Monitoring, treatment options

Long COVID-19 | 391

groups were formed: “symptomatic COVID-19” (n = 68, all mildmoderate), asymptomatic cases (n = 77), and symptom-free without evidence for infection (n = 54). The strength tests were comparable between the groups. However, there was a significant decrease in VO2 max in the symptomatic cases. Approximately 19% had a decrease in VO2 max of more than 10%, whereas none of the uninfected showed such a decrease (Crameri 2020).

As early as August 2020, a preliminary guideline for the treatment of “long COVID-19” was published in the British Medical Journal (Greenhalgh 2020). After excluding serious ongoing complications or comorbidities, the recommendation was to manage patients “pragmatically and symptomatically with an emphasis on holistic support while avoiding over-investigation”. It was noted that “many patients recover spontaneously (if slowly) with holistic support, rest, symptomatic treatment, and gradual increase in activity”. According to the authors, blood tests should “be ordered selectively and for specific clinical indications after a careful history and examination; the patient may not need any”. In the largest and longest study to date from Wuhan, however, 35% of the patients showed a decreased glomerular filtration rate (GFR). Unexpectedly, 13% (107 of 822) of those who did not develop acute kidney injury during their hospital stay and presented with normal renal function, based on estimated GFR during the acute phase, exhibited a decline in eGFR (< 90 mL/min per 1,73 m2) at 6 months of follow-up (Huang 2021). It seems therefore reasonable to monitor renal function at least once in long COVID-19 cases. Fortunately, new onset diabetes mellitus and thrombosis were extremely rare in the Wuhan cohort study (Huang 2021). From our point of view, the control of blood glucose or D-dimers (as well as the use anticoagulation as suggested by some experts) does not seem to be necessary. This also applies to inflammatory parameters which can be slightly elevated in a considerable proportion of patients even after months (Moreno-Pérez 2021). These remain without consequences.

392 | CovidReference.com

Case 1

51-year-old resident surgeon with mild-to-moderate COVID-19 (outpatient, no oxygen, but severe headache, nausea, no fever, 2-3 days of dyspnea). Unable to work (including quarantine) for 24 days. Reintegration to work (starting with 3 hrs) after another 35 days. Current comment (after 90 days): “Still fluctuating days of strongest exhaustion, only very gradual recovery. I am glad to be able to get my work done. However, every day, I still have to sleep 1-3 hours after work. Improvement is slow. I was already jogging again, but still feelings of fatigue rapidly occuring, like ‘plug out’”.

Case 2

44-year-old psychiatrist with mild-to-moderate COVID-19 (outpatient, no oxygen). Beyond the two weeks of quarantine, there is dyspnea on exertion, severe exhaustion and cephalgia, concentration disorders, mild anxiousdepressive symptoms (self-assessment) and anosmia/ageusia. Another 21 days of incapacity for work (total 35), followed by slow reintegration to work over a further 42 days. Current comment (after 90 days): “Now just the second week of normal working hours. No longer headaches on all days. Fatigue still evident, severe on some days. Sense of smell and taste still not present. Sport is not to be thought of.”

A light endurance training (including walking or Pilates, increasing intensity only very gradually) may be useful, as may relaxation techniques. Gradual reintegration into working life, as in the two case studies, is often helpful. Patience, empathy and a cautious (not too ambitious) goal-setting are required. Especially in severe cases, inpatient rehabilitation may be useful, preferably in multidisciplinary settings; some experiences have already been published (Puchner 2021, Brigham 2021). Numerous clinical therapeutic trials of long COVID are ongoing or planned, including those with steroids, but also different drugs such as naltrexone, leronlimab, montelukast, or deupirfenidone. Up to now, no results have been published. In addition, many large prospective clinical trials will study long haulers prospectively and in a standardized manner in order to better understand the long-term effects on lung function, the cardiovascular system, hematologic parameters, renal function, and many other organ systems. For example, in the United Kingdom, the Post-Hospitalisation COVID-19 Study (PHOSP-COVID) will follow 10.000 patients for a year, analysing clinical factors such as blood tests and scans, and collecting data on biomarkers. Finally, existing cohort studies have also refocused and integrated COVID-19 aspects