Post Covid complications and Long Haul COVID syndromes

1. Post COVID 19
Syndromes
Dr Palepu B Gopal
MD,FRCA,CCST,FCCM,FICCM
Critical Care Medicine

2. Time Course & Features of
COVID 19 & Post COVID 19

3. COVID 19 Syndromic Overlap

4. Characterized by persistent symptoms and/or delayed or
long-term complications beyond 4 weeks from the
onset of symptoms
Categories
4–12 weeks Subacute or ongoing COVID-19 symptoms
Beyond 12 wks Chronic or post-COVID-19 syndrome
Long COVID
Etiology 1. Cellular damage
2. Robust immune response & cytokine production
3. Pro-coagulant state
Nature Medicine.VOL 27 ,April 2021
Post-acute COVID-19 Syndrome

5. Studies of Post COVID-19 Syndrome & Prevalence

6. Symptoms in 1733 Post Hospitalization
for COVID 19 in China

7. Percentage of participants who reported COVID-19
symptoms during acute illness and at follow-up
JAMA Network Open. 2021;4(2):

8. COVID 19 : Distinct Acute and Post COVID Features

9. • Difficult ventilator weaning
• Prolonged Non invasive Ventilation 6 to 30%
• Chronic Oxygen dependence 53 to 78%
• Dyspnoea, decreased exercise capacity & hypoxia 11-43%
• Median 6-min walking Test lower than normal 25% at 6 months
• Pulmonary physiology - Reduced diffusion capacity, Restrictive pattern
•CT Findings 3 months after discharge in 25-65%
Ground-glass opacities & fibrotic damage
Primarily of reticulations or traction ronchiectasis
• Lung autopsy Endothelial injury & microangiopathy
Pulmonary micro & macrothrombosis - 20–30%
• Mechanisms
Viral invasion of alveolar epithelial & endothelial cells
Viral-independent mechanisms Immunological damage
Perivascular inflammation
ARDS like picture
Pulmonary Sequelae of COVID 19

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Pathogenesis of COVID ARDS (CARDS)

11. CT Chest & CT Pulm Angiogram in
COVID-19 Survivor

12. British Thoracic Society Respiratory follow up
Psychiatric Asessment
Thromboembolic sequelae diagnosis
Criteria for evaluation Based on the severity of acute COVID-19
Level of Care recieved (ICU or HDU)
Chest X-ray in all patients at 12 weeks
Consider PFTs , 6MWT, Sputum sampling & Echocardiogram
• Assessment of progression or recovery at 6 and 12 months
Pulse Oximetry, 6MWTs, PFTs , HRCT Chest
CT pulmonary angiogram as appropriate
• Corticosteroids May be beneficial in a subset of patients with
post-COVID iflammatory lung disease
• Lung transplantation Done but Unproven
• Antifibrotic therapies Clinical Trials
Management of Pulmonary Sequelae

13. Respiratory Follow-up Algorithm for Patients of COVID-19
Pneumonia Cared for in ICU, HDU or with Severe Disease
Peter M George et al. Thorax 2020;75:1009-1016
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14. • Continued hyperinflammatory and hypercoagulable state
• Mechanisms of thromboinflammation
Endothelial injury Complement activation
Platelet activation Platelet–leukocyte interactions
Neutrophil extracell traps Pro-inflamm cytokines release
Hypoxia Disruption of coagulant pathways
• Similar to thrombotic microangiopathy syndromes
• Thromboembolic events noted in <5% in post-acute COVID-19
• 2.5% cumulative incidence of thrombosis at 30 d following discharge
Segmental pulmonary embolism
Intracardiac thrombus
Thrombosed arteriovenous fistula
Ischemic stroke & Central Sinus Venous Thrombosis
Management
• Extended thromboprophylaxis Oral anticoagulants & LMWH
• For pts with risk factors immobility
persistently elevated d-dimers
high-risk comorbidities such as cancer
• Therapeutic anticoagulation Iimaging-confirmed VTE for ≥3 months
Hematologic Sequalae of COVID 19

15. Damage to Myocardium in COVID 19 Infection

16. • Persistent symptoms Palpitations 10% Fatigue 34 -63%
Dyspnea 11-43% Chest pain 5-21%
• Cardiac MRI Myocardial inflammation in 60% for > 2 months
• Long-term sequelae may Increased cardiometabolic demand
Myocardial fibrosis or scarring
Arrhythmias & tachycardia
• Autonomic dysfunction Postural orthostatic tachycardia syndrome
Inappropriate sinus tachycardia
• Stress Cardiomyopathy Increased incidence during the COVID-19
pandemic than before
• Mechanisms Direct viral invasion Down regulation of ACE2
Myocardial structural integrity affected by
Inflammation & immunologic response
Cardiomyocyte death
Fibro-fatty displacement of desmosomal proteins
• Autopsy studies Virus in the heart tissue of 62.5% of patients
• Management Serial clinical examinations, Echo and ECG follow-up
Abstinence from competitive sports or aerobic
activity for 3–6 months
Cardiovascular Sequelae of COVID 19

