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38      Post-COVID Care
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40      On this page
41    </h2><ul class="in-page-nav-list"><li class="in-page-nav-list-item"><a data-scroll-id="please-note-that-as-of-april-2023-this-website-is-no-longer-actively-being-updated-b8zp8szdc3t&quot;&gt;&lt;span style=&quot;font-weight:700" href="#please-note-that-as-of-april-2023-this-website-is-no-longer-actively-being-updated-b8zp8szdc3t&quot;&gt;&lt;span style=&quot;font-weight:700" class="in-page-nav__link in-page-nav__link--h3">Please note that as of April 2023, this website is no longer actively being updated. </a></li><li class="in-page-nav-list-item"><a data-scroll-id="post-acute-covid-syndrome-pacs-rygkc3bz6et" href="#post-acute-covid-syndrome-pacs-rygkc3bz6et" class="in-page-nav__link in-page-nav__link--h2">Post-Acute COVID Syndrome (PACS)</a></li><li class="in-page-nav-list-item"><a data-scroll-id="course-of-recovery-f2bwlocmt0r5" href="#course-of-recovery-f2bwlocmt0r5" class="in-page-nav__link in-page-nav__link--h3">Course of Recovery</a></li><li class="in-page-nav-list-item"><a data-scroll-id="prevalence-of-pacs-z2fjryilm7ld" href="#prevalence-of-pacs-z2fjryilm7ld" class="in-page-nav__link in-page-nav__link--h3">Prevalence of PACS</a></li><li class="in-page-nav-list-item"><a data-scroll-id="symptom-patterns-8f2uijkwdqo3" href="#symptom-patterns-8f2uijkwdqo3" class="in-page-nav__link in-page-nav__link--h3">Symptom Patterns</a></li><li class="in-page-nav-list-item"><a data-scroll-id="pathophysiology-hbierzjv3014" href="#pathophysiology-hbierzjv3014" class="in-page-nav__link in-page-nav__link--h3">Pathophysiology</a></li><li class="in-page-nav-list-item"><a data-scroll-id="outpatient-workup-6jcumwn5jvke" href="#outpatient-workup-6jcumwn5jvke" class="in-page-nav__link in-page-nav__link--h2">Outpatient Workup </a></li><li class="in-page-nav-list-item"><a data-scroll-id="post-covid-clinic-visits-967bvvjlws" href="#post-covid-clinic-visits-967bvvjlws" class="in-page-nav__link in-page-nav__link--h3">Post-COVID Clinic Visits </a></li><li class="in-page-nav-list-item"><a data-scroll-id="work-up-65b4xw7f0sv5" href="#work-up-65b4xw7f0sv5" class="in-page-nav__link in-page-nav__link--h3">Work-Up</a></li><li class="in-page-nav-list-item"><a data-scroll-id="general-management-isih4vy9683v" href="#general-management-isih4vy9683v" class="in-page-nav__link in-page-nav__link--h3">General Management</a></li><li class="in-page-nav-list-item"><a data-scroll-id="vaccination-after-covid-infection-vj4wd4h6w9yn" href="#vaccination-after-covid-infection-vj4wd4h6w9yn" class="in-page-nav__link in-page-nav__link--h3">Vaccination after COVID Infection</a></li><li class="in-page-nav-list-item"><a data-scroll-id="pulmonary-concerns-bknygux3jwb3" href="#pulmonary-concerns-bknygux3jwb3" class="in-page-nav__link in-page-nav__link--h2">Pulmonary Concerns</a></li><li class="in-page-nav-list-item"><a data-scroll-id="dyspnea-or-cough-pl2qtdojlviv" href="#dyspnea-or-cough-pl2qtdojlviv" class="in-page-nav__link in-page-nav__link--h3">Dyspnea or Cough</a></li><li class="in-page-nav-list-item"><a data-scroll-id="pulmonary-function-tests-z1e3k92fxgq7" href="#pulmonary-function-tests-z1e3k92fxgq7" class="in-page-nav__link in-page-nav__link--h3">Pulmonary Function Tests</a></li><li class="in-page-nav-list-item"><a data-scroll-id="radiographic-abnormalities-ye9weoy15eem" href="#radiographic-abnormalities-ye9weoy15eem" class="in-page-nav__link in-page-nav__link--h3">Radiographic Abnormalities</a></li><li class="in-page-nav-list-item"><a data-scroll-id="interstitial-lung-disease-gsit8cwj3igo" href="#interstitial-lung-disease-gsit8cwj3igo" class="in-page-nav__link in-page-nav__link--h3">Interstitial Lung Disease</a></li><li class="in-page-nav-list-item"><a data-scroll-id="rheumatologic-concerns-wqdtw0vz4asv" href="#rheumatologic-concerns-wqdtw0vz4asv" class="in-page-nav__link in-page-nav__link--h2">Rheumatologic Concerns</a></li><li class="in-page-nav-list-item"><a data-scroll-id="fever-qz4h6r9sxj9q" href="#fever-qz4h6r9sxj9q" class="in-page-nav__link in-page-nav__link--h3">Fever</a></li><li class="in-page-nav-list-item"><a data-scroll-id="joint-pain-jx15b6fuan58" href="#joint-pain-jx15b6fuan58" class="in-page-nav__link in-page-nav__link--h3">Joint Pain</a></li><li class="in-page-nav-list-item"><a data-scroll-id="neurologic-and-neuropsychiatric-concerns-az0llqo38w98" href="#neurologic-and-neuropsychiatric-concerns-az0llqo38w98" class="in-page-nav__link in-page-nav__link--h2">
41Neurologic and Neuropsychiatric Concerns</a></li><li class="in-page-nav-list-item"><a data-scroll-id="incidence-fbzsdxoch8mt" href="#incidence-fbzsdxoch8mt" class="in-page-nav__link in-page-nav__link--h3">Incidence</a></li><li class="in-page-nav-list-item"><a data-scroll-id="fatigue-and-brain-fog-o5zyvqmfv6no" href="#fatigue-and-brain-fog-o5zyvqmfv6no" class="in-page-nav__link in-page-nav__link--h3">Fatigue and “Brain Fog”</a></li><li class="in-page-nav-list-item"><a data-scroll-id="anxiety-and-depression-5vtz8ypvr887" href="#anxiety-and-depression-5vtz8ypvr887" class="in-page-nav__link in-page-nav__link--h3">Anxiety and Depression</a></li><li class="in-page-nav-list-item"><a data-scroll-id="prolonged-anosmia-and-ageusia-cgwdicgt2ot6" href="#prolonged-anosmia-and-ageusia-cgwdicgt2ot6" class="in-page-nav__link in-page-nav__link--h3">Prolonged Anosmia and Ageusia</a></li><li class="in-page-nav-list-item"><a data-scroll-id="headache-jdzvelbxg9wq" href="#headache-jdzvelbxg9wq" class="in-page-nav__link in-page-nav__link--h3">Headache</a></li><li class="in-page-nav-list-item"><a data-scroll-id="dysautonomia-and-pots-e9h9w1nhepmd" href="#dysautonomia-and-pots-e9h9w1nhepmd" class="in-page-nav__link in-page-nav__link--h3">Dysautonomia and POTS</a></li><!----><!