Tiffany Walker MD Assistant Professor Emory University School of Medicine Atlanta GA Financial Relationships With Ineligible Companies Formerly Described as Commercial Interests by the ACCME Within the Last 2 Years ID: 1043354
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1. Long COVID: Diagnosis and ManagementTiffany Walker, MDAssistant Professor Emory University School of MedicineAtlanta, GA
2. Financial Relationships With Ineligible Companies (Formerly Described as Commercial Interests by the ACCME) Within the Last 2 Years:Dr Walker has no financial relationships with ineligible companies to disclose. (Updated 03/16/23)
3. Learning ObjectivesAfter attending this presentation, learners will be able to:Describe Long COVID epidemiology and identify symptomsCharacterize Long COVID physiology Describe diagnostic and management approaches
4. Long COVID Case52F with obesity, COVID-19 vaccinated CC: Fatigue and ForgetfulnessFatigueMemory, concentration difficulties PalpitationsSleep impairmentAbnormalities: (+) Cognitive screen, D-dimer: 980, CRP: 10
5. WHO Case DefinitionPrior SARS-CoV-2 infectionSymptoms 3 months from the onset New onset since recovery or persistMay fluctuate or relapse over timeCannot be explained by an alternative diagnosisImpact on everyday functioningA clinical case definition of post COVID-19 condition : https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1.
6. IncidenceBull-Otterson L, Baca S, Saydah S, et al. MMWR Morb Mortal Wkly Rep 2022
7. ARS Question 1: Which is the most common symptom of Long COVID? A. Joint painB. DizzinessC. FatigueD. HeadachesE. Dyspnea
8. 8Which is the most common symptom of Long COVID?ⓘ Start presenting to display the poll results on this slide.
9. Symptom Rates, 1 year(N=8,591, 18 studies)Han Q, Zheng B, Daines L, et. al. Pathogens 2022Percent of Cohort
10. Symptom ClustersReese JT, Blau H, Bergquist T, et al. EBioMedicine. 2022
11. Symptom ClustersReese JT, Blau H, Bergquist T, et al. EBioMedicine. 2022
12. Symptom ClustersReese JT, Blau H, Bergquist T, et al. EBioMedicine. 2022 Davis HE, Assaf GS, McCorkell L, et al. EClinicalMedicine 2021 Postural Orthostatic Tachycardia Syndrome (POTS) symptomsPalpitationsVertigo/DizzinessFatigueBrain fogSleep disturbances
13. Symptom ClustersReese JT, Blau H, Bergquist T, et al. EBioMedicine. 2022
14. Symptom ClustersReese JT, Blau H, Bergquist T, et al. EBioMedicine. 2022 Davis HE, Assaf GS, McCorkell L, et al. EClinicalMedicine 2021 Myalgic Encephalomyelitis/Chronic Fatigue Syndrome?Major (3/3)Reduction in previous activity level/fatiguePost-exertional malaiseUnrefreshing sleepMinor (1/2)Cognitive impairmentOrthostatic intolerance
15. Learning ObjectivesAfter attending this presentation, learners will be able to:Describe Long COVID epidemiology and identify symptomsCharacterize Long COVID physiology Describe diagnostic and management approaches
16. Pulmonary FunctionPASC durationNMild/Severe COVID-19FEV1FVCFEV1/FVCTLCDLCO6 months34925%/75%6%4%6%16%33%12 months24423%/77%4%4%4%13%36%Huang L, Yao Q, Gu X, et al. Lancet 2021Huang C, Huang L, Wang Y, et al. Lancet 2021
17. VTE/PEBull-Otterson L, Baca S, Saydah S, et al.. MMWR Morb Mortal Wkly Rep 2022Han Q, Zheng B, Daines L, Sheikh A. Pathogens 2022
18. Cardiovascular SequelaeBull-Otterson L, Baca S, Saydah S, et al.. MMWR Morb Mortal Wkly Rep 2022Han Q, Zheng B, Daines L, Sheikh A. Pathogens 2022
19. Bull-Otterson L, Baca S, Saydah S, et al.. MMWR Morb Mortal Wkly Rep 2022Han Q, Zheng B, Daines L, Sheikh A. Pathogens 2022Cardiovascular Sequelae
20. Bull-Otterson L, Baca S, Saydah S, et al.. MMWR Morb Mortal Wkly Rep 2022Han Q, Zheng B, Daines L, Sheikh A. Pathogens 2022Cardiovascular Sequelae
21. Bull-Otterson L, Baca S, Saydah S, et al.. MMWR Morb Mortal Wkly Rep 2022Han Q, Zheng B, Daines L, Sheikh A. Pathogens 2022Cardiovascular Sequelae
22. Bull-Otterson L, Baca S, Saydah S, et al.. MMWR Morb Mortal Wkly Rep 2022Han Q, Zheng B, Daines L, Sheikh A. Pathogens 2022Cardiovascular Sequelae
