Recommendations of an international expert commission for health professionals

By Henrik Szőke, et al. Published September 27, 2021 in Anthromedics

Abstract

A growing number of people are affected by a Long COVID syndrome with often long-lasting, significant impairment of their health. Different pictures with prolonged hyperinflammation, damage and functional restriction of the musculature, the heart, the nervous system and the sensory organs occur. A relatively large group of rather younger patients shows symptoms of post-viral chronic fatigue syndrome/myalgic encephalomyelitis syndrome (CFS/MES). These patients more often had a rather mild COVID-19 course and may subsequently develop long-lasting CF/ME symptoms. This article presents aspects for an understanding the disorder as well as a multimodal treatment concept of Anthroposophic Medicine.  

Definitions

Acute COVID-19 disease: the first four weeks of illness.

Persistent post-COVID syndrome (PPCS; ICD-10: U09.9) or Long COVID: mostly used synonymously with post-COVID, especially for post-COVID symptoms that persist longer than 12 weeks (12): residual symptoms/permanent damage or post-infectious symptoms existing four weeks or more after the onset of the disease.   

Risk factors, triggers, prevalence

The severity of the acute phase and the triggering mutation of the pathogen do not correlate with the frequency and severity of Long COVID. Three months after disease onset, approximately ten to 65 percent of all registered adult COVID patients report persistent symptoms (345). In childhood, these symptoms occur much less frequently (67).

Patients with severe symptoms show a high incidence of complex post-intensive care syndrome (PICS), the first signs of which may already appear in the acute phase. Approximately half of patients receiving intensive care experience a Long COVID symptom (8).

The frequency, duration and extent of long-term pulmonary sequelae, immunosuppression and general impairment of quality of life are significantly related to the severity of the acute phase (9).

People over the age of 55 and with pre-existing conditions (known risk groups for severe COVID-19 disease progression: distress, exhaustion, depression, anxiety disorder, overweight, etc.) are significantly more often and more severely affected (10).

Competitive sportspeople also seem to be more affected (11). The frequency of other symptoms does not show such a clear correlation with the course of the disease, the level of inflammatory laboratory parameters or the severity of the acute disease.

Children only seem to be affected by Post or Long COVID significantly less. Because of many asymptomatic courses in children (12), only preliminary assertions can be made (13). In children, too, pre-existing conditions can facilitate Long COVID symptoms (67). Still unclear, as they have been little studied, are the psychosocial consequences of a long lockdown.

Symptoms, pathophysiology and diagnosis

Cardinal symptoms:  

  • Tiredness/fatigue/general weakness;
  • Breathlessness/dyspnoea, especially on exertion, including a feeling of constriction and chest pain with or without objective restriction of lung function (obstructive/restrictive);
  • Palpitations without objective impairment of cardiac function;
  • Headache, especially during/after exertion;
  • Cognitive disorders (concentration, memory, “brain fog” etc.);
  • Anxiety can accompany all of the above disorders in specific ways (see below).

Symptoms may present as a dry irritating cough, in the form of pain (head, muscle, joints, chest) and myopathy (CIM). With cardiac involvement: acute myocardial infarction, microinfarctions, ventricular or atrial fibrosis with ischaemic/non-ischaemic cardiomyopathy, myocarditis, symptomatic/subclinical dysfunction, various arrhythmias. Hair loss and various exanthema may occur on the skin.

In children, the main symptoms are fatigue, sleep disorders, taste and smell disorders and headaches.

Despite the frequent gastrointestinal complaints of the acute phase, they appear less frequently in PPCS. However, severe gastrointestinal motility disorders have been described.

The most common long-term neurological disorders (PCND) include: sleep disorder, dizziness, taste and smell disorders (14), polyneuropathy (CIP), ischaemia/apoplexy due to endothelitis and coagulopathy, autoinflammatory demyelination, encephalitis (15). The central nervous system seems to be affected more than the peripheral. The most common mental and psychological disorders include: memory disorders, impaired concentration, lack of presence of mind (“brain fog”), stress intolerance, anxiety (16) and depression, post-traumatic stress symptoms (PTSD) (17), obsessive-compulsive disorder (OCD), subjective distress and deterioration in quality of life (1819). Here, nocebo effects must also be taken into account, which can be attributed to pandemic measures such as social distancing (2021). Ten to 15 percent of those affected take psychoactive substances, ten percent have suicidal thoughts.