----><li class="in-page-nav-list-item"><a data-scroll-id="hematologic-concerns-w34oxzt914mq" href="#hematologic-concerns-w34oxzt914mq" class="in-page-nav__link in-page-nav__link--h2">Hematologic Concerns</a></li><li class="in-page-nav-list-item"><a data-scroll-id="delayed-thrombosis-i2adktaazwpp" href="#delayed-thrombosis-i2adktaazwpp" class="in-page-nav__link in-page-nav__link--h3">Delayed Thrombosis</a></li><li class="in-page-nav-list-item"><a data-scroll-id="cardiac-concerns-81b56iceb3ah" href="#cardiac-concerns-81b56iceb3ah" class="in-page-nav__link in-page-nav__link--h2">Cardiac Concerns</a></li><li class="in-page-nav-list-item"><a data-scroll-id="chest-tightness-and-discomfort-wd53c3s0rf76" href="#chest-tightness-and-discomfort-wd53c3s0rf76" class="in-page-nav__link in-page-nav__link--h3">Chest Tightness and Discomfort</a></li><li class="in-page-nav-list-item"><a data-scroll-id="cardiac-dysfunction-p1jfjbp8ef8u" href="#cardiac-dysfunction-p1jfjbp8ef8u" class="in-page-nav__link in-page-nav__link--h3">Cardiac Dysfunction</a></li><li class="in-page-nav-list-item"><a data-scroll-id="renal-concerns-lhhoyyv23om1" href="#renal-concerns-lhhoyyv23om1" class="in-page-nav__link in-page-nav__link--h2">Renal Concerns</a></li><li class="in-page-nav-list-item"><a data-scroll-id="post-icu-syndrome-f42ysl6mf4r1" href="#post-icu-syndrome-f42ysl6mf4r1" class="in-page-nav__link in-page-nav__link--h2">Post-ICU Syndrome </a></li><li class="in-page-nav-list-item"><a data-scroll-id="gastrointestinal-concerns-l7nafbusssgt" href="#gastrointestinal-concerns-l7nafbusssgt" class="in-page-nav__link in-page-nav__link--h2">Gastrointestinal Concerns</a></li><li class="in-page-nav-list-item"><a data-scroll-id="functional-gi-disorders-bmxuw3jmud8h" href="#functional-gi-disorders-bmxuw3jmud8h" class="in-page-nav__link in-page-nav__link--h3">Functional GI Disorders</a></li></ul></div><div class="g-divider"></div><div class="g-main-content"><div><style type="text/css">
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3394  .lst-kix_fg05l4pyrrlg-6>li:before {
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5172  }
5173
5174  ul.lst-kix_rfz3i8rvhpe6-6 {
5175    list-style-type: none
5176  }
5177
5178  ul.lst-kix_rfz3i8rvhpe6-5 {
5179    list-style-type: none
5180  }
5181
5182  .lst-kix_oovh1eqkb89z-6>li {
5183    counter-increment: lst-ctn-kix_oovh1eqkb89z-6
5184  }
5185
5186  ul.lst-kix_rfz3i8rvhpe6-4 {
5187    list-style-type: none
5188  }
5189
5190  ul.lst-kix_rfz3i8rvhpe6-3 {
5191    list-style-type: none
5192  }
5193
5194  ul.lst-kix_rfz3i8rvhpe6-2 {
5195    list-style-type: none
5196  }
5197
5198  ul.lst-kix_rfz3i8rvhpe6-1 {
5199    list-style-type: none
5200  }
5201
5202  ul.lst-kix_rfz3i8rvhpe6-0 {
5203    list-style-type: none
5204  }
5205
5206  .lst-kix_c0fwaf4x9f9c-1>li:before {
5207    content: ""counter(lst-ctn-kix_c0fwaf4x9f9c-1, lower-latin) ". "
5208  }
5209
5210  .lst-kix_uzd0wj8sqzdy-3>li:before {
5211    content: ""counter(lst-ctn-kix_uzd0wj8sqzdy-3, decimal) ". "
5212  }
5213
5214  .lst-kix_fb2rugqy9f82-5>li {
5215    counter-increment: lst-ctn-kix_fb2rugqy9f82-5
5216  }
5217
5218  .lst-kix_dwmz4jxzcool-1>li:before {
5219    content: ""counter(lst-ctn-kix_dwmz4jxzcool-1, lower-latin) ". "
5220  }
5221
5222  ol.lst-kix_5svwa0ccdd9s-1.start {
5223    counter-reset: lst-ctn-kix_5svwa0ccdd9s-1 0
5224  }
5225
5226  ol.lst-kix_sq1mrmbpxwta-8.start {
5227    counter-reset: lst-ctn-kix_sq1mrmbpxwta-8 0
5228  }
5229
5230  .lst-kix_7ep99chpynl2-5>li:before {
5231    content: "■  "
5232  }
5233
5234  ol.lst-kix_op1aqp67ffp9-5.start {
5235    counter-reset: lst-ctn-kix_op1aqp67ffp9-5 0
5236  }
5237
5238  .lst-kix_4uu96ne38ad6-2>li:before {
5239    content: ""counter(lst-ctn-kix_4uu96ne38ad6-2, lower-roman) ". "
5240  }
5241
5242  .lst-kix_i4kbmii7v2u5-4>li {
5243    counter-increment: lst-ctn-kix_i4kbmii7v2u5-4
5244  }
5245
5246  .lst-kix_jjf673v4s7ew-7>li {
5247    counter-increment: lst-ctn-kix_jjf673v4s7ew-7
5248  }
5249
5250  .lst-kix_jyqchcu61auh-2>li:before {
5251    content: ""counter(lst-ctn-kix_jyqchcu61auh-2, lower-roman) ". "
5252  }
5253
5254  .lst-kix_yqxmwu2qe4f5-4>li {
5255    counter-increment: lst-ctn-kix_yqxmwu2qe4f5-4
5256  }
5257
5258  .lst-kix_fb2rugqy9f82-7>li {
5259    counter-increment: lst-ctn-kix_fb2rugqy9f82-7
5260  }
5261
5262  ol.lst-kix_vgnzyq2eu8c6-4.start {
5263    counter-reset: lst-ctn-kix_vgnzyq2eu8c6-4 0
5264  }
5265
5266  .lst-kix_lbkxggsujkvy-5>li {
5267    counter-increment: lst-ctn-kix_lbkxggsujkvy-5
5268  }
5269
5270  .lst-kix_qxcj2qgnj7k-2>li {
5271    counter-increment: lst-ctn-kix_qxcj2qgnj7k-2
5272  }
5273
5274  .lst-kix_noixtpkhicu-5>li:before {
5275    content: ""counter(lst-ctn-kix_noixtpkhicu-5, lower-roman) ". "
5276  }
5277
5278  .lst-kix_prv07yriqauf-3>li {
5279    counter-increment: lst-ctn-kix_prv07yriqauf-3
5280  }
5281
5282  .lst-kix_6ioo2y6mzy2q-3>li {
5283    counter-increment: lst-ctn-kix_6ioo2y6mzy2q-3
5284  }
5285
5286  .lst-kix_p2v7in6p50z9-5>li {
5287    counter-increment: lst-ctn-kix_p2v7in6p50z9-5
5288  }
5289
5290  .lst-kix_x6crmnr1rctw-5>li:before {
5291    content: ""counter(lst-ctn-kix_x6crmnr1rctw-5, lower-roman) ". "
5292  }
5293
5294  .lst-kix_aj6zhvwkyyiu-6>li {
5295    counter-increment: lst-ctn-kix_aj6zhvwkyyiu-6
5296  }
5297
5298  .lst-kix_isq8egaojkrp-8>li:before {
5299    content: "■  "
5300  }
5301
5302  .lst-kix_532mmkp77txs-2>li:before {
5303    content: "■  "
5304  }
5305
5306  .lst-kix_m0pi9j1llatt-8>li:before {
5307    content: ""counter(lst-ctn-kix_m0pi9j1llatt-8, lower-roman) ". "
5308  }
5309
5310  .lst-kix_m0pi9j1llatt-2>li:before {
5311    content: ""counter(lst-ctn-kix_m0pi9j1llatt-2, lower-roman) ". "
5312  }
5313
5314  .lst-kix_jjf673v4s7ew-5>li:before {
5315    content: ""counter(lst-ctn-kix_jjf673v4s7ew-5, lower-roman) ". "
5316  }
5317
5318  ol.lst-kix_5ttlchkjwi2m-0.start {
5319    counter-reset: lst-ctn-kix_5ttlchkjwi2m-0 0
5320  }
5321
5322  .lst-kix_5ykri12fbbq7-2>li {
5323    counter-increment: lst-ctn-kix_5ykri12fbbq7-2
5324  }
5325
5326  .lst-kix_4y5cbfqis3jf-7>li:before {
5327    content: "○  "
5328  }
5329
5330  .lst-kix_42vq4uyvy4hi-8>li {
5331    counter-increment: lst-ctn-kix_42vq4uyvy4hi-8
5332  }
5333
5334  ol.lst-kix_ux2dzx3bmjfa-1.start {
