What Happens After COVID-19

As I prepared to spend a half day in the clinic seeing patients who were recovering from COVID-19, I didn’t know what to expect. On the way to work, I thought about Mr. M—a man with COVID-19 whom I had met on the 176th day of his hospitalization. He had first been diagnosed and hospitalized in July as the second wave of the virus washed over our city. Six months later, he had endured 3 stays in the intensive care unit and undergone tracheostomy and feeding tube placement, and the extent of his recovery remained uncertain. I wondered if his case was typical of what I would encounter in the COVID-19 recovery clinic.

As I would soon learn, there are multiple paths of recovery for patients with COVID-19, and it is difficult to predict who may do well and who may have lingering symptoms.

My first clinic patient was an octogenarian who had been hospitalized for several weeks and required supplemental oxygen. I feared the worst for him. I was pleasantly surprised, however, to hear that he was doing well and even taking daily walks to a beach near his home—a trip that included more than 100 stairs. The next patient had also done well. He was a man in his fifties who had developed a deep venous thrombosis and pulmonary embolus during the course of his infection but was now completely asymptomatic. Our final patient that day, Ms. A, had been diagnosed with COVID-19 based on clinical symptoms and never required hospitalization. Given her mild case, I wondered what brought her to our recovery clinic. It turned out that her postinfectious symptoms were the worst of all the patients I would see that day. Months after diagnosis she felt short of breath with even basic activity. How could this be?

In the year since COVID-19 was first reported in the United States, lingering physical and cognitive symptoms have been reported in survivors. An Annals of Internal Medicine study (1) provides helpful context for understanding recovery from COVID-19. Researchers in Michigan found that of 488 patients who were hospitalized for COVID-19 and completed a telephone survey, 159 had persistent physical symptoms and 238 had persistent psychological symptoms when surveyed 60 days after discharge. Among this group, 58 patients had new difficulties with activities of daily living because of persistent symptoms.

The patients we have cared for in the hospital and clinic also illustrate the heterogeneity of outcomes for survivors of COVID-19. Although Mr. M’s outcome was not good, it at least seemed understandable. Survivors of the intensive care unit have long been known to be at risk for functional, cognitive, and psychosocial sequelae of their acute illness (2). By contrast, the ongoing symptoms that Ms. A was experiencing were harder to explain.

Although we know that different patients will have different outcomes after COVID-19 illness, it would be more useful to be able to predict which patients are likely to have long-term symptoms. This will require more longitudinal data of survivors of COVID-19. This is particularly true given that emerging evidence suggests that persons can go on to have chronic symptoms regardless of initial illness severity (3).

A recent National Institutes of Health workshop on COVID-19 recovery (4) found significant knowledge gaps in our understanding of, risk factors for, and pathophysiology of postacute COVID-19. There isn’t even consistency about language, with the constellation of findings variously referred to as “long COVID” or “long haulers,” among other names. This heterogeneity makes it hard to evaluate, diagnose, and treat patients with postacute COVID-19.

I hope that emerging research will bring more clarity to who is likely to experience postacute sequelae of COVID-19 and how best to help them. Until we have a better understanding of the mechanisms underlying these persistent symptoms of COVID-19, our ability to fully advise patients will be limited. Ms. A asked us if the pulmonary clinic was even the right place to figure out what was wrong. The implication was clear: Her experience remains beyond our current ability to understand.

References 

1. Chopra V, Flanders SA, O'Malley M, et al. Sixty-day outcomes among patients hospitalized with COVID-19 [Letter]. Ann Intern Med. 2021;174:576-578. [PMID: 33175566] doi:10.7326/M20-5661
2. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017;5:90-92. [PMID: 28721340] doi:10.1515/jtim-2016-0016
3. Townsend L, Dowds J, O'Brien K, et al. Persistent poor health after COVID-19 is not associated with respiratory complications or initial disease severity. Ann Am Thorac Soc. 2021;18:997-1003. [PMID: 33413026] doi:10.1513/AnnalsATS.202009-1175OC
4. Lerner AM, Robinson DA, Yang L, et al. Toward understanding COVID-19 recovery: National Institutes of Health workshop on postacute COVID-19. Ann Intern Med. 2021. [PMID: 33780290] doi:10.7326/M21-1043