Workup of Long Covid Symptoms

Intro

Long Covid involves symptoms that develop during or after COVID-19, continue for ≥4 weeks, and are not explained by an alternative diagnosis. In one meta-analysis, it was shown that at 3 months post infection, 6% of patients had symptoms of long covid. Common symptom clusters include:

• fatigue/bodily pain  
• mood/cognitive problems
• respiratory problems
• cardiac problems

Less common persistent physical symptoms include anosmia, joint pain, headache, sicca syndrome, rhinitis, dysgeusia, poor appetite, dizziness (from orthostasis, postural tachycardia, or vertigo), myalgias, insomnia, hoarseness, alopecia, sweating, reduced libido, and diarrhea.

Recommendations for Investigations

It is important to differentiate symptoms following a covid-infection from other well documented post-illness syndromes, including post ICU syndrome, post-viral syndrome and post-hospitalization syndrome. 

General: routine post-covid assessments are not recommended unless patient had a severe covid infection or requests medical attention.

Cardiac: 

12-lead electrocardiogram is recommended for those with cardiac symptoms, and there is a low threshold for ordering TTE. 

Pulmonary:

For all patients who had a pulmonary infiltrate or other abnormality identified on imaging during the acute course of COVID-19 illness, obtain follow-up chest imaging, typically chest radiography, at 12 weeks. For patients with new or progressive symptoms, earlier imaging is indicated. If suspicion is high for another etiology, CT chest is recommended.

For those with persistent, progressive, or new respiratory symptoms and patients recovering from ARDS, pulmonary function tests (PFTs), including spirometry, lung volumes, and diffusion capacity and a six-minute walk test is recommended.

Neuro:

Screen for cognitive impairments with MOCA, and compare with baseline when available.

Imaging is not routinely recommended unless concern for another etiology.

Olfactory/gustatory:

In most cases, these symptoms resolve slowly over several weeks and do not require intervention except for education.

Dermatologic: 

Ask about alopecia and skin lesions (including any residual effects from "COVID toes" or pernio-like acral lesions), other COVID-19 related skin lesions, necrotic skin lesions related to vasopressor use, or decubitus ulcers. We examine any affected areas, assess for healing, and evaluate for secondary infection. Wound care consultation may be warranted. Some patients recovering from COVID-19 have reported alopecia, which should be managed similarly to non-COVID-19 patients.

*Treatment for long-covid is largely symptomatic and based on therapies for treatment of similar conditions

References

https://pubmed-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/36215063/

https://www-uptodate-com.myaccess.library.utoronto.ca/contents/covid-19-evaluation-and-management-of-adults-with-persistent-symptoms-following-acute-illness-long-covid?search=long%20covid&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3543077690

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