5335    counter-reset: lst-ctn-kix_ux2dzx3bmjfa-1 0
5336  }
5337
5338  .lst-kix_uymripwijbx3-3>li:before {
5339    content: ""counter(lst-ctn-kix_uymripwijbx3-3, decimal) ". "
5340  }
5341
5342  ol.lst-kix_okfsxetz2opt-2.start {
5343    counter-reset: lst-ctn-kix_okfsxetz2opt-2 0
5344  }
5345
5346  .lst-kix_4v5f1jggpbe5-2>li {
5347    counter-increment: lst-ctn-kix_4v5f1jggpbe5-2
5348  }
5349
5350  .lst-kix_d10w4txur36y-7>li:before {
5351    content: "○  "
5352  }
5353
5354  ul.lst-kix_tx3hjbgftogj-1 {
5355    list-style-type: none
5356  }
5357
5358  ul.lst-kix_tx3hjbgftogj-2 {
5359    list-style-type: none
5360  }
5361
5362  .lst-kix_pk97dfqrpb7m-8>li:before {
5363    content: ""counter(lst-ctn-kix_pk97dfqrpb7m-8, lower-roman) ". "
5364  }
5365
5366  ul.lst-kix_tx3hjbgftogj-0 {
5367    list-style-type: none
5368  }
5369
5370  ol.lst-kix_cua0zmvdf8ca-2.start {
5371    counter-reset: lst-ctn-kix_cua0zmvdf8ca-2 0
5372  }
5373
5374  .lst-kix_z7xdknh39u1h-4>li {
5375    counter-increment: lst-ctn-kix_z7xdknh39u1h-4
5376  }
5377
5378  .lst-kix_x6crmnr1rctw-5>li {
5379    counter-increment: lst-ctn-kix_x6crmnr1rctw-5
5380  }
5381
5382  .lst-kix_okfsxetz2opt-8>li {
5383    counter-increment: lst-ctn-kix_okfsxetz2opt-8
5384  }
5385
5386  ul.lst-kix_tx3hjbgftogj-7 {
5387    list-style-type: none
5388  }
5389
5390  ul.lst-kix_tx3hjbgftogj-8 {
5391    list-style-type: none
5392  }
5393
5394  ul.lst-kix_tx3hjbgftogj-5 {
5395    list-style-type: none
5396  }
5397
5398  ul.lst-kix_tx3hjbgftogj-6 {
5399    list-style-type: none
5400  }
5401
5402  .lst-kix_pk97dfqrpb7m-2>li:before {
5403    content: ""counter(lst-ctn-kix_pk97dfqrpb7m-2, lower-roman) ". "
5404  }
5405
5406  ul.lst-kix_tx3hjbgftogj-3 {
5407    list-style-type: none
5408  }
5409
5410  .lst-kix_yqxmwu2qe4f5-6>li {
5411    counter-increment: lst-ctn-kix_yqxmwu2qe4f5-6
5412  }
5413
5414  ul.lst-kix_tx3hjbgftogj-4 {
5415    list-style-type: none
5416  }
5417
5418  .lst-kix_okhindhrjvjq-3>li:before {
5419    content: "●  "
5420  }
5421
5422  ol.lst-kix_7ps7z22p7z5h-3.start {
5423    counter-reset: lst-ctn-kix_7ps7z22p7z5h-3 0
5424  }
5425
5426  .lst-kix_rack5ivym2uw-5>li:before {
5427    content: ""counter(lst-ctn-kix_rack5ivym2uw-5, lower-roman) ". "
5428  }
5429
5430  .lst-kix_g9loi34ccti1-7>li {
5431    counter-increment: lst-ctn-kix_g9loi34ccti1-7
5432  }
5433
5434  .lst-kix_hy7q99iznadc-2>li {
5435    counter-increment: lst-ctn-kix_hy7q99iznadc-2
5436  }
5437
5438  .lst-kix_okhindhrjvjq-5>li:before {
5439    content: "■  "
5440  }
5441
5442  .lst-kix_qxcj2qgnj7k-6>li {
5443    counter-increment: lst-ctn-kix_qxcj2qgnj7k-6
5444  }
5445
5446  .lst-kix_pk97dfqrpb7m-0>li:before {
5447    content: ""counter(lst-ctn-kix_pk97dfqrpb7m-0, decimal) ". "
5448  }
5449
5450  .lst-kix_eamkdm6w165n-4>li {
5451    counter-increment: lst-ctn-kix_eamkdm6w165n-4
5452  }
5453
5454  .lst-kix_385vbjfsbg0j-3>li {
5455    counter-increment: lst-ctn-kix_385vbjfsbg0j-3
5456  }
5457
5458  .lst-kix_hjodcpzo1gv-5>li:before {
5459    content: ""counter(lst-ctn-kix_hjodcpzo1gv-5, lower-roman) ". "
5460  }
5461
5462  .lst-kix_ux2dzx3bmjfa-7>li {
5463    counter-increment: lst-ctn-kix_ux2dzx3bmjfa-7
5464  }
5465
5466  .lst-kix_71m7y2cvysq0-3>li:before {
5467    content: ""counter(lst-ctn-kix_71m7y2cvysq0-3, decimal) ". "
5468  }
5469
5470  .lst-kix_c69me314nk6r-3>li {
5471    counter-increment: lst-ctn-kix_c69me314nk6r-3
5472  }
5473
5474  .lst-kix_2k84ncmqobst-3>li:before {
5475    content: ""counter(lst-ctn-kix_2k84ncmqobst-3, decimal) ". "
5476  }
5477
5478  .lst-kix_fb2rugqy9f82-0>li {
5479    counter-increment: lst-ctn-kix_fb2rugqy9f82-0
5480  }
5481
5482  .lst-kix_9gj2risgrxbz-1>li:before {
5483    content: "○  "
5484  }
5485
5486  .lst-kix_dlrmgu9apskl-0>li:before {
5487    content: ""counter(lst-ctn-kix_dlrmgu9apskl-0, decimal) ". "
5488  }
5489
5490  .lst-kix_uyl10oi50gdh-8>li:before {
5491    content: ""counter(lst-ctn-kix_uyl10oi50gdh-8, lower-roman) ". "
5492  }
5493
5494  .lst-kix_8sszuxi6e1ur-2>li:before {
5495    content: "■  "
5496  }
5497
5498  ol.lst-kix_cedbd820up2x-1.start {
5499    counter-reset: lst-ctn-kix_cedbd820up2x-1 0
5500  }
5501
5502  ol.lst-kix_jg6ra9i0tpxi-1.start {
5503    counter-reset: lst-ctn-kix_jg6ra9i0tpxi-1 0
5504  }
5505
5506  .lst-kix_nea8iuda764x-6>li:before {
5507    content: "●  "
5508  }
5509
5510  .lst-kix_cedbd820up2x-5>li {
5511    counter-increment: lst-ctn-kix_cedbd820up2x-5
5512  }
5513
5514  ol.lst-kix_okfsxetz2opt-4.start {
5515    counter-reset: lst-ctn-kix_okfsxetz2opt-4 0
5516  }
5517
5518  .lst-kix_8sszuxi6e1ur-4>li:before {
5519    content: "○  "
5520  }
5521
5522  .lst-kix_dlrmgu9apskl-2>li:before {
5523    content: ""counter(lst-ctn-kix_dlrmgu9apskl-2, lower-roman) ". "
5524  }
5525
5526  .lst-kix_7c0nqnqmymjn-2>li:before {
5527    content: "-  "
5528  }
5529
5530  .lst-kix_nea8iuda764x-0>li:before {
5531    content: "●  "
5532  }
5533
5534  .lst-kix_6ioo2y6mzy2q-0>li:before {
5535    content: ""counter(lst-ctn-kix_6ioo2y6mzy2q-0, decimal) ". "
5536  }
5537
5538  .lst-kix_uzd0wj8sqzdy-0>li {
5539    counter-increment: lst-ctn-kix_uzd0wj8sqzdy-0
5540  }
5541
5542  .lst-kix_dlrmgu9apskl-8>li:before {
5543    content: ""counter(lst-ctn-kix_dlrmgu9apskl-8, lower-roman) ". "
5544  }
5545
5546  .lst-kix_ss5ljp98o3oi-5>li:before {
5547    content: ""counter(lst-ctn-kix_ss5ljp98o3oi-5, lower-roman) ". "
5548  }
5549
5550  ul.lst-kix_ev2zqzxtx3tv-8 {
5551    list-style-type: none
5552  }
5553
5554  .lst-kix_hy7q99iznadc-2>li:before {
5555    content: ""counter(lst-ctn-kix_hy7q99iznadc-2, lower-roman) ". "
5556  }
5557
5558  ul.lst-kix_ev2zqzxtx3tv-7 {
5559    list-style-type: none
5560  }
5561
5562  ul.lst-kix_ev2zqzxtx3tv-6 {
5563    list-style-type: none
5564  }
5565
5566  .lst-kix_qtp2for02r8j-7>li:before {
5567    content: "○  "
5568  }
5569
5570  .lst-kix_oovh1eqkb89z-4>li:before {
5571    content: ""counter(lst-ctn-kix_oovh1eqkb89z-4, lower-latin) ". "
5572  }
5573
5574  .lst-kix_kz1xh0fb0bu6-3>li:before {
5575    content: "●  "
5576  }
5577
5578  .lst-kix_oovh1eqkb89z-2>li:before {
