Those who have become severely unwell and have been treated on intensive care units may take a few months to fully recover, regardless of their illness.
However, with COVID-19, there is increasing evidence that some people who have relatively mild symptoms at home may also have prolonged illness.
Extreme fatigue, palpitations, muscle aches, pins and needles and many more symptoms are being reported after the effects of the virus. Approximately 10 percent of the 3.9 million people who contributed to the COVID Symptom Study App last longer than four weeks.
Chronic fatigue – classified as fatigue beyond six weeks – has been recognized in many different clinical settings, from cancer treatment to inflammatory arthritis. It may be disabled.
If 1 percent of 290,000 or people with COVID-19 in the UK remain under the weather for three months, it would mean that thousands would not be able to return to work. Presumably they will have complex requirements that the NHS is not currently ready to address.
COVID-19 is not the only cause of chronic fatigue. Prolonged fatigue is well recognized after other viral infections such as Epstein-Barr virus, which causes infectious mononucleosis (also known as gland fever). Post-viral fatigue was also seen in Hong Kong in 2003 in a quarter of those infected with the original Saras virus.
When it comes to treating chronic fatigue, there has already been an emphasis on effective treatment of the underlying disease, in the belief that it will reduce fatigue. However, there is no specific treatment for most viral infections, and because COVID-19 is very new, we do not yet know how to manage COVID fatigue later.
What can happen after COVID fatigue?
Although we know that permanent fatigue can sometimes follow other viral infections, detailed mechanistic insights are lacking for the most part. A viral infection in the lungs, brain, fat, or other tissue may be a mechanism. A prolonged and inappropriate immune response may have been cleared after infection.
However, a previous study has given us some information. When people were given a chemical called interferon-alpha as a treatment for hepatitis C, it caused flu-like illness in many patients and viral fatigue in some.
Researchers have studied this “artificial infection response” as a model of chronic fatigue. They found that baseline levels of two molecules in the body that promote inflammation – interleukin-6 and interleukin-10 – predict the development of people following chronic fatigue.
In particular, these same pro-inflammatory molecules are seen in the “cytokine storm” of critically ill COVID-19 patients. This suggests that there may be a pattern of immune system activation during viral infection that is relevant to ongoing symptoms.
Further support for interleukin-6 to play any other type of role comes from the successful use of tocilizumab – a treatment that reduces the effects of interleukin-6 and reduces inflammation – to treat severe COVID-19 for.
What needs to happen next
At Twinsuke in King’s College London, we investigate the genetic and environmental factors that influence disease by studying twins. We are using the COVID Symptom Study App to check for long lasting symptoms.
We are sending questionnaires to volunteer adult twins on our database, many of which were involved in immune system studies long before the coronovirus epidemic. Our goal is to define “post-covid syndrome” and look for markers in blood to shed more light on the immune system contributing to long-term symptoms.
This would be a challenging study to design: people with COVID-19 were more than just viral infections in general. His illness has occurred during a time of unprecedented social change, restrictions in movement, and great anxiety and difficult-to-determine risks – all with 24-hour news.
Some patients are very ill at home and have considered themselves close to death. For this reason, we will also examine post-traumatic stress, as the interpretation of reported symptoms must be set in context.
Chronic fatigue does not occur within the treatment of a single medical specialty, so it is often overlooked in the medical school curriculum, and doctors are poorly trained in the diagnosis and management of chronic fatigue. But recent progress has been made and online training is available for doctors which covers how to care for people with at least the most severe symptoms.
Guidance is also now available for patients to manage chronic fatigue and conserve energy. The important thing to stress is that taking a gym membership and pushing exercise is the wrong thing to do and it can set people back to a great extent.
Minor efforts – mental or physical – should be followed by rest. Return to work, when this happens, should be a gradual and graded process. Learning speed movements is the order of the day.
Frances Williams, Genomic Epidemiology and Honorable Consultant Rheumatologist, King’s College London.
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