Pathophysiology

With regard to the pathophysiological processes, two polar tendencies are evident in severe courses:

  • Persistent inflammation (endothelitis, myositis, myocarditis (with elevated serum parameters: CRP, D-dimers, LDH)), increased thromboembolic events (22).
  • Fibrosing stiffness in the lungs and other tissues, chronic proliferative inflammation with fibrosis.

Immunologically, both the triggering virus (persistent reservoirs, viral fragments/spike proteins, reverse transcription into the human genome) and autoantibodies and immune regulation disorders can play a role here. An excessive first phase up to a so-called cytokine storm can be followed by a similarly excessive reaction, such as the compensatory anti-inflammatory response syndrome (CARS) and the persistent inflammation, immunosuppression, catabolism syndrome (PICS).

Persistent inflammation-related damage can occur in the lungs and airways (23). Innervation disorders and weakened respiratory muscles may also contribute to complex respiratory insufficiency after COVID (24).

Myocardial lesions occurring in the heart are already signalled in the acute phase by elevated troponin levels. Myocarditis, right heart strain, rening-angiotensin axis dysfunction, coagulopathy, neurovegetative influences and systemic prolonged hyperinflammation can lead to rhythm and conduction disorders, microfibroses and cardiomyopathies.

Endothelitis and disorders of the blood-brain barrier play an essential role in damage to the sensory and nervous system.

Diagnosis

An individualised medical history is required, which also includes the time before falling ill with COVID, and a complete physical examination, which is specifically supplemented by laboratory and functional diagnostics (pulmonological, cardiological, neurological). The change in quality of life can be evaluated by questionnaires (e.g. SF-36, E5-QD) or by Management of Daily Life questionnaires.
After the initial staging, regular follow-up examinations and a final examination are indicated.

Extended understanding of disease from the perspective of Anthroposophic Medicine

The dynamics of infectious diseases are determined by the interaction of the microorganism with the affected person, their susceptibility to the pathogen and their fabric of forces. COVID-19 in the first instance clearly shows the importance of age and biographical development. Genetic disorders (Down’s syndrome) can significantly reinforce the relevance of the ageing processes. The vitality of the body decreases with age and can be impeded by obesity, metabolic diseases such as diabetes mellitus and others. A significant role in post-COVID is played by disorders and dissociations in the patient’s fabric of forces. These normally proceed in a dynamic equilibrium between a dissolving and hardening tendency (25). In contrast, chronic inflammation and a degenerative, hardening (sclerosing) tendency dominate and persist in Long COVID, which are experienced mentally as exhaustion and are accompanied by the weakening of generative vital processes.

The decisive factor is whether, especially at night, during sleep, the inflammatory degenerative tendency recedes in favor of vital generative processes. This day-night rhythm can be severely disrupted in Long COVID. From an anthroposophical perspective and therapeutic experience, the focus here is on strengthening of the warmth organisation (“I-organisation”) in order to achieve the changeover from persistent inflammatory processes to a day-night rhythm with nightly predominant generative processes. Other, often younger patients suffer predominantly from a post-viral dissociation of their bodily vitality. This is where treatment primarily starts, to support the patients so that they can direct the organism again with the power of their individuality, perceive themselves, and deploy their vitality. In doing so, it is essential to revitalize the body itself and make it receptive to psychological impulses. It is about overcoming both the psychological alienation/dissociation from our own body and the clear feeling in some patients that their individuality is cut off from the spiritual sphere.

A normally low level of effort proves exhausting for many. Even breathing loses its naturalness. Dyspnoea, fatigue are often accompanied by anxiety. Not infrequently, there are also cognitive impairments in the ability to think and concentrate and in memory retention. Some patients say that they experience something alien within them that feels different from other infectious diseases they have been through. They often feel powerless and paralysed inside. More

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