5579    content: ""counter(lst-ctn-kix_oovh1eqkb89z-2, lower-roman) ". "
5580  }
5581
5582  .lst-kix_pyn7w98n2g5h-1>li:before {
5583    content: "○  "
5584  }
5585
5586  .lst-kix_hy7q99iznadc-8>li:before {
5587    content: ""counter(lst-ctn-kix_hy7q99iznadc-8, lower-roman) ". "
5588  }
5589
5590  .lst-kix_xv1pdu365xf9-8>li:before {
5591    content: "■  "
5592  }
5593
5594  .lst-kix_avdaitienlwt-3>li {
5595    counter-increment: lst-ctn-kix_avdaitienlwt-3
5596  }
5597
5598  .lst-kix_uzd0wj8sqzdy-7>li {
5599    counter-increment: lst-ctn-kix_uzd0wj8sqzdy-7
5600  }
5601
5602  .lst-kix_xv1pdu365xf9-2>li:before {
5603    content: "■  "
5604  }
5605
5606  ol.lst-kix_6hm2e5tzmmi8-6.start {
5607    counter-reset: lst-ctn-kix_6hm2e5tzmmi8-6 0
5608  }
5609
5610  ol.lst-kix_m0pi9j1llatt-1.start {
5611    counter-reset: lst-ctn-kix_m0pi9j1llatt-1 0
5612  }
5613
5614  ol.lst-kix_m0pi9j1llatt-7.start {
5615    counter-reset: lst-ctn-kix_m0pi9j1llatt-7 0
5616  }
5617
5618  .lst-kix_b22uvd2azowp-3>li:before {
5619    content: ""counter(lst-ctn-kix_b22uvd2azowp-3, decimal) ". "
5620  }
5621
5622  .lst-kix_hjodcpzo1gv-2>li {
5623    counter-increment: lst-ctn-kix_hjodcpzo1gv-2
5624  }
5625
5626  ol.lst-kix_xf5zb3gcanjp-1.start {
5627    counter-reset: lst-ctn-kix_xf5zb3gcanjp-1 0
5628  }
5629
5630  .lst-kix_ss5ljp98o3oi-2>li {
5631    counter-increment: lst-ctn-kix_ss5ljp98o3oi-2
5632  }
5633
5634  .lst-kix_wvynemq8noap-2>li {
5635    counter-increment: lst-ctn-kix_wvynemq8noap-2
5636  }
5637
5638  .lst-kix_il2766ynoer8-7>li:before {
5639    content: "○  "
5640  }
5641
5642  .lst-kix_szji4w8wo8g5-6>li {
5643    counter-increment: lst-ctn-kix_szji4w8wo8g5-6
5644  }
5645
5646  .lst-kix_4v5f1jggpbe5-8>li:before {
5647    content: ""counter(lst-ctn-kix_4v5f1jggpbe5-8, lower-roman) ". "
5648  }
5649
5650  .lst-kix_qt8p1uictec0-6>li:before {
5651    content: ""counter(lst-ctn-kix_qt8p1uictec0-6, decimal) ". "
5652  }
5653
5654  .lst-kix_w0emwdh8q3vt-0>li:before {
5655    content: "-  "
5656  }
5657
5658  ol.lst-kix_42vq4uyvy4hi-3.start {
5659    counter-reset: lst-ctn-kix_42vq4uyvy4hi-3 0
5660  }
5661
5662  .lst-kix_hhv7hs1tzwa3-1>li:before {
5663    content: ""counter(lst-ctn-kix_hhv7hs1tzwa3-1, lower-latin) ". "
5664  }
5665
5666  ul.lst-kix_ev2zqzxtx3tv-5 {
5667    list-style-type: none
5668  }
5669
5670  ul.lst-kix_ev2zqzxtx3tv-4 {
5671    list-style-type: none
5672  }
5673
5674  .lst-kix_cedbd820up2x-1>li {
5675    counter-increment: lst-ctn-kix_cedbd820up2x-1
5676  }
5677
5678  ul.lst-kix_ev2zqzxtx3tv-3 {
5679    list-style-type: none
5680  }
5681
5682  ul.lst-kix_ev2zqzxtx3tv-2 {
5683    list-style-type: none
5684  }
5685
5686  ul.lst-kix_ev2zqzxtx3tv-1 {
5687    list-style-type: none
5688  }
5689
5690  .lst-kix_qtp2for02r8j-1>li:before {
5691    content: "○  "
5692  }
5693
5694  ul.lst-kix_ev2zqzxtx3tv-0 {
5695    list-style-type: none
5696  }
5697
5698  .lst-kix_5gfpsxzgoce2-6>li:before {
5699    content: "●  "
5700  }
5701
5702  ol.lst-kix_x6crmnr1rctw-1.start {
5703    counter-reset: lst-ctn-kix_x6crmnr1rctw-1 0
5704  }
5705
5706  .lst-kix_4iv1aedi5h4w-2>li:before {
5707    content: "■  "
5708  }
5709
5710  ol.lst-kix_vgnzyq2eu8c6-6.start {
5711    counter-reset: lst-ctn-kix_vgnzyq2eu8c6-6 0
5712  }
5713
5714  ol.lst-kix_fb2rugqy9f82-8.start {
5715    counter-reset: lst-ctn-kix_fb2rugqy9f82-8 0
5716  }
5717
5718  .lst-kix_i4kbmii7v2u5-3>li:before {
5719    content: ""counter(lst-ctn-kix_i4kbmii7v2u5-3, decimal) ". "
5720  }
5721
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5826  ul.lst-kix_t69w2ebduk2f-1 {
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5834  ul.lst-kix_t69w2ebduk2f-0 {
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5862  .lst-kix_lbkxggsujkvy-6>li:before {
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5865
5866  .lst-kix_ey5qphywc3q1-7>li:before {
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5869
5870  .lst-kix_yqxmwu2qe4f5-3>li:before {
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5878  .lst-kix_dwmz4jxzcool-6>li {
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5918  ul.lst-kix_t69w2ebduk2f-4 {
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5930  ol.lst-kix_5ttlchkjwi2m-2.start {
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5966  ol.lst-kix_aj6zhvwkyyiu-7 {
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5978  ol.lst-kix_aj6zhvwkyyiu-5 {
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5990  ol.lst-kix_aj6zhvwkyyiu-8 {
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5998  ol.lst-kix_aj6zhvwkyyiu-2 {
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6002  .lst-kix_cedbd820up2x-0>li {
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6010  ol.lst-kix_aj6zhvwkyyiu-0 {
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6018  .lst-kix_op1aqp67ffp9-7>li {
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6034  ol.lst-kix_cua0zmvdf8ca-8.start {
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6062  .lst-kix_tx3hjbgftogj-3>li:before {
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6081
6082  .lst-kix_5ykri12fbbq7-3>li:before {
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6094  .lst-kix_xofh9trtihq4-0>li {
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6134  .lst-kix_yqxmwu2qe4f5-0>li:before {
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6213
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6230  ol.lst-kix_6ioo2y6mzy2q-8 {
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10978  ul.lst-kix_t1oiap2l95em-2 {
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10982  ul.lst-kix_t1oiap2l95em-0 {
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10990  .lst-kix_hhv7hs1tzwa3-0>li {
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11006  ul.lst-kix_t1oiap2l95em-8 {
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11018  ul.lst-kix_t1oiap2l95em-6 {
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11041
11042  .lst-kix_ux2dzx3bmjfa-5>li {
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11054  ol.lst-kix_hjodcpzo1gv-2.start {
