COVID-19: Evaluation and Care of Patients With Persistent Symptoms Following Acute SARS-CoV-2 Infection
Authors: Christine Laine, Deborah Cotton
Journal: Annals of Internal Medicine (2021)

Special Articles11 June 2021COVID-19: Evaluation and Care of Patients With Persistent Symptoms Following Acute SARS-CoV-2 InfectionFREEChristine Laine, MD, MPH and Deborah Cotton, MD, MPHChristine Laine, MD, MPHEditor in Chief, Annals of Internal Medicine Search for more papers by this author and Deborah Cotton, MD, MPHEditor in Chief, Annals of Internal Medicine Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-2342 Eligible for CME Point-of-CareCME/MOC SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail As of 8 June 2021, the Centers for Disease Control and Prevention (CDC) reported that more than 140 million Americans were fully vaccinated—corresponding to about 42% of the total population, 50% of the population older than 12 years, 53% older than 18 years, and 75% older than 75 years (1). Infection rates and COVID-19–related hospitalizations and deaths are dropping in the United States, and life is beginning to regain some semblance of prepandemic normalcy for many across the nation. Yet it is important to note that this is not the case in other parts of the world. The global community must recognize that the pandemic won't be over until it is over everywhere. It is also important to acknowledge that life has not returned to normal for many who lost loved ones to COVID-19 or for those who recovered from acute SARS-CoV-2 infection but have persistently poor health.Knowledge about COVID-19 emerges rapidly, and we have witnessed great progress since Annals of Internal Medicine and the American College of Physicians hosted our first COVID-19 forum in October 2020. That initial forum described the science, the approval process, development of clinical indications, and the policy environment of vaccines that were in initial phase 3 trials (2). Subsequent forums addressed promoting vaccine acceptance (3), vaccine allocation and distribution (4), and common clinical questions about the 3 vaccines that have received emergency use authorization from the U.S. Food and Drug Administration (5). If you missed the first 4 programs, you can view them on Annals.org. The fifth program, held on 9 June 2021, focused on the evaluation and management of persons who continue to have symptoms despite recovering from acute COVID-19. Panelists included Dr. Lori Newman, National Institutes of Health (NIH); Dr. John T. Brooks, CDC; and Dr. Aluko Hope, Medical Director of the Long COVID-19 Program, Oregon Health & Science University. Readers can view the program in the Video that accompanies this article.Video. ACP/Annals COVID-19 Forum V: Evaluation and Care of Patients With Persistent Symptoms Following Acute SARS-CoV-2 Infection The ACP/Annals COVID-19 Vaccine Forum V, held on 9 June 2021, features speakers Dr. CAPT Lori Newman, Dr. John T. Brooks, Dr. Aluko A. Hope, and Dr. Deborah Cotton. (Duration 1:00:00)Dr. Newman summarized highlights of the NIH's December 2020 workshop on post–COVID-19 recovery (6) and the NIH's more recent efforts on this topic (7). She highlighted the important contributions of “citizen scientists” in identifying and helping to study the brewing public health problem of persistently poor health after acute COVID-19. She estimated that even if this condition occurred in only 10% of infected persons, it could afflict more than 17 million people globally. Dr. Brooks discussed how the CDC is developing interim clinical guidance on the diagnosis, evaluation, and management of persistent symptoms after acute COVID-19. He noted that the guidance has had to rely on limited evidence to date and is certain to evolve as new data emerge. He also emphasized the importance of clinical experience in guiding patient care while we await more definitive evidence. Dr. Hope, director of one of the first post–COVID-19 clinics in New York City and now the director of a post–COVID-19 program in Oregon, shared his insights from this type of clinical experience. He discussed the broad spectrum of symptoms that people are experiencing and the need for careful epidemiologic studies of the condition and its risk factors. Because of the breadth and variability of clinical presentation, Dr. Hope emphasized the need for a team-based, multidisciplinary approach to care. He believes that post–COVID-19 programs must work in collaboration with—not in place of—patients' primary care physicians.Just as the prevention and care of acute SARS-CoV-2 infection continue to evolve as new data emerge, so will the prevention and care of ongoing symptoms after acute infection. The panelists agreed on the following 3 issues. First, the absence of objective findings or positive results on laboratory or imaging studies must not negate patients' symptoms. Second, the medical community must learn from its experience with other postviral conditions, such as myalgic encephalomyelitis/chronic fatigue syndrome, and avoid clinical approaches that have greater potential for harm than for healing. Finally, coordinated, multidisciplinary efforts are essential both for clinical care and for research to better understand the pathophysiology, epidemiology, and effective management of persistent symptoms after SARS-CoV-2 infection.References1. Centers for Disease Control and Prevention. COVID Data Tracker. Accessed at https://covid.cdc.gov/covid-data-tracker/#datatracker-home on 8 June 2021. Google Scholar2. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: what physicians need to know. Ann Intern Med. 2020;173:830. [PMID: 33074704] doi:10.7326/M20-6841 LinkGoogle Scholar3. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: promoting vaccine acceptance. Ann Intern Med. 2021;174:252-3. [PMID: 33347321] doi:10.7326/M20-8008 LinkGoogle Scholar4. Laine C, Cotton D, Moyer DV. COVID-19 vaccine distribution and allocation: what physicians need to know. Ann Intern Med. 2021;174:413-4. [PMID: 33492990]. doi:10.7326/M21-0331 LinkGoogle Scholar5. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: practical clinical considerations. Ann Intern Med. 2021;174:694. [PMID: 33769829] doi:10.7326/M21-1260 LinkGoogle Scholar6. 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;174:999-1003. [PMID: 33780290] doi:10.7326/M21-1043 LinkGoogle Scholar7. RECOVER website. Accessed at https://recovercovid.org on 10 June 2021. Google Scholar Comments 0 Comments Sign In to Submit A Comment Michael CarsonHackensack Meridian Health14 June 2021 Objective Comments Re Bill Sardi's comment: Have you checked B1 levels in any patients? Early data is fine, we need that as things evolve, but your comment would be strengthened with evidence re this potential blind spot. Before I recommend patients pay out of pocket for prescription meds or supplements, I prefer to have some data to drive the recommendation. Bill SardiKnowledge of Health, Inc.11 June 2021 Reason for long-haul COVID-19 symptoms. My personal investigation is there is a blind spot in the investigation of persistent symptoms attributed to COVID-19. Alcohol consumption is up 500%. Sleeplessness increases consumption of stimulants like coffee and tea. Sugar consumption increases with stress and anxiety. All four of these factors interfere with vitamin B1 (thiamine) absorption, metabolism and transport. B1 controls the autonomic nervous system. Tachycardia, shortness of breath, digestive and bowel problems, loss of smell and ringing in the ears, crushing fatigue, eye muscle twitch, hair loss, ataxia, tingling, low blood pressure, memory loss (amnesia), nystagmus, cough, loss of appetite, common symptoms attributed to COVID-19, could be induced by B1 deficiency (aka beriberi). These symptoms can occur among non-alcoholics. Disclosures: Involved in marketing dietary supplements. Dr Muhammad FarooqInternal Medicine,Shaikh Zayed Federal Postgraduate Medical Institute,Lahore15 June 2021 Excellent learning opportunity & thought provoking on PASC I really enjoyed the session throughout with excellent speakers hosted by knowledgeable persons who remained up to date, I really loved this opportunity & learned a lot especially on the topic PASC which in near future seems to be alarming. Ronald A. PrimasMt. Sinai Hospital, NYC17 June 2021 Thank you for this very informative session! Thank you so much for this very informative session. I have quite a few patients with PASC who will benefit from the learning objectives. Good point by Dr. Sardi. It makes sense clinically. I will start to measure B1 levels in addition and see it's clinical relevence. Thank you again. Author, Article, and Disclosure InformationAuthors: Christine Laine, MD, MPH; Deborah Cotton, MD, MPHAffiliations: Editor in Chief, Annals of Internal Medicine Deputy Editor, Annals of Internal Medicine Disclosures: Disclosure forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-2342.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center and consultancy with Boston Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports employment with the Perelman School of Medicine, University of Pennsylvania, and consultancies with the U.S. Food and Drug Administration and the State of Colorado.Corresponding Author: Christine Laine, MD, MPH, Editor in Chief, Annals of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, claine@acponline.org.This article was published at Annals.org on 11 June 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoCOVID-19 Vaccine: What Physicians Need to Know Christine Laine , Deborah Cotton , and Darilyn V. Moyer COVID-19 Vaccine: Promoting Vaccine Acceptance Christine Laine , Deborah Cotton , and Darilyn V. Moyer COVID-19 Vaccine Distribution and Allocation: What Physicians Need to Know Christine Laine , Deborah Cotton , and Darilyn V. Moyer COVID-19 Vaccine: Practical Clinical Considerations Christine Laine , Deborah Cotton , Darilyn V. Moyer COVID-19: Clinical and Public Health Implications of SARS-CoV-2 Immunology Christine Laine , Deborah Cotton , Darilyn V. Moyer COVID-19: Challenging Clinical Questions Christine Laine , Darilyn V. Moyer , Deborah Cotton Outpatient Evaluation and Management of COVID-19 Christine Laine , Deborah Cotton , Darilyn V. 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Moyer, MD, Deborah Cotton, MD, MPHCOVID-19: Clinical and Public Health Implications of SARS-CoV-2 ImmunologyChristine Laine, MD, MPH, Deborah Cotton, MD, MPH, Darilyn V. Moyer, MDPrevalence of Symptoms More Than Seven Months After Diagnosis of Symptomatic COVID-19 in an Outpatient SettingMayssam Nehme, MD, Olivia Braillard, MD, François Chappuis, MD, PhD, Delphine S. Courvoisier, PhD, and Idris Guessous, MD, PhD, on behalf of theCoviCare Study Team August 2021Volume 174, Issue 8 Page: 1159-1160 Keywords COVID-19 Infectious diseases Prevention, policy, and public health ePublished: 11 June 2021 Issue Published: August 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...