It is now evident that COVID-19 is not simply an illness of the pulmonary system, but a disease that can have a long-lasting impact on organ systems.
A review article published in Nature Medicine provides an initial glimpse at the long-term multiorgan effects associated with a COVID-19 infection. The authors, who were led by Elaine Y Wan, MD, a cardiologist with Columbia University Irving Medical Center, suggests a framework for the care of COVID-19 long-haulers through the creation of COVID-19 clinics with multidisciplinary medical teams who would address any long-term medical condition of patients who have had COVID-19. The article was published online March 22.
“It is crucial for healthcare systems and hospitals to recognize the need to establish dedicated COVID-19 clinics, where specialists from multiple disciplines are able to provide integrated care,” she and her colleagues wrote.
Wan et al, provide a comprehensive review of the current literature on post-acute COVID-19, its pathophysiology and its organ-specific sequelae. Fatigue, shortness of breath, brain fog, loss of sense of smell or taste, anxiety, depression, and post-traumatic stress disorder (PTSD) are among the most common symptoms of long-haulers. Published data suggest at least one-third of patients who required hospitalization for COVID-19 have experienced 1 of these long-term side effects.
“This scale of the pandemic with regards to the number of people infected with SARS-CoV-2 and substantial percentage of those with long-haul symptoms in preliminary reports has not been seen before in our lifetime. Long lasting consequences are expected for all fields of medicine, including pulmonology, cardiology, neurology, endocrinology, nephrology, psychiatry and others,” said Kartik Sehgal, MD, an oncologist at Dana-Farber Cancer Institute in Boston. Dr Sehgal served as co-corresponding author of the article with Dr Wan.
Long-haulers may have heterogeneous presentations. Common presentations include fast heart rates, dizziness, difficulties with concentration and/or memory, and difficulties with sleeping and mood. “It is crucial for internists as well as subspecialists to keep current of past infection with SARS-CoV-2 as one of the differential diagnoses. It has become an integral part of history taking now,” Dr Sehgal said.
“The roadmap for optimal management of post-acute COVID-19 is through inter-disciplinary care in COVID-19 recovery clinics.” It is crucial to multiply efforts to help identify those at highest risk for long COVID to ensure structured care in these clinics with efficient access to subspecialists as needed,” he said.
ENDOCRINE DISORDERS AMONG LONG-HAULERS
Endocrine manifestations in long-haulers appear to be due to direct viral injury, immunological and inflammatory damage, as well as iatrogenic complications. Endocrine sequelae may include new or worsening control of existing diabetes mellitus, the authors suggest.
Other concerns are subacute thyroiditis and bone demineralization. They recommend that patients with newly diagnosed diabetes—in the absence of traditional risk factors for type 2 diabetes—undergo additional diagnostic testing. Patients with suspected hypothalamic–pituitary–adrenal axis (HPA axis) suppression, or hyperthyroidism, should also undergo undergo appropriate testing.
“Abnormalities of glucose metabolism such as euglycemic ketosis and diabetic ketoacidosis, as well as new diagnoses of diabetes mellitus during or after acute COVID-19, will need follow up with an endocrinologist, preferably within the framework of multidisciplinary COVID-19 recovery clinic,” Dr Sehgal said.
“Those without traditional risk factors for type II diabetes mellitus must be screened for type I diabetes-associated autoantibodies. Hormonal abnormalities, for example involving thyroid and adrenal gland, must be considered in case of unusual symptoms and without obvious explanation after standard evaluation,” he said.
Early in the pandemic, the initial focus was to maximize prevention and control modifiable risk factors for diabetes and cardiovascular disease, said David Drucker, MD, an endocrinologist with Mount Sinai Hospital, Toronto. But now, post COVID-19 infection, patients are increasingly presenting with new symptoms.
“The extent to which COVID-19 will present new distinct challenges for individuals and the endocrine community remains uncertain and will require careful follow-up and study,” he said.
There is a lack of evidence about SARS-CoV-2 within pancreatic islet cells in those who develop COVID-19. Alvin C Powers, MD, chief of the division of diabetes, endocrinology and metabolism at Vanderbilt University Medical Center in Nashville, said COVID-19 may exacerbate or bring out undiagnosed diabetes.
“Does COVID cause diabetes? It is controversial,” Dr Powers said. “There is going to be a lot more scrutiny of people who have had COVID. The bottom line is that we have to monitor these people.”