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11062  ol.lst-kix_4v5f1jggpbe5-1.start {
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11074  ol.lst-kix_oovh1eqkb89z-1.start {
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11077
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11080  }
11081
11082  .lst-kix_sq1mrmbpxwta-3>li:before {
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11084  }
11085
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11088  }
11089
11090  .lst-kix_b22uvd2azowp-5>li {
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11097
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11100  }
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11102  ol.lst-kix_noixtpkhicu-1.start {
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11116  }
11117
11118  ul.lst-kix_3ybhlpvgu4q5-8 {
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11124  }
11125
11126  .lst-kix_8a9e37jpst1h-0>li:before {
11127    content: "●  "
11128  }
11129
11130  ul.lst-kix_3ybhlpvgu4q5-0 {
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11134  ul.lst-kix_3ybhlpvgu4q5-1 {
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11142  ul.lst-kix_3ybhlpvgu4q5-3 {
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11164  }
11165
11166  .lst-kix_jjf673v4s7ew-6>li:before {
11167    content: ""counter(lst-ctn-kix_jjf673v4s7ew-6, decimal) ". "
11168  }
11169
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11172  }
11173
11174  .lst-kix_rinnepadptik-7>li {
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11181
11182  .lst-kix_d10w4txur36y-0>li:before {
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11184  }
11185
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11200  }
11201
11202  ol.lst-kix_yqxmwu2qe4f5-0.start {
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11208  }
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11210  ol.lst-kix_oovh1eqkb89z-6.start {
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11216  }
11217
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11220  }
11221
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11225
11226  .lst-kix_4y5cbfqis3jf-0>li:before {
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11228  }
11229
11230  .lst-kix_1ma56klcq62q-7>li {
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11240  }
11241
11242  .lst-kix_6ioo2y6mzy2q-7>li:before {
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11244  }
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11249
11250  .lst-kix_71m7y2cvysq0-2>li:before {
11251    content: ""counter(lst-ctn-kix_71m7y2cvysq0-2, lower-roman) ". "
11252  }
11253
11254  .lst-kix_dlrmgu9apskl-1>li {
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11264  }
11265
11266  .lst-kix_9gj2risgrxbz-5>li:before {
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11268  }
11269
11270  .lst-kix_8sszuxi6e1ur-8>li:before {
11271    content: "■  "
11272  }
11273
11274  .lst-kix_dlrmgu9apskl-6>li:before {
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11278  .lst-kix_yckyyolxljf2-0>li {
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11284  }
11285
11286  .lst-kix_xf5zb3gcanjp-1>li {
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11306  .lst-kix_ja2fu3kkmjot-8>li {
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11312  }
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11314  .lst-kix_noixtpkhicu-5>li {
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11319    content: ""counter(lst-ctn-kix_hy7q99iznadc-4, lower-latin) ". "
11320  }
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11389
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11391    content: ""counter(lst-ctn-kix_qxcj2qgnj7k-8, lower-roman) ". "
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11399    content: ""counter(lst-ctn-kix_h9h6a4rh1gdn-0, decimal) ". "
11400  }
11401
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11420  }
11421
11422  .lst-kix_5s1ijb2a0x48-3>li:before {
11423    content: "●  "
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11431    content: ""counter(lst-ctn-kix_5ttlchkjwi2m-7, lower-latin) ". "
11432  }
11433
11434  .lst-kix_6ioo2y6mzy2q-2>li {
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11463    content: "■  "
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11465
11466  ol.lst-kix_dlrmgu9apskl-5 {
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11469
11470  .lst-kix_7ixa8n4crse4-2>li:before {
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11473
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11477
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11493
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11495    counter-increment: lst-ctn-kix_lbkxggsujkvy-6
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11497
11498  ol.lst-kix_hy7q99iznadc-4.start {
11499    counter-reset: lst-ctn-kix_hy7q99iznadc-4 0
11500  }
11501
11502  ol.lst-kix_b22uvd2azowp-4.start {
11503    counter-reset: lst-ctn-kix_b22uvd2azowp-4 0
11504  }
11505
11506  .lst-kix_qtp2for02r8j-0>li:before {
11507    content: "●  "
11508  }
11509
11510  ol.lst-kix_u7hqbr2olha6-3.start {
11511    counter-reset: lst-ctn-kix_u7hqbr2olha6-3 0
11512  }
11513
11514  ol.lst-kix_b22uvd2azowp-5.start {
11515    counter-reset: lst-ctn-kix_b22uvd2azowp-5 0
11516  }
11517
11518  .lst-kix_4v5f1jggpbe5-8>li {
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11520  }
11521
11522  .lst-kix_5svwa0ccdd9s-3>li {
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11524  }
11525
11526  .lst-kix_571s5dvrwc6m-3>li:before {
11527    content: "●  "
11528  }
11529
11530  .lst-kix_vgnzyq2eu8c6-5>li:before {
11531    content: ""counter(lst-ctn-kix_vgnzyq2eu8c6-5, lower-roman) ". "
11532  }
11533
11534  .lst-kix_anc6apxm2toc-8>li:before {
11535    content: "■  "
11536  }
11537
11538  .lst-kix_t2smkz8bvgb2-5>li:before {
11539    content: "■  "
11540  }
11541
11542  .lst-kix_h9h6a4rh1gdn-3>li {
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11544  }
