicians have found that Long COVID (LC) symptoms can extend up to 12 weeks in many cases with serious consequences, says the Head of Pulmonology at UKZN, Professor Kennedy Nyamande, who was speaking at a UKZN College of Health Sciences webinar.

Nyamande, together with the Head of Internal Medicine at UKZN, Professor Nombulelo Magula, and registrars in the Department of Internal Medicine Drs Sandile Kubheka and Ntobeko Biyela presented on their experiences of LC and its clinical implications.

According to the National Institute for Communicable Diseases (NICD), LC is generally defined as COVID-19-related symptoms present for more than 28 days after the onset of an acute Coronavirus infection.

Nyamande mentioned that many people do not test for COVID-19 despite having symptoms with their condition worsening before hospitalisation with serious consequences.

Biyela said patients with LC present with symptoms such as a cough, low grade fever, breathlessness, headaches, chest pain, dyspnea, neurocognitive difficulties, muscle pain and or weakness, thromboembolic conditions, gastrointestinal upsets, metabolic derangements and or skin rashes, tachycardia, insomnia and anxiety.

The speakers discussed case studies of patients with LC:

In Case 1, a 53-year-old man presented with breathlessness after climbing a few stairs, a symptom which occurred five months after he was diagnosed with SARS-CoV-2. This patient, who had a history of Type 2 diabetes and a coronary artery bypass, was treated in the Intensive Care Unit (ICU) with High Flow Nasal Oxygen (HFNO) and Non-Invasive Ventilation (NIV) as well as high doses of prednisone. The patient was discharged and is currently asymptomatic.

In Case 2, a 66-year-old woman was diagnosed with LC presenting with pulmonary hypertension (PHT), interstitial lung disease (ILD) and pulmonary embolism (PE). After receiving three weeks of prednisone, the patient was discharged with medication but returned a month later presenting with similar symptoms as she had defaulted on her medication. In hospital treatment included Warfarin, low molecular weight heparin (LMWH) as well as prednisone. Twelve days after re-admission the patient died.

Nyamande stressed that it was important to consider the patient’s history, conduct a thorough physical exam, run specific tests, diagnose the patient and then refer them to a specialist for the appropriate care. ‘LC often presents according to where the virus invades the brain stem and is mediated. This is referred to as persistent brainstem dysfunction and is common in patients with LC. Many patients need to be referred to mental health services due to presenting with post-traumatic stress disorder, depression and neuro LC. It is also essential for the patient to receive social support from their religious organisations, cultural groupings, family and friends,’ he said.

Biyela presented two case studies of patients with LC in hospital care.

Case 1 involved a 49-year-old Indian man who presented with shortness of breath, tachycardia and muscle pain. He had no comorbidities but had a BMI of 39kg/m2. He was diagnosed with severe community acquired pneumonia, Class 2 obesity and hypoxia. The patient’s inflammatory markers were high and he had been exposed to two colleagues with COVID-19 in his workplace. Seven days after his contact, he went on holiday as he was asymptomatic. On day 11, he developed symptoms and on day 12 was admitted to hospital. The patient was treated with double oxygen, dexamethasone as well as physiotherapy. On day 53, he was diagnosed with pulmonary fibrosis and chronic thromboembolic disease.

Biyela mentioned that people with obesity were at a very high risk for infection as Human ACE2 gene expression is higher in both human subcutaneous adipose tissue and human visceral adipose tissue. Using the spike-like protein on its surface, the SARS-CoV-2 virus binds to ACE2 receptors with ease. Thus adipose tissue provides a seamless port of entry for the virus. After treatment, the patient was discharged on day 86.

In case 2, a 49-year-old African woman living with HIV who was virally suppressed, presented with a dry cough and pain. She was hypoxic and required minimal oxygen. She also presented with secondary bacterial infection. She was diagnosed with severe COVID pneumonia and PE but recovered and was discharged on day 77.

Kubheka’s presentation at the webinar focused on the social and health system determinants of health outcomes. Kubheka, who is South Africa’s youngest doctor having graduated with a medical degree from UKZN at the age of 20, is currently pursuing a Masters of Medicine degree in Internal Medicine at UKZN.

Kubheka said: ‘Nothing is equal about the impact COVID-19 has had on the marginalised compared to other populations. The World Health Organization’s guidelines stipulate the importance of self-isolation for those who test positive. In the South African situation where there is a lack of sufficient housing, this is not possible. Due to poor sanitation, overcrowding and no water; prophylactic measures are impossible to achieve in our settings.’

Kubheka further stated that South Africa had more than 1.6 million positive COVID-19 cases with two-thirds of the testing done in the private sector.

However, despite all of the challenges, Magula said: ‘Positive outcomes can be achieved despite inequalities in our healthcare system. Looking at the many cases of LC that presented in our hospitals, the recovery rate has been excellent with specialist care.’

Words: MaryAnn Francis

Photographs: Supplied