The Conundrum of 'Long-COVID-19': A Narrative Review

Abstract

COVID-19 is an ongoing pandemic with many challenges that are now extending to its intriguing long-term sequel. 'Long-COVID-19' is a term given to the lingering or protracted illness that patients of COVID-19 continue to experience even in their post-recovery phase. It is also being called 'post-acute COVID-19', 'ongoing symptomatic COVID-19', 'chronic COVID-19', 'post COVID-19 syndrome', and 'long-haul COVID-19'. Fatigue, dyspnea, cough, headache, brain fog, anosmia, and dysgeusia are common symptoms seen in Long-COVID-19, but more varied and debilitating injuries involving pulmonary, cardiovascular, cutaneous, musculoskeletal and neuropsychiatric systems are also being reported. With the data on Long-COVID-19 still emerging, the present review aims to highlight its epidemiology, protean clinical manifestations, risk predictors, and management strategies. With the re-emergence of new waves of SARS-CoV-2 infection, Long-COVID-19 is expected to produce another public health crisis on the heels of current pandemic. Thus, it becomes imperative to emphasize this condition and disseminate its awareness to medical professionals, patients, the public, and policymakers alike to prepare and augment health care facilities for continued surveillance of these patients. Further research comprising cataloging of symptoms, longer-ranging observational studies, and clinical trials are necessary to evaluate long-term consequences of COVID-19, and it warrants setting-up of dedicated, post-COVID care, multi-disciplinary clinics, and rehabilitation centers.

Keywords: Long-COVID; Long-COVID-19; chronic COVID; ongoing symptomatic COVID-19; post-COVID; post-COVID-19 syndrome.

Figure 1

A pictorial illustration of the common clinical manifestations observed in Long-COVID-19.

Figure 2

A 45-year-old male, a reformed smoker, and occasional alcohol consumer with sequel of COVID-19 pneumonia. The baseline CT chest at the time of admission, axial image (A) showing peripheral areas of consolidation (black arrows) with surrounding ground glass opacities (GGOs) in bilateral upper lobes. He had persistent cough even at the time of discharge, and follow-up CT chest (6 weeks after discharge), axial image (B) showing resolution in peripheral consolidation, but persistent area of interstitial thickening (black arrows) in bilateral lungs.

Figure 3

A 48-year-old male who was hospitalized for COVID-19 pneumonia, presents with persistent dyspnea and fatigue after 8 weeks of discharge. High resolution computed tomography (HRCT) chest, axial (A) and coronal (B) reformatted images, showing bilateral peripheral areas of ground glass opacity (GGO) (black arrows) and interstitial thickening (right > left) with traction bronchiectasis (red arrows) in right middle and lower lobe.

Figure 4

Cardiac MRI images in a 45-year-old female patient with Long-COVID-19 myocarditis, at 5 weeks after discharge from hospital: (A) fat saturated T2- weighted image in short axis view at basal left ventricle (LV) shows normal myocardial signal intensity, suggesting absence of edema. (B) Late gadolinium enhancement (LGE) PSIR sequence in short axis view done at 15 minutes post contrast shows presence of linear LGE in anteroseptal segment of the basal LV (white arrows), denoting presence of fibrosis, likely sequel of myocardial injury due to the prior COVID infection.

Figure 5

Cutaneous manifestations of Long-COVID-19 in different patients after varying duration of initial diagnosis: (A) hemorrhagic guttate psoriatic lesions on the back in previously known psoriasis patient (5 weeks after symptom onset) (B) retiform maculopapular itchy rash on the trunk (10 weeks after disease onset) (C) persistent, asymptomatic COVID toe (12 weeks after initial diagnosis) (D) erythema multiforme lesions on the right foot (6 weeks following symptom onset).

Figure 6

53-year male patient with history of COVID-19 induced ARDS and prolonged ICU stay. Follow-up (12 weeks after discharge) MRI brain for altered sensorium shows presence of multiple microbleeds on SWI images seen as multiple hypointense foci (white arrows) predominantly at grey-white matter junction (A) and corpus callosum (B) likely suggestive of critical illness induced microbleeds.

Figure 7

A pictorial demonstration of the various risk factors which when present, make the patients of COVID-19 more susceptible to develop Long-COVID-19.