11545
11546  .lst-kix_5ttlchkjwi2m-4>li:before {
11547    content: ""counter(lst-ctn-kix_5ttlchkjwi2m-4, lower-latin) ". "
11548  }
11549
11550  .lst-kix_yywi7t5w7kas-2>li:before {
11551    content: "■  "
11552  }
11553
11554  .lst-kix_op1aqp67ffp9-4>li:before {
11555    content: ""counter(lst-ctn-kix_op1aqp67ffp9-4, lower-latin) ". "
11556  }
11557
11558  .lst-kix_upbybt4j9vng-1>li:before {
11559    content: ""counter(lst-ctn-kix_upbybt4j9vng-1, lower-latin) ". "
11560  }
11561
11562  .lst-kix_l0xs0goj48dq-3>
11562li:before {
11563    content: "●  "
11564  }
11565
11566  .lst-kix_g9loi34ccti1-6>li:before {
11567    content: ""counter(lst-ctn-kix_g9loi34ccti1-6, decimal) ". "
11568  }
11569
11570  .lst-kix_op1aqp67ffp9-1>li:before {
11571    content: ""counter(lst-ctn-kix_op1aqp67ffp9-1, lower-latin) ". "
11572  }
11573
11574  .lst-kix_u7hqbr2olha6-1>li {
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11576  }
11577
11578  ol.lst-kix_u7hqbr2olha6-2.start {
11579    counter-reset: lst-ctn-kix_u7hqbr2olha6-2 0
11580  }
11581
11582  .lst-kix_g9loi34ccti1-3>li:before {
11583    content: ""counter(lst-ctn-kix_g9loi34ccti1-3, decimal) ". "
11584  }
11585
11586  .lst-kix_uyl10oi50gdh-4>li:before {
11587    content: ""counter(lst-ctn-kix_uyl10oi50gdh-4, lower-latin) ". "
11588  }
11589
11590  .lst-kix_4iv1aedi5h4w-1>li:before {
11591    content: "○  "
11592  }
11593
11594  .lst-kix_9gj2risgrxbz-2>li:before {
11595    content: "■  "
11596  }
11597
11598  ol.lst-kix_71m7y2cvysq0-0.start {
11599    counter-reset: lst-ctn-kix_71m7y2cvysq0-0 0
11600  }
11601
11602  .lst-kix_hjodcpzo1gv-1>li:before {
11603    content: ""counter(lst-ctn-kix_hjodcpzo1gv-1, lower-latin) ". "
11604  }
11605
11606  ol.lst-kix_b22uvd2azowp-3.start {
11607    counter-reset: lst-ctn-kix_b22uvd2azowp-3 0
11608  }
11609
11610  .lst-kix_zdub0tcpciis-8>li:before {
11611    content: ""counter(lst-ctn-kix_zdub0tcpciis-8, lower-roman) ". "
11612  }
11613
11614  ol.lst-kix_noixtpkhicu-5.start {
11615    counter-reset: lst-ctn-kix_noixtpkhicu-5 0
11616  }
11617
11618  .lst-kix_jg6ra9i0tpxi-6>li:before {
11619    content: ""counter(lst-ctn-kix_jg6ra9i0tpxi-6, decimal) ". "
11620  }
11621
11622  .lst-kix_zbaiwx14bzsa-8>li:before {
11623    content: "■  "
11624  }
11625
11626  .lst-kix_i4kbmii7v2u5-3>li {
11627    counter-increment: lst-ctn-kix_i4kbmii7v2u5-3
11628  }
11629
11630  .lst-kix_fg05l4pyrrlg-7>li {
11631    counter-increment: lst-ctn-kix_fg05l4pyrrlg-7
11632  }
11633
11634  ol.lst-kix_b22uvd2azowp-0.start {
11635    counter-reset: lst-ctn-kix_b22uvd2azowp-0 0
11636  }
11637
11638  .lst-kix_5zwxpkllz4a4-2>li:before {
11639    content: "■  "
11640  }
11641
11642  ol.lst-kix_u7hqbr2olha6-4.start {
11643    counter-reset: lst-ctn-kix_u7hqbr2olha6-4 0
11644  }
11645
11646  ol.lst-kix_yqxmwu2qe4f5-4.start {
11647    counter-reset: lst-ctn-kix_yqxmwu2qe4f5-4 0
11648  }
11649
11650  .lst-kix_p2v7in6p50z9-0>li:before {
11651    content: ""counter(lst-ctn-kix_p2v7in6p50z9-0, decimal) ". "
11652  }
11653
11654  .lst-kix_rinnepadptik-4>li {
11655    counter-increment: lst-ctn-kix_rinnepadptik-4
11656  }
11657
11658  ol.lst-kix_u7hqbr2olha6-7.start {
11659    counter-reset: lst-ctn-kix_u7hqbr2olha6-7 0
11660  }
11661
11662  .lst-kix_pdx9aq6bx3we-3>li:before {
11663    content: ""counter(lst-ctn-kix_pdx9aq6bx3we-3, decimal) ". "
11664  }
11665
11666  .lst-kix_pk97dfqrpb7m-0>li {
11667    counter-increment: lst-ctn-kix_pk97dfqrpb7m-0
11668  }
11669
11670  .lst-kix_ja2fu3kkmjot-2>li:before {
11671    content: ""counter(lst-ctn-kix_ja2fu3kkmjot-2, lower-roman) ". "
11672  }
11673
11674  ol.lst-kix_hy7q99iznadc-7.start {
11675    counter-reset: lst-ctn-kix_hy7q99iznadc-7 0
11676  }
11677
11678  .lst-kix_7c0nqnqmymjn-3>li:before {
11679    content: "-  "
11680  }
11681
11682  .lst-kix_ss5ljp98o3oi-4>li:before {
11683    content: ""counter(lst-ctn-kix_ss5ljp98o3oi-4, lower-latin) ". "
11684  }
11685
11686  .lst-kix_c69me314nk6r-2>li {
11687    counter-increment: lst-ctn-kix_c69me314nk6r-2
11688  }
11689
11690  ol.lst-kix_hy7q99iznadc-8.start {
11691    counter-reset: lst-ctn-kix_hy7q99iznadc-8 0
11692  }
11693
11694  ol.lst-kix_noixtpkhicu-6.start {
11695    counter-reset: lst-ctn-kix_noixtpkhicu-6 0
11696  }
11697
11698  .lst-kix_x6crmnr1rctw-0>li {
11699    counter-increment: lst-ctn-kix_x6crmnr1rctw-0
11700  }
11701
11702  .lst-kix_wvynemq8noap-0>li:before {
11703    content: ""counter(lst-ctn-kix_wvynemq8noap-0, decimal) ". "
11704  }
11705
11706  .lst-kix_jyqchcu61auh-4>li:before {
11707    content: ""counter(lst-ctn-kix_jyqchcu61auh-4, lower-latin) ". "
11708  }
11709
11710  .lst-kix_6hm2e5tzmmi8-0>li {
11711    counter-increment: lst-ctn-kix_6hm2e5tzmmi8-0
11712  }
11713
11714  .lst-kix_kz1xh0fb0bu6-2>li:before {
11715    content: "■  "
11716  }
11717
11718  ol.lst-kix_yqxmwu2qe4f5-5.start {
11719    counter-reset: lst-ctn-kix_yqxmwu2qe4f5-5 0
11720  }
11721
11722  .lst-kix_vgnzyq2eu8c6-6>li {
11723    counter-increment: lst-ctn-kix_vgnzyq2eu8c6-6
11724  }
11725
11726  .lst-kix_xv1pdu365xf9-1>li:before {
11727    content: "○  "
11728  }
11729
11730  .lst-kix_hy7q99iznadc-1>li:before {
11731    content: ""counter(lst-ctn-kix_hy7q99iznadc-1, lower-latin) ". "
11732  }
11733
11734  .lst-kix_42vq4uyvy4hi-8>li:before {
11735    content: ""counter(lst-ctn-kix_42vq4uyvy4hi-8, lower-roman) ". "
11736  }
11737
11738  .lst-kix_m0pi9j1llatt-7>li {
11739    counter-increment: lst-ctn-kix_m0pi9j1llatt-7
11740  }
11741
11742  .lst-kix_4uu96ne38ad6-0>li:before {
11743    content: ""counter(lst-ctn-kix_4uu96ne38ad6-0, decimal) ". "
11744  }
11745
11746  ol.lst-kix_4v5f1jggpbe5-8.start {
11747    counter-reset: lst-ctn-kix_4v5f1jggpbe5-8 0
11748  }
11749
11750  .lst-kix_q5vuyidi085b-3>li:before {
11751    content: "●  "
11752  }
11753
11754  .lst-kix_j37emd332w9v-3>li:before {
11755    content: ""counter(lst-ctn-kix_j37emd332w9v-3, decimal) ". "
11756  }
11757
11758  ol.lst-kix_385vbjfsbg0j-0.start {
11759    counter-reset: lst-ctn-kix_385vbjfsbg0j-0 0
11760  }
11761
11762  ol.lst-kix_m0pi9j1llatt-4.start {