23. Unrecognized Brain FogGrady Long COVID Registry (n=96)20/34 (59%) reporting brain fog had impairments24/62 (39%) not reporting brain fog had impairmentsGoldstein FC, Hajjar I, Summers A, Truong A, Echols MR, Lee FE, MD, Han JE, Walker TA. Pre-print. 2022
24. Learning ObjectivesAfter attending this presentation, learners will be able to:Describe Long COVID epidemiology and identify symptomsCharacterize Long COVID physiology Describe diagnostic and management approaches
25. Does my patient have Long COVID?Do they meet the WHO Case Definition?They have Long COVID ? YESNO
26. ARS Question 2: 58M with HTN, DM2, and CKD3 presenting with 6 months of fatigue, brain fog, polyarticular joint pain, diffuse myalgias. Exam is within normal limits. Which test is NOT indicated?A. Complete blood countB. Complete metabolic panelC. ANA IFAD. TSH and free T4E. B12
27. 2758M with HTN, DM2, and CKD3 presenting with 6 months of fatigue, brain fog, polyarticular joint pain, diffuse myalgias. Exam is within normal limits. Which test is NOT indicated?ⓘ Start presenting to display the poll results on this slide.
28. Recommended Laboratory TestingCDC. Caring for people with post-COVID condition. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/care-post-covid.html/access
29. Recommended Laboratory TestingCDC. Caring for people with post-COVID condition. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/care-post-covid.html/access
30. Targeted Laboratory TestingCDC. Caring for people with post-COVID condition. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/care-post-covid.html/access
31. Targeted Laboratory TestingCDC. Caring for people with post-COVID condition. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/care-post-covid.html/access
32. Targeted Diagnostic TestingCDC. Caring for people with post-COVID condition. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/care-post-covid.html/access
33. Targeted Diagnostic TestingCDC. Caring for people with post-COVID condition. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/care-post-covid.html/accessAdditional diagnosticsPulmonary function testsCT chest V/Q scanEKG TTEEMG/Nerve conductionPolysomnographyNeurocognitive testingEndoscopyGastric emptying study
34. Psychiatric Assessment ToolsCDC. Caring for people with post-COVID condition. https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/care-post-covid.html/access
35. Management
36. Nirmatrelvir/RitonavirPersistent viral reservoirSARS-CoV-2 detected in gut biopsies 4 months post-infection Spike antigen detected up to 12 months post-infection Nirmatrelvir/Ritonavir Trials15-day coursePrimary outcomesComposite symptom scoresSymptom specific patient reported outcomesQuality of life scalesGaebler C, Wang Z, Lorenzi JCC, et al. Nature 2021Swank Z, Senussi Y, Manickas-Hill Z, et al. Clin Infect Dis 2022https://clinicaltrials.gov/ct2/show/NCT05668091https://clinicaltrials.gov/ct2/show/NCT05576662https://clinicaltrials.gov/ct2/show/NCT05595369
37. NHLBI RECOVER InitiativeDefine natural history, risk factors, pathobiology, treatment17,000 meta cohortGeographically distributed hubsComprehensive surveysSpecimen collection for biorepositoryTriggered diagnostic testingClinical trials under development
38. SummaryLong COVID may affect 20-25% of COVID-19 survivorsCommon symptoms: fatigue/PEM, dyspnea, brain fog, sleep, pain syndromes, dizzy, palpitations, anxiety/depressionMultiple Long COVID phenotypes Work-up and management should be guided by clinical suspicionValidate your patient
