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Post-COVID-19 Syndrome: Theoretical Basis, Identification, and Management
Post-COVID-19 Syndrome: Theoretical Basis, Identification, and Management
Post-COVID-19 Syndrome: Theoretical Basis, Identification, and Management
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postviral syndrome that emerged with the smooth muscle contraction and increased
first severe acute respiratory syndrome (SARS) glandular secretions.8 Although ß2-adrenergic
that appeared in 2002, which was also caused receptors and M3 acetylcholine receptors have
by a coronavirus.2 Anthony Fauci, MD, direc- other functions, these functions are pertinent
tor of the National Institute of Allergy and to understanding the theoretical cause of ME/
Infectious Diseases, has suggested that the CFS. These receptors balance each other’s activ-
long-hauler presentation is similar to myal- ity to maintain physiological stability. The pro-
gic encephalomyelitis/chronic fatigue syn- duction of autoantibodies for ß2-adrenergic
drome (ME/CFS).2 Exploring the etiology receptors and M3 acetylcholine receptors
of ME/CFS can provide insight into post- theoretically would lead to the reversal of
COVID syndrome. these receptor actions and result in significant
Myalgic encephalomyelitis/chronic fatigue smooth muscle dysfunction with consequent
syndrome is defined by the Institute of Medi- fatigue as well as other significant functional
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SCORDO ET AL W W W .AACN ACCON LIN E .ORG
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VO L U M E 3 2 • N U MB E R 2 • SUM M ER 2021 P OST – COVID - 19 SYND ROM E
Pseudochilblain
Painful, swollen red bumps with Tends to occur in younger
some vesicles or pustules patients
Typically appears on fingers and Occurs later in disease
toes; may be asymmetrical Associated with less severe
disease
Vesicular
Blister, monomorphic lesions Tends to occur in middle-aged
Appears on trunk, limbs patients
Associated with medium
severity of disease
May appear before other
symptoms
Frequently involves itching
Livedoid
Necrotic Uncommon
Truncal or on fingers/toes Usually occurs in elderly
patients
Associated with severe disease
Suggestive of coagulopathies
or vascular changes
a
Data were derived from Casas et al.24 Sources of images: Microsoft Bing images (pseudochilblain, vesicular), National Institutes of Health (urti-
caria), authors’ files (maculopapular, livedoid). Vesicular image republished under the Creative Commons Attribution-Share Alike 3.0 (http://cre-
ativecommons.org/licenses/by-sa/3.0/deed.en). Urticaria image republished under the Creative Commons Attribution Share Alike 2.0 (https://
creativecommons.org/licenses/by/2.0/).
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patients’ ability to work, with resultant loss of be useful to identify patients who were infected
employer-based health insurance. This situa- with SARS-CoV-2 and whose symptoms may
tion, coupled with the increasing number of be related to post-COVID syndrome. The find-
patients with post-COVID symptoms, places a ings may offer some reassurance to patients.
further burden on the health care system and
presents clinicians with increasing challenges. Fatigue Assessments
Post–COVID-19 clinics have opened in a few and Interventions
states and provide a multidisciplinary approach Fatigue, along with shortness of breath,
to management of symptomatic individuals.28 may be multifactorial and shares features
However, many areas lack these resources. with chronic fatigue syndrome described after
Patients with persistent symptoms should other serious viral or bacterial infections.16
first consult their primary care provider for A complete blood count to rule out anemia
an initial evaluation and appropriate referrals, as one cause, along with chest radiography,
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SCORDO ET AL W W W .AACN ACCON LIN E .ORG
10. Moldofsky H, Patcai J. Chronic widespread musculo- 24. Casas CG, Català A, Hernández GC, et al. Classification of
skeletal pain, fatigue, depression and disordered sleep the cutaneous manifestations of COVID-19: a rapid prospec-
in chronic post-SARS syndrome; a case-controlled study. tive nationwide consensus study in Spain with 375 cases.
BMC Neurol. 2011;11:37. doi:10.1186/1471-2377-11-37 Br J Dermatol. 2020;183(1):71-77. doi:10.1111/bjd.19163
11. Perrin R, Riste L, Hann M, Walther A, Mukherjee A, 25. Iadecola C, Anrather J, Kamel H. Effects of COVID-19
Heald A. Into the looking glass: post-viral syndrome on the nervous system. Cell. 2020;183(1):16-27.e1.
post COVID-19. Med Hypotheses. 2020;144:110055. 26. Roy D, Ghosh R, Dubey S, Dubey MJ, Benito-León J,
doi:/10.1016/j.mehy.2020.110055 Ray BK. Neurological and neuropsychiatric impacts of
12. Hives L, Bradley A, Richards J, et al. Can physical assess- COVID-19 pandemic. Can J Neurol Sci. 2020;48(1):9-24.
ment techniques aid diagnosis in people with chronic 27. Varatharaj A, Thomas N, Ellul MA, et al. Neurological
fatigue syndrome/myalgic encephalomyelitis? a diag- and neuropsychiatric complications of COVID-19 in 153
nostic accuracy study. BMJ Open. 2017;7(11):e017521. patients: a UK-wide surveillance study. Lancet Psychia-
doi:10.1136/bmjopen-2017-017521 try. 2020;7(10):875-882.
13. Kida S, Pantazis A, Weller RO. CSF drains directly from 28. Survivor Corps. Accessed March 20, 2021 https://www.
the subarachnoid space into nasal lymphatics in the rat: survivorcorps.com
anatomy, histology and immunological significance. 29. Lambert NJ; Survivor Corps. COVID-19 “Long Hauler”
Neuropathol Appl Neurobiol. 1993;19(6):480-488. Symptoms Survey Report. Indiana University School of
14. Montoya JG, Holmes TH, Anderson JN, et al. Cytokine Medicine; 2020. Accessed March 20, 2021. https://dig.
CE Evaluation Instructions
This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the
following objectives:
1. Describe the theoretical pathophysiology of long-term symptoms following infection with
SARS-CoV-2.
2. Relate post–COVID-19 symptoms to pathophysiologic mechanisms.
3. Identify at least 2 strategies for managing patients with post–COVID-19 symptoms.
Contact hour: 1.0
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