The omicron wave of the past few months is slowly ebbing away in Germany, for the time being. But beyond possible new waves of infection, Covid-19 has other long-term consequences. Many have cured the disease at home and survived it largely without consequences. “But even in healthy young people who have had mild cold symptoms, the infection can linger for a long time,” says Björn-Erik Ole Jensen. The infectiologist heads the Covid-19 aftercare outpatient clinic at the University Hospital Düsseldorf and he is a spokesman for the scientific project “Beyond Covid”.
It can already be seen from the long waiting time in the outpatient clinics – sometimes so long that “Long Covid” has already gradually changed to “Post Covid” for those affected. One speaks of “Long Covid” when symptoms are still present four weeks after a positive PCR test or the first appearance of symptoms. “Post Covid” begins three months after the acute infection.
Before the corona infection, these people were in the middle of life, are now unable to work and need support on many levels.
Judith Bellmann-Strobl, Charité – Universitätsmedizin Berlin
About ten percent of corona patients are affected. It is often people between the ages of 20 and 50, about twice as many women as men, who recover only slowly after an acute infection that is not too severe. But it also includes Covid hospital patients. The symptoms of post-Covid patients affect almost all organ systems. One of the main complaints is pathological exhaustion, called fatigue, coupled with stress intolerance. Physical performance is reduced.
“Anyone who tries to exercise as usual has symptoms such as shortness of breath, tachycardia and rapid fatigue,” says Jensen. “The standard examinations of heart and lung function are often unremarkable.” Neurocognitive disorders such as word-finding disorders, attention, memory and concentration problems also often occur – even after a mild course. A third to three quarters of Covid-19 hospital patients still have cognitive problems after three to six months.
The cognitive fingerprint of the virus
In 2020, doctors from Cambridge University and Imperial College London examined the cognitive performance of 46 Covid 19 hospital patients, 16 of whom were artificially ventilated. They were followed up for a period of up to ten months. A computer test carried out on average six months after Covid-19 showed that the patients needed significantly longer for the test answers and processed them less precisely than the control group, which comprised 66,000 healthy people. This was still the case six months later. The 16 patients who had to be artificially ventilated were hardest hit.
The study participants have an intelligence quotient that is on average ten points lower than that of the healthy participants. Ten IQ points roughly corresponds to what the natural aging process of 50 to 70 years costs in terms of mental performance. It wasn’t just finding the right word that caused problems for those affected, the thought processes also took longer. “Patients made very slow progress, but at least things were going in the right direction,” said study author David Menon of the University of Cambridge. However, it is quite possible that some of those affected will never fully recover.
Thanks to the vaccinations, there are less severe Covid 19 courses. “But even mild courses can impair mental performance for a while,” warns Jensen. Also infections with the omicron variant, albeit less frequently. “Omicron can even cause Long and Post Covid in those who have been vaccinated three times.” According to initial data, the vaccination roughly halves the risk.
The virus is gone, but the immune response continues
Other symptoms may occur, most notably the frequent – temporary – loss of smell and taste. Some smell nothing at all or everything smells and tastes disgusting. Skin changes, cardiological problems such as tachycardia and palpitations, joint pain, headaches and hair changes including hair loss also occur.
How is it possible that these symptoms can last for weeks? “The viral infection ramps up the immune system quite a bit in some people. The vehement defensive struggle also leads to inflammatory reactions,” says senior physician Judith Bellmann-Strobl, who heads the post-Covid consultation at the Buch campus of the Berlin Charité. Even if the virus has long since been defeated by the immune system, the immune response can continue to have an effect for up to a year. That’s the case even in people with mild or no symptoms, researchers at Cedar-Sinai Medical Center have found.
The good news: “Many of those affected recover significantly three to six months after the acute infection,” says Bellmann-Strobl. In every tenth post-Covid patient, however, it is to be feared that a virus-related chronic fatigue syndrome (myalgic encephalomyelitis, ME/CFS) will develop. ME/CFS is a common and severe multisystem disease in which the immune system, autonomic nervous system and energy metabolism in cells are dysregulated.
What makes you sick?
So far, it is not sufficiently understood what exactly happens in the body. Various, possibly interacting or simultaneously present mechanisms are discussed as causes: The immune system could remain in an alarm state because virus residues, i.e. small protein pieces of the virus, are still present in certain immune cells or in the lymph nodes. The immune system could then damage organs directly.
Furthermore, it is discussed to what extent increased permeability of the blood-brain barrier caused by viruses and inflammation leads to an increased entry of inflammatory substances into the brain. This could alert local immune cells, trigger inflammation in the brain and damage nerve cells.
Covid-19 not only leads to the formation of antibodies that can neutralize the Sars-Cov-2 docking point on the cell surfaces. It can also be autoantibodies that occur during the long-lasting immune reaction, as US researchers discovered last year. It is suspected that these autoantibodies could continue to attack endogenous tissue and organs for months after the acute infection. Researchers suspect that the autonomic nervous system, which controls vital functions such as breathing, heartbeat, digestion and metabolism, is also affected. This could explain problems with breathing, circulation, blood pressure, and the heart. It is striking that many of the symptoms are similar to those of autoimmune diseases such as ME/CFS.
Difficult diagnosis, too few contact points, so far only symptom relief
As long as it is not clear what exactly happens in the body, there are no diagnostic criteria for Post Covid. However, the patients come to the post-Covid outpatient clinic with a bundle of complaints. A very time-consuming exclusion diagnosis must be carried out. “What we can do is treat those affected symptomatically, alleviate the symptoms and involve a psychosomatic doctor from the start,” says Bellmann-Strobl.
A look at the guidelines shows what is possible: Oxygen therapy in the case of persistent lung damage and sleep-supporting medication instead of classic sleeping pills in the case of sleep disorders. Breathing exercises can help with shortness of breath. For people with exercise intolerance, the focus is on pacing. This means dividing your strength, taking everything much more slowly, avoiding sensory overload and keeping physical and mental stress within limits. In everyday life, this turns out to be a real challenge. “It’s not easy when you’d like to but can’t or shouldn’t,” says the doctor.
At some point, you will reach your limits with symptomatic treatment. However, there is still neither an approved therapy nor approved medication for post-Covid. The Berlin start-up “Berlin Cures” has developed an active ingredient for the treatment of autoimmune-related cardiac insufficiency. He could potentially help with Post Covid too. The molecule blocks the binding sites of autoantibodies that are directed against certain receptors that are part of the autonomic nervous system. A clinical study, which initially clarifies tolerability and safety aspects, is ongoing. Experience reports are encouraging, but also indicate that some of those affected apparently not only form autoantibodies for a short time, but permanently.
Studies are in preparation for immunoadsorption, a blood wash that removes autoantibodies from the blood outside the body so that the cleaned blood then flows back into the body. The testing of this therapeutic approach could start soon. For those affected, however, “soon” is still far too long.
“These people were in the middle of life before the corona infection, are now unable to work, often still have children to look after, but they have no strength for them, and need support on many levels,” says doctor Bellmann-Strobl.
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