COVID-19 infection, transmission, hospitalizations, and deaths are still far from over.

As of today (23rd March 2021), the total number of registered cases is 124 million worldwide resulting in 2.72 million deaths.

124 million patients have recovered from COVID-19 infection. Patients who have recovered might experience strange symptoms for as long as six months after recovery.

Most of these patients who develop the so-called post-COVID syndrome are among the following:

• Patients who are aged, above 60 years of age
• Those patients who had severe COVID-19 infection and required hospitalization
• Patients for whom mechanical ventilation was necessary
• Patients who required oxygen even after hospital discharge
• Patients who had other comorbid conditions like diabetes, heart diseases, and stroke
• Patients who develop complications during their illness such as kidney disease, heart disease, neurological diseases, sepsis, shock, liver injury, psychiatric disorder, and ARDS (severe lung damage).
• Patients who had deaths of their close relatives
• Patients on treatment for anxiety and depression
• Patients with poor psychological support from their family and their BOSS (such as those with a stressful job and issues with salaries or medical leaves).

What are the symptoms of POST-COVID Syndrome?

POST-COVID syndrome is a new term and the symptoms are not well known.

However, it is applied to symptoms and signs that are reported by the patients after days, weeks, or months of COVID-19 infection that can not be explained by another medical condition.

Most patients with post-COVID syndrome present with more than one symptom.

However, fatigue is almost universal in these patients. Some patients may experience extreme fatigue and may become bed-bound.

Fatigue and extreme Fatigue!

Fatigue after COVID infection is probably similar in clinical manifestations as fatigue after other viral infections/ chronic fatigue syndrome.

The exact mechanism is not yet known, however, in a letter to the editor, Dr. Ray Perrin hypothesized that inflammatory mediators such as interferon Gamma and Interleukin 7 may enter the brain via the olfactory nerves that are present in the nose and responsible for the sensations of smell [Ref].

These cytokines may enter the hypothalamus and result in fever and autonomic dysfunction.

This could last for weeks or months. Patients who have organ dysfunction, hypoxemia (low oxygen in the blood), or another condition especially involving the nerves or muscles may have more severe symptoms.

Last week, I saw a 35 years of age diabetic patient who was brought in a wheelchair with extreme weakness. He reported extreme weakness over the past two weeks. He could not perform his daily activities and had to take a leave from his job. He had no fever, cough, or shortness of breath and was not diagnosed or treated for COVID-19 infection until then. His labs were normal except for uncontrolled blood sugars and NCS suggestive of acute on chronic axonal neuropathy. His COVID PCR was negative but his HRCT chest was suggestive of COVID-19 infection with a CT-severity score of 14.

Fatigue in patients with Post-COVID syndrome is usually associated with other symptoms such as reduced sleep, low appetite, anxiety, restlessness, burning and tingling sensations in the hands and feet, palpitations, apprehension, chest discomfort, and air hunger. Patients may develop a lack of concentration and difficulty focusing. They may report confusion, forgetfulness, and have unclear thoughts. These symptoms are also termed "Post-COVID Brain Fog". POSt-COVID Brain Fog might be related to "post-traumatic stress disorder", a condition affecting the behavior, cognition, and mood of a person who has recently experienced a traumatic event including a serious medical condition.

In my clinical practice, I have observed that young people with financial and work-related stress have more of these symptoms after they recover from COVID-19 infection. Most of these individuals, I term them as "Perfectionists". Their medical illness restricts them from working at their full physical and mental capacity. They feel responsible for their inability which add-up to their stress.

How to manage patients with Long-COVID Symptoms especially "Brain Fog" and "extreme Fatigue"

There are no definitive or clear-cut guidelines regarding the management of these patients.

The first and most important point to stress here is to rule out any medical condition that could be causing these symptoms.

Medical conditions that may manifest with extreme fatigue in the context of COVID-19 infection include:

• An ongoing COVID-19 infection or lung damage resulting in hypoxemia, chest pain, shortness of breath, and fatigue. These patients may require monitoring of resting and exertional oxygen saturations. A high-resolution CT chest may help in diagnosing active lung inflammation versus persistent or progressive lung damage.
• Post-infectious Myositis is another complication of COVID-19 infection [Ref] that may present with body aches and muscle weakness. Patients may present with difficulty in standing from a sitting position or combing hair. These patients should have muscle enzymes (creatine kinase, aldolase, and LDH) and electromyography is done to confirm the diagnosis.
• Neuropathy: Neuropathies such as Guillain-Barre Syndrome may follow any infection including COVID-19 infection. These patients should be promptly identified as the involvement of the respiratory muscles in a patient with an already damaged lung can be deadly.
• Organ dysfunction: Patients may develop organ dysfunction such a kidney disease, liver damage, heart disease, and neurological disorders that may persist for weeks to months. Patients should have relevant investigations done prior to labeling them as having Post-COVID syndrome.
• Diabetes: Post-COVID dysglycemia is common. Patients at risk of developing full-blown diabetes include those who receive corticosteroids, immobile patients, obese individuals, patients with prediabetes, family history of diabetes, or those who have had pancreatitis. Furthermore, patients may be advised to take liquid diets that usually contain high carbohydrates such as fresh juices or high caloric diets like dates, etc. Fatigue, lethargy, weakness, paraesthesias, and weight loss are all very common in patients with very high blood sugars. Appropriate evaluation and management are essential in these patients.

After all the related medical conditions have been excluded, patients with COVID Brain Fog and Fatigue should be positively counseled.

The most important aspect of the counseling is to make the patients believe that they do not have any organic medical illness that could be life-endangering.

Patients should be asked to start with a graded physical exercise. An early morning walk starting from as little as five minutes a day for the first week and gradually increasing the duration to a minimum of thirty minutes of daily walk should be emphasized. A healthy diet with natural products like fruits, dairy products, and fresh vegetables may help restore essential vitamins.

Five to ten pieces of dry-fruit such as almonds and walnuts should be encouraged.

Two to three cups of green tea with honey may be soothing for the chest and is a great source of antioxidants. Spiritual therapy (such as Zikr, recitation of the Holy Quran, Nawafil, and prayers) and Yoga may relax the brain and restore memory, physical and mental strength.

The role of Vitamins in Post-Covid Syndrome and Weakness:

The role of vitamin replacement in Post-Covid Syndrome is controversial. However, it is important that a deficiency of essential vitamins might add to at least some of the symptoms.

Important vitamins that might help boost immunity include Vitamin C, Zinc, and Vitamin D.

Vitamin C helps epithelial regeneration and prevents flu and respiratory infections.

Zinc is another commonly used mineral that boosts immunity and helps mucosal regeneration.

It is even used to treat children with recurrent diarrhea and respiratory infections.

Vitamin D has been associated with a number of medical illnesses. The deficiency of vitamin D can cause muscular and skeletal weakness.

In COVID-19 infections, vitamin D levels have been negatively associated with COVID severity and mortality.

In Conclusion:

Post-COVID Syndrome manifests as weakness, brain fog, fatigue, and skeletal pains. Recovery may take weeks to months. Patients should adhere to a healthy lifestyle including a healthy diet, physical activity, and spiritual therapy.

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