11763    counter-reset: lst-ctn-kix_m0pi9j1llatt-4 0
11764  }
11765
11766  .lst-kix_ok8f0e8jo9ao-2>li:before {
11767    content: "■  "
11768  }
11769
11770  .lst-kix_q5vuyidi085b-5>li:before {
11771    content: "■  "
11772  }
11773
11774  .lst-kix_pdx9aq6bx3we-3>li {
11775    counter-increment: lst-ctn-kix_pdx9aq6bx3we-3
11776  }
11777
11778  .lst-kix_sq1mrmbpxwta-7>li {
11779    counter-increment: lst-ctn-kix_sq1mrmbpxwta-7
11780  }
11781
11782  .lst-kix_1ma56klcq62q-5>li:before {
11783    content: ""counter(lst-ctn-kix_1ma56klcq62q-5, lower-roman) ". "
11784  }
11785
11786  ol.lst-kix_uzd0wj8sqzdy-5.start {
11787    counter-reset: lst-ctn-kix_uzd0wj8sqzdy-5 0
11788  }
11789
11790  ol.lst-kix_42vq4uyvy4hi-6.start {
11791    counter-reset: lst-ctn-kix_42vq4uyvy4hi-6 0
11792  }
11793
11794  ol.lst-kix_71m7y2cvysq0-4.start {
11795    counter-reset: lst-ctn-kix_71m7y2cvysq0-4 0
11796  }
11797
11798  .lst-kix_uzd0wj8sqzdy-5>li:before {
11799    content: ""counter(lst-ctn-kix_uzd0wj8sqzdy-5, lower-roman) ". "
11800  }
11801
11802  ol.lst-kix_h9h6a4rh1gdn-6.start {
11803    counter-reset: lst-ctn-kix_h9h6a4rh1gdn-6 0
11804  }
11805
11806  .lst-kix_1ma56klcq62q-3>li:before {
11807    content: ""counter(lst-ctn-kix_1ma56klcq62q-3, decimal) ". "
11808  }
11809
11810  .lst-kix_z7xdknh39u1h-2>li {
11811    counter-increment: lst-ctn-kix_z7xdknh39u1h-2
11812  }
11813
11814  .lst-kix_yp19xsz9kfvf-5>li:before {
11815    content: "■  "
11816  }
11817
11818  .lst-kix_uzd0wj8sqzdy-7>li:before {
11819    content: ""counter(lst-ctn-kix_uzd0wj8sqzdy-7, lower-latin) ". "
11820  }
11821
11822  ol.lst-kix_yozg26yu47wn-2 {
11823    list-style-type: none
11824  }
11825
11826  ol.lst-kix_yozg26yu47wn-3 {
11827    list-style-type: none
11828  }
11829
11830  ol.lst-kix_yozg26yu47wn-4 {
11831    list-style-type: none
11832  }
11833
11834  ol.lst-kix_yozg26yu47wn-5 {
11835    list-style-type: none
11836  }
11837
11838  ol.lst-kix_hhv7hs1tzwa3-5.start {
11839    counter-reset: lst-ctn-kix_hhv7hs1tzwa3-5 0
11840  }
11841
11842  ol.lst-kix_yozg26yu47wn-6 {
11843    list-style-type: none
11844  }
11845
11846  ol.lst-kix_yozg26yu47wn-7 {
11847    list-style-type: none
11848  }
11849
11850  ol.lst-kix_fb2rugqy9f82-1.start {
11851    counter-reset: lst-ctn-kix_fb2rugqy9f82-1 0
11852  }
11853
11854  ol.lst-kix_yozg26yu47wn-8 {
11855    list-style-type: none
11856  }
11857
11858  .lst-kix_q4lc5o20lixo-0>li:before {
11859    content: "●  "
11860  }
11861
11862  ol.lst-kix_yozg26yu47wn-0 {
11863    list-style-type: none
11864  }
11865
11866  .lst-kix_xf5zb3gcanjp-2>li:before {
11867    content: ""counter(lst-ctn-kix_xf5zb3gcanjp-2, lower-roman) ". "
11868  }
11869
11870  ol.lst-kix_yozg26yu47wn-1 {
11871    list-style-type: none
11872  }
11873
11874  ol.lst-kix_xofh9trtihq4-7.start {
11875    counter-reset: lst-ctn-kix_xofh9trtihq4-7 0
11876  }
11877
11878  .lst-kix_u78xwmlh6opl-8>li:before {
11879    content: "■  "
11880  }
11881
11882  .lst-kix_xf5zb3gcanjp-4>li:before {
11883    content: ""counter(lst-ctn-kix_xf5zb3gcanjp-4, lower-latin) ". "
11884  }
11885
11886  .lst-kix_xf5zb3gcanjp-8>li:before {
11887    content: ""counter(lst-ctn-kix_xf5zb3gcanjp-8, lower-roman) ". "
11888  }
11889
11890  ol.lst-kix_j37emd332w9v-1.start {
11891    counter-reset: lst-ctn-kix_j37emd332w9v-1 0
11892  }
11893
11894  .lst-kix_prv07yriqauf-3>li:before {
11895    content: ""counter(lst-ctn-kix_prv07yriqauf-3, decimal) ". "
11896  }
11897
11898  ol.lst-kix_lbkxggsujkvy-2.start {
11899    counter-reset: lst-ctn-kix_lbkxggsujkvy-2 0
11900  }
11901
11902  .lst-kix_xf5zb3gcanjp-0>li {
11903    counter-increment: lst-ctn-kix_xf5zb3gcanjp-0
11904  }
11905
11906  .lst-kix_h9h6a4rh1gdn-6>li {
11907    counter-increment: lst-ctn-kix_h9h6a4rh1gdn-6
11908  }
11909
11910  ol.lst-kix_6hm2e5tzmmi8-3.start {
11911    counter-reset: lst-ctn-kix_6hm2e5tzmmi8-3 0
11912  }
11913
11914  .lst-kix_q4lc5o20lixo-6>li:before {
11915    content: "●  "
11916  }
11917
11918  .lst-kix_c69me314nk6r-4>li:before {
11919    content: ""counter(lst-ctn-kix_c69me314nk6r-4, lower-latin) ". "
11920  }
11921
11922  .lst-kix_ok8f0e8jo9ao-8>li:before {
11923    content: "■  "
11924  }
11925
11926  ol.lst-kix_pk97dfqrpb7m-1.start {
11927    counter-reset: lst-ctn-kix_pk97dfqrpb7m-1 0
11928  }
11929
11930  ol.lst-kix_yozg26yu47wn-2.start {
11931    counter-reset: lst-ctn-kix_yozg26yu47wn-2 0
11932  }
11933
11934  ol.lst-kix_jyqchcu61auh-4.start {
11935    counter-reset: lst-ctn-kix_jyqchcu61auh-4 0
11936  }
11937
11938  .lst-kix_u78xwmlh6opl-2>li:before {
11939    content: "■  "
11940  }
11941
11942  ol.lst-kix_yqxmwu2qe4f5-1.start {
11943    counter-reset: lst-ctn-kix_yqxmwu2qe4f5-1 0
11944  }
11945
11946  ol.lst-kix_rack5ivym2uw-5.start {
11947    counter-reset: lst-ctn-kix_rack5ivym2uw-5 0
11948  }
11949
11950  .lst-kix_f8p4itvvgbu7-6>li {
11951    counter-increment: lst-ctn-kix_f8p4itvvgbu7-6
11952  }
11953
11954  .lst-kix_gbm21569mhs3-8>li:before {
11955    content: "■  "
11956  }
11957
11958  .lst-kix_c69me314nk6r-5>li {
11959    counter-increment: lst-ctn-kix_c69me314nk6r-5
11960  }
11961
11962  .lst-kix_4uu96ne38ad6-2>li {
11963    counter-increment: lst-ctn-kix_4uu96ne38ad6-2
11964  }
11965
11966  .lst-kix_pdx9aq6bx3we-0>li:before {
11967    content: ""counter(lst-ctn-kix_pdx9aq6bx3we-0, decimal) ". "
11968  }
11969
11970  .lst-kix_gbm21569mhs3-4>li:before {
11971    content: "○  "
11972  }
11973
11974  .lst-kix_4t51vvbsrxok-4>li:before {
11975    content: "○  "
11976  }
11977
11978  .lst-kix_4t51vvbsrxok-6>li:before {
11979    content: "●  "
11980  }
11981
11982  .lst-kix_mutcrk3bayi0-0>li:before {
11983    content: "●  "
11984  }
11985
11986  .lst-kix_4v5f1jggpbe5-4>li {
11987    counter-increment: lst-ctn-kix_4v5f1jggpbe5-4
11988  }
11989
11990  .lst-kix_pdx9aq6bx3we-8>li:before {
11991    content: ""counter(lst-ctn-kix_pdx9aq6bx3we-8, lower-roman) ". "
11992  }
11993
11994  .lst-kix_felcjf3k7fe6-4>li {
11995    counter-increment: lst-ctn-kix_felcjf3k7fe6-4
11996  }
11997
11998  .lst-kix_oovh1eqkb89z-4>li {