39. References1. A clinical case definition of post COVID-19 condition by a Delphi consensus. Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1. Accessed April 26, 2022.Bull-Otterson L, Baca S, Saydah S, et al. Post–COVID Conditions Among Adult COVID-19 Survivors Aged 18–64 and ≥65 Years — United States, March 2020–November 2021. MMWR Morb Mortal Wkly Rep 2022;71:713–717. 2. Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet 2021; 397:220-32.3. COVID-19 Dashboard. Available at: https://coronavirus.jhu.edu/map.html. Accessed April 26, 2022.4. AAPMR. PASC Dashboard. Available at: https://pascdashboard.aapmr.org/ Accessed 7/22/2022.5. Davis HE, Assaf GS, McCorkell L, et al. Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EClinicalMedicine 2021; 38:101019.6. Taquet M, Dercon Q, Luciano S, Geddes JR, Husain M, Harrison PJ. Incidence, co-occurrence, and evolution of long-COVID features: A 6-month retrospective cohort study of 273,618 survivors of COVID-19. PLoS Med 2021; 18:e1003773.7. Lopez-Leon S, Wegman-Ostrosky T, Perelman C, et al. More than 50 Long-term effects of COVID-19: a systematic review and meta-analysis. medRxiv 2021.8. Chen C, Haupert SR, Zimmermann L, Shi X, Fritsche LG, Mukherjee B. Global Prevalence of Post COVID-19 Condition or Long COVID: A Meta-Analysis and Systematic Review. J Infect Dis 2022.9. Han Q, Zheng B, Daines L, Sheikh A. Long-Term Sequelae of COVID-19: A Systematic Review and Meta-Analysis of One-Year Follow-Up Studies on Post-COVID Symptoms. Pathogens 2022; 11.10. Seeßle J, Waterboer T, Hippchen T, et al. Persistent Symptoms in Adult Patients 1 Year After Coronavirus Disease 2019 (COVID-19): A Prospective Cohort Study. Clin Infect Dis 2022; 74:1191-8.11. Bateman L, Bested AC, Bonilla HF, et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Essentials of Diagnosis and Management. Mayo Clin Proc 2021; 96:2861-78.12. Larsen NW, Stiles LE, Miglis MG. Preparing for the long-haul: Autonomic complications of COVID-19. Auton Neurosci 2021; 235:102841.13. Plash WB, Diedrich A, Biaggioni I, et al. Diagnosing postural tachycardia syndrome: comparison of tilt testing compared with standing haemodynamics. Clin Sci (Lond) 2013; 124:109-14.14. Garrigues E, Janvier P, Kherabi Y, et al. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. J Infect 2020; 81:e4-e6.15. Zhou H, Lu S, Chen J, et al. The landscape of cognitive function in recovered COVID-19 patients. J Psychiatr Res 2020; 129:98-102.16. Woodruff MC, Ramonell RP, Haddad NS, et al. Dysregulated naïve B cells and de novo autoreactivity in severe COVID-19. Nature 2022.17. Gaebler C, Wang Z, Lorenzi JCC, et al. Evolution of antibody immunity to SARS-CoV-2. Nature 2021; 591:639-44.18. Swank Z, Senussi Y, Manickas-Hill Z, et al. Persistent circulating SARS-CoV-2 spike is associated with post-acute COVID-19 sequelae. Clin Infect Dis 2022.19. Peluso MJ, Deitchman AN, Torres L, et al. Long-term SARS-CoV-2-specific immune and inflammatory responses in individuals recovering from COVID-19 with and without post-acute symptoms. Cell Rep. 2021 Aug 10;36(6):109518.20. Huang Y, Tan C, Wu J, et al. Impact of coronavirus disease 2019 on pulmonary function in early convalescence phase. Respir Res 2020; 21:163.21. Huang L, Yao Q, Gu X, et al. 1-year outcomes in hospital survivors with COVID-19: a longitudinal cohort study. Lancet 2021; 398:747-58.22. Zhao YM, Shang YM, Song WB, et al. Follow-up study of the pulmonary function and related physiological characteristics of COVID-19 survivors three months after recovery. EClinicalMedicine 2020; 25:100463.23. Woo MS, Malsy J, Pöttgen J, et al. Frequent neurocognitive deficits after recovery from mild COVID-19. Brain Commun 2020; 2:fcaa205.24. Krishnan K, Miller AK, Reiter K, Bonner-Jackson A. Neurocognitive Profiles in Patients With Persisting Cognitive Symptoms Associated With COVID-19. Arch Clin Neuropsychol 2022.25. Hampshire A, Trender W, Chamberlain SR, et al. Cognitive deficits in people who have recovered from COVID-19. EClinicalMedicine 2021; 39:101044.26. Oaklander AL, Mills AJ, Kelley M, et al. Peripheral Neuropathy Evaluations of Patients With Prolonged Long COVID. Neurol Neuroimmunol Neuroinflamm 2022; 9.27. Glynne P, Tahmasebi N, Gant V, Gupta R. Long-COVID following mild SARS CoV-2 infection: characteristic T cell alterations and response to antihistamines. medRxiv 2021:2021.06.06.21258272.28. CDC. Caring for people with post-COVID condition. Available at: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/care-post-covid.html/access 9/1/2022.
40. Q and A Session