17. Neuropsychiatric Sequelae of COVID 19

18. New Neurological Symptoms Post COVID 19 Illness

19. • Persistent abnormalities Fatigue 34-63% Headache
Dysautonomia Brain fog
Joint Pains 9-27% Muscle Pain 2-20%
• Anxiety and/or depression 23%
• Sleep disturbances 24 – 30%
• Post Traumatic Stress Disorder 30–40%
• Long-term post-critical illness cognitive impairment in 20–40%
• Ischemic or hemorrhagic stroke Hypoxic–anoxic damage
Posterior reversible encephalopathy syndrome
Acute disseminated myelitis
• Acute critical illness myopathy and neuropathies
• Pathophysiology Immune dysregulation
Inflammation
Microvascular thrombosis
Adverse effects of medications
Psychosocial impacts of infection
• High index of suspicion and specialist referral
• Neuropsychological evaluation iwith Standard screening tools
• Rehabilitation for Transient or permanent neurological deficits
Neuropsychiatric Sequelae of COVID 19

20. Neurological Symptoms – Brain Fog

21. • Decreased glomerular filtration rate in 35% of pts at 6 months
• Resolution of AKI in the majority of COVID-19 patients
• Requirement of RRT for severe AKI indicates high mortality
• COVID-19-associated nephropathy (COVAN) in Africans
• Patients with persistent impaired renal function benefit from
early and close follow-up in AKI survivor clinics
Renal Sequelae of COVID 19

22. • New or worsening control of existing diabetes mellitus
•Subacute thyroiditis and bone demineralization
• Post COVID Diabetic ketoacidosis without known DM
Subacute thyroiditis & thyrotoxicosis
• Etiology Direct viral injury
Immunological and inflam damage
Adverse effects of Treatment
• Referral to endocrinology Newly diagnosed diabetes
Suspected HPA suppression
Hyperthyroidism
Endocrine Sequelae of COVID 19

23. • Diarrhoea 1-10%
• Nausea and Vomiting
• Mild Abdominal pain
• Post-infectious irritable bowel syndrome and dyspepsia
• Prolonged viral fecal shedding
• Potential alteration of the gut microbiome
• Enrichment of opportunistic organisms
• Depletion of beneficial commensals
• Gut–lung axis : Gut microbiota alter course of respiratory
infections
Dermatologic Sequelae of COVID 19
• Hair loss 20% of COVID-19 survivors
• Skin Rash 10 %
Gastrointestinal Sequelae of COVID 19

24. Nutrition & Rehabilitation Issues in Post COVID
19
• Decline in quality of life (EuroQol visual analog scale) in 44.1%
• Decline in Health-related quality of life and functional capacity
• Muscle wasting, feeding difficulties and frailty – poor outcome
• Malnutrition has been noted in 26–45% of patients
• Assess for Swallowing function Nutritional status
Measures of functional independence
• Early rehabilitation programs are safe and effective
• High risk for post-acute COVID-19 syndromes
Severe illness during acute COVID-19 and/or
Required care in an ICU
Most susceptible to complications
elderly
multiple organ comorbidities
Post-transplant
Active cancer history
Highest burden of persistent symptoms

25. • Fungal sinusitis
• Cheek/eye pain
• Headache
• Proptosis or bulging of eye ball
• Double vision or Diplopia
• Blurred vision
• Total vision loss
• Altered sensorium
• Blackish discharge from nose
• Palatal discolouration
ENT Sequelae in Post COVID 19

27. • Diagnostic criteria: <21 years old with
fever, elevated inflammatory markers
multiple organ dysfunction
current or recent SARS-CoV-2 infection and
exclusion of other plausible diagnoses
• Typically affects children >7 years
• Higher incidence in African, Afro-Caribbean or Hispanic
• Complications coronary artery aneurysm
Encephalopathy
Stroke
Seizures
Multisystem Inflammatory Syndrome
in Children (MIS-C)

28. Post COVID- 19 Clinics
Integrated Multi- disciplinary Care

29. Interdisciplinary Management in
Post COVID-19 Clinics

30. • Care for patients with COVID-19 does not
conclude at the time of hospital discharge
• Lookout for Post COVID sequelae is vital
• Multi -disciplinary comprehensive care
maintains and improves quality of life