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Clinical Overview of Long COVID
- Long COVID is an infection-associated chronic condition that affects one or more organ systems.
- Primary care providers can manage Long COVID using patient-centered approaches.
- Objective laboratory or imaging findings should not be used as the only measure or assessment of a patient’s well-being.
- Healthcare providers should set achievable patient care goals through shared decision-making, and approach treatment by focusing on specific symptoms or conditions.
- Healthcare providers can help patients with Long COVID by validating their symptoms and connecting them to additional care, services, and supports, as appropriate.
- Providers should also promote COVID-19 vaccines as a means of preventing Long COVID.
Introduction to Long COVID
Long COVID, also known as “Post-COVID Conditions (PCC)”, is an infection-associated chronic condition that can occur after SARS-CoV-2 infection, the virus that causes COVID-19, and is present for at least 3 months as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems. The definition for Long COVID will continue to be evaluated as data are collected, analyzed, and reported and our understanding of the chronic condition improves. Most patients appear to recover from their initial acute COVID-19 illness within 4 weeks, even though many patients continue to recover between 4 and 12 weeks. Long COVID is associated with:
- Development of new or recurrent symptoms and conditions after the symptoms of initial acute COVID-19 illness have resolved.
- Symptoms that can emerge, persist, resolve, and reemerge over varying lengths of time.
- A spectrum of physical, social, and psychological consequences.
- Functional limitations that can affect patient wellness and quality of life.
Causes
It can be difficult to distinguish symptoms caused by Long COVID from symptoms that occur for alternative reasons.
Long COVID is heterogeneous and may be attributed to different underlying pathophysiologic processes. Possible etiologies include:
- Organ damage resulting from acute phase infection
- Complications from a dysregulated inflammatory state
- Microvascular dysfunction
- Ongoing viral activity associated with an intra-host viral reservoir
- Autoimmunity
- Inadequate antibody response
- Other potential causes
Risk factors
Researchers are actively studying the prevalence, mechanism, duration, and severity of symptoms following acute SARS-CoV-2 infection, as well as risk factors associated with developing Long COVID. Research shows certain groups of people are more likely to develop Long COVID, including:
- Women
- Hispanic people
- People who experienced more severe outcomes of COVID-19, including hospitalization or being admitted to the intensive care
- People with underlying health conditions
- People who did not get a COVID-19 vaccine
Clinical features
Signs and symptoms
A wide range of symptoms and clinical findings can occur in people with varying degrees of illness from acute SARS-CoV-2 infection. These effects can overlap with multiorgan complications, or with effects of treatment or hospitalization and can persist after the acute COVID-19 illness has resolved. While more than 200 Long COVID symptoms have been identified, commonly reported symptoms include:
- Bloating/constipation/diarrhea
- Difficulty concentrating
- Light headedness/fast heart rate
- Memory change
- Persistent fatigue
- Post-exertional malaise
- Problems with smell
- Problems with taste
- Recurring headaches
- Shortness of breath/cough
- Sleep disturbance
*Post-exertional malaise (PEM) is the worsening of symptoms following even minor physical or mental exertion, with symptoms typically worsening 12 to 48 hours after activity and lasting for days or even weeks.
Some patients may feel embarrassed about their symptoms, have experienced stigma or experienced difficulty in being believed. It is important for healthcare providers to:
- Not dismiss symptoms that are difficult to explain.
- Practice empathy in conversations with patients.
- Encourage patients to report any new or changing symptoms or any changes in activities or routines.
Presentation
Different onset patterns for Long COVID have been identified, including symptoms and conditions that can:
- Emerge, evolve, persist, resolve, and reemerge over time following initial acute COVID-19 illness.
- Develop following asymptomatic disease or a period of acute symptom relief or remission.
- Worsen pre-existing symptoms or conditions
Documentation
Documenting SARS-CoV-2 infection and Long COVID, also referred to as “Post-COVID Conditions,” is critical for accurate public health surveillance.
Post-COVID Condition was incorporated into the International Classification of Diseases, ICD-10-CM as of October 1, 2021.
U09.9 Post COVID-19 Condition, unspecified– to establish a link with COVID-19; not to be used in cases that still are presenting with acute COVID-19. The code should be used for patients with a history of probable or confirmed SARS-CoV-2 infection and who are identified with a Post-COVID Condition.
Keep reading: Additional assign codes for specific conditions and symptoms can be found at 2022 ICD-10-CM Guidelines.
Prevention
Preventing severe outcomes of COVID-19 illness reduces people’s risk of developing Long COVID. These severe outcomes include hospitalization, admission to the intensive care unit, or intubation.
Healthcare providers can advise their patients on protecting themselves against severe COVID-19 by:
Research shows COVID-19 vaccination is an effective tool in helping to prevent Long COVID. Healthcare providers should encourage their patients to get an updated COVID-19 vaccine.
Testing and diagnosis
Clinicians may clinically evaluate and diagnose Long COVID based on patient history and findings from a physical examination, while others might require directed diagnostic testing. Currently, no laboratory test can be used to definitively diagnose Long COVID or to distinguish Long COVID from conditions with different etiologies.
A positive SARS-CoV-2 viral test or serologic (antibody) test are not required to establish a diagnosis of Long COVID, but can help assess for current or previous infection.
Treatment and symptom management
For most patients, the goal of medical management of Long COVID is to optimize function and quality of life through established symptom management approaches, which may include:
- Focusing on the most bothersome symptoms identified by the patient.
- Creating a comprehensive rehabilitation plan.
- Optimizing management of underlying medical conditions.
- Creating patient diaries and calendars to document changes in health conditions and symptom severity.
Patients with Long COVID may experience some of the symptoms that occur in other disorders. These patients may benefit from symptom management approaches used to manage symptoms of:
- Myalgic encephalomyelitis/chronic fatigue syndrome.
- Fibromyalgia
- Post-treatment Lyme disease syndrome,
- Dysautonomia
- Mast cell activation syndrome.
Treatment of Long COVID should be tailored to a patient’s specific symptoms or conditions, including FDA-approved or over-the-counter medications. Holistic support for the patient throughout their illness can also be beneficial. Healthcare providers play a significant role in supporting their patients and can further help patients with Long COVID by:
- Validating their symptoms
- Recognizing and validating the impact of illness on quality of life.
- Completing a full clinical evaluation based on signs and symptoms reported by the patient
- Connecting them to additional care, services and supports, as appropriate.