September 24, 2020

Virus or post-traumatic stress fault?

People who have been seriously ill and have been treated in intensive care units must have a few months to fully recover, regardless of the condition. However, with COVID-19 it is observed that recovery is also very long in those patients in whom the disease was mild and who, therefore, were not hospitalized.

Extreme fatigue, palpitations, muscle aches, pins and needles are just a few of the many side effects that are under consideration today. About 10% of the 3.9 million people who participated through a app in a study to find out the symptoms of the new coronavirus (COVID Symptom Study app) claimed that the effects of the disease were sustained for more than four weeks.

Chronic fatigue, classified as lasting longer than six weeks, is seen in clinical settings ranging from cancer treatment to inflammatory arthritis. It can be disabling. If 1% of the approximately 290,000 people who have had COVID-19 in the UK still feel unwell three months after contracting the disease, there are still thousands of people today for whom it is impossible to return to your workplace. They will likely have complex needs for which health systems are currently unprepared.

COVID-19 is not the only cause that justifies chronic fatigue. It appears after other viral infections such as Epstein-Barr virus, which causes an infectious mononucleosis (also known as glandular fever). It is also observed in a quarter of the population infected with the SARS that ravaged Hong Kong in 2003.

In treating chronic fatigue, to date the emphasis has been on effective treatment for the underlying disease, with the idea that this will decrease fatigue. However, there is no specific medication for most viral infections, and since COVID-19 is so new, how to treat fatigue is still unknown.

What could cause post-coronavirus fatigue?

While we know that long-lasting fatigue follows other viral illnesses, for most the mechanism is unknown. One of them could be a persistent viral infection in the lungs, brain, fatty tissues, or other places. It could also be due to a prolonged and inappropriate immune response after infection.

Despite this, a study published in 2018 shed some light. When patients with hepatitis C were treated with a chemical called interferon-alpha, a few developed a flu-like illness. In others, postviral fatigue occurred.

Researchers have studied this “artificial response to infection” as a model for chronic fatigue. They found that baseline levels of these two inflammation-promoting molecules in the body (interleukin 6 and 10) predicted the later development of chronic fatigue in patients.

Of particular interest is the fact that these same proinflammatory molecules are seen in the cytokine storm of many patients severely affected by COVID-19. This suggests that there could be a pattern of activation of the immune system during the viral response that is relevant to the symptoms manifested.

He successful use of tocilizumab (a treatment that reduces the impact of interleukin 6 and reduces inflammation) in severe cases of COVID-19 also supports the suspicion that interleukin 6 may be playing some role.

The Conversation

What needs will arise

In TwinsUK Genetic and environmental factors influencing the disease are investigated by King’s College London, the UK’s largest registry of adult twins for scientific purposes.

With the app COVID Symptom Study Longer symptoms are examined. To do this, questionnaires are sent to volunteer adult twins registered in the database, many of whom had been included well before the pandemic, in studies of immune systems. From here our goal is to define a postcovid syndrome and pay attention to blood markers to explain how immune mechanisms contribute to long-term symptoms.

This is a study whose design poses several challenges: people with COVID-19 have had more than a simple viral infection suffered in a context of normality. They have fallen ill at a time when the world was undergoing unprecedented social change. Around her, movement restrictions and a period brimming with anxiety in which it was difficult to quantify the risks, since they were bombarded informatively 24 hours a day. A good number of patients spent the illness at home and felt on the verge of death.

For this reason, post-traumatic stress is also being studied, since the interpretation of the reported symptoms has to be made in their context.

Chronic fatigue is not the province of a single medical specialty, which is why it is often overlooked in careers and doctors are barely trained to diagnose or treat it. However, it is true that in recent months some progress has been made in this regard and that there is already training on-line for health professionals, in order that they learn to approach at least the cases of those patients whose symptoms are more pronounced.

It also has guidelines for patients and designed to help them deal with chronic fatigue and maintain energy. Among all the recommendations, it is worth highlighting the one that insists that joining the gym and forcing yourself to exercise is negative, and that it only makes people turn back. Small efforts, both mental and physical, should be followed by doses of rest. Returning to work, when it arrives, should also be a gradual and phased process. Learning to pace activities is increasingly the order of the day.

Frances Williams She is a professor of “Genomic Epidemiology” and “Hon Consultant Rheumatologist” at King’s College, London.

This article was originally published on The Conversation. You can read it here.


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