11999    counter-increment: lst-ctn-kix_oovh1eqkb89z-4
12000  }
12001
12002  .lst-kix_pdx9aq6bx3we-2>li:before {
12003    content: ""counter(lst-ctn-kix_pdx9aq6bx3we-2, lower-roman) ". "
12004  }
12005
12006  .lst-kix_ey5qphywc3q1-5>li {
12007    counter-increment: lst-ctn-kix_ey5qphywc3q1-5
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12009
12010  .lst-kix_t69w2ebduk2f-3>li:before {
12011    content: "●  "
12012  }
12013
12014  .lst-kix_385vbjfsbg0j-1>li {
12015    counter-increment: lst-ctn-kix_385vbjfsbg0j-1
12016  }
12017
12018  ol.lst-kix_ja2fu3kkmjot-7.start {
12019    counter-reset: lst-ctn-kix_ja2fu3kkmjot-7 0
12020  }
12021
12022  .lst-kix_xofh9trtihq4-4>li {
12023    counter-increment: lst-ctn-kix_xofh9trtihq4-4
12024  }
12025
12026  .lst-kix_hjodcpzo1gv-4>li {
12027    counter-increment: lst-ctn-kix_hjodcpzo1gv-4
12028  }
12029
12030  .lst-kix_42vq4uyvy4hi-3>li {
12031    counter-increment: lst-ctn-kix_42vq4uyvy4hi-3
12032  }
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12722  ul.lst-kix_ok8f0e8jo9ao-4 {
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12726  ol.lst-kix_oovh1eqkb89z-1 {
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12738  ol.lst-kix_oovh1eqkb89z-0 {
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12742  ul.lst-kix_ok8f0e8jo9ao-6 {
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12810  ol.lst-kix_op1aqp67ffp9-5 {
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12814  ol.lst-kix_op1aqp67ffp9-8 {
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12830  .lst-kix_rack5ivym2uw-7>li:before {
12831    content: ""counter(lst-ctn-kix_rack5ivym2uw-7, lower-latin) ". "
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12833
12834  .lst-kix_m0pi9j1llatt-0>li:before {
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12837
12838  .lst-kix_6ioo2y6mzy2q-2>li:before {
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12866  ul.lst-kix_7qvy9vcgq8k1-0 {
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12870  ul.lst-kix_7qvy9vcgq8k1-1 {
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12926  ol.lst-kix_cedbd820up2x-4.start {
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12934  .lst-kix_71m7y2cvysq0-1>li:before {
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13029
13030  .lst-kix_7wfhnk2rzhpp-2>li:before {
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15450<h3 id="h.b8zp8szdc3t"><span style="font-weight:700">Please note that as of April 2023, this website is no longer actively being updated.<a class="anchor-point" id="please-note-that-as-of-april-2023-this-website-is-no-longer-actively-being-updated-b8zp8szdc3t"><span style="font-weight:700"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></span></h3>
15451<p><span style="font-style:italic">
15451Literature Review (Post-COVID Patient Care): </span><span style="font-style:italic;"><a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA?filter_Topic=Post-COVID%20Patient%20Care" rel="noopener noreferrer" target="_blank">Gallery View</a></span><span style="font-style:italic">, </span><span style="font-style:italic;"><a href="https://airtable.com/shrpTeICVWxrPb4nn/tbl2bwt3ywyTqJUlA?filter_Topic=Post-COVID%20Patient%20Care" rel="noopener noreferrer" target="_blank">Grid View</a></span></p>
15452<h2 id="h.rygkc3bz6et">Post-Acute COVID Syndrome (PACS)<a class="anchor-point" id="post-acute-covid-syndrome-pacs-rygkc3bz6et"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15453<p><span style="font-style:italic">Updated Date: May 24, 2021</span></p>
15454<h3 id="h.f2bwlocmt0r5">Course of Recovery<a class="anchor-point" id="course-of-recovery-f2bwlocmt0r5"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15455<p>Data on COVID-19 recovery are still emerging. However, it is clear that the course of recovery is highly variable among patients, may be prolonged over months, and is dependent on severity and particular manifestations of the initial illness. Anecdotal evidence suggests that recovery can be highly dynamic, with periods of improvement followed by periods of apparent acute worsening. Generally, recovery is thought to occur within about 2 weeks for mild infections and 2-3 months in severe infections (<a href="https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---24-february-2020" rel="noopener noreferrer" target="_blank">WHO</a>). </p>
15456<p></p>
15457<p>Long term symptoms after COVID are often called "Long-COVID" in the popular media, but generally called post-acute COVID-19 syndrome (PACS), chronic COVID-19, post-COVID syndrome (PCS), or post-acute sequelae of SARS-CoV-2 infection (PASC) by the medical community. Various definitions for each of these exist, though increasingly they <span style="font-weight:700;font-style:italic">refer to symptoms occurring &gt;4 weeks after COVID infection, without active viral activity or reinfection. </span></p>
15458<p></p>
15459<p>A recent Nature summary (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/reccc2Y88gzJyCWGV" rel="noopener noreferrer" target="_blank">Nalbandian et al</a>) proposes two separate categories of PACS quoted here:</p>
15460<ol class="lst-kix_6ioo2y6mzy2q-0 start level-0" start="1">
15461  <li><span style="font-style:italic">Subacute or ongoing symptomatic COVID-19, which includes symptoms and abnormalities present from 4–12 weeks beyond acute COVID-19</span></li>
15462  <li><span style="font-style:italic">Chronic or post-COVID-19 syndrome, which includes symptoms and abnormalities persisting or present beyond 12 weeks of the onset of acute COVID-19 and n
15462ot attributable to alternative diagnoses</span></li>
15463</ol>
15464<h3 id="h.z2fjryilm7ld">Prevalence of PACS<a class="anchor-point" id="prevalence-of-pacs-z2fjryilm7ld"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15465<p>In one study of 4,182 cases, 13.3% reported symptoms lasting ≥28 days, 4.5% for ≥8 weeks, and 2.3% for ≥12 weeks (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recZugyYT6Qf1QvKy" rel="noopener noreferrer" target="_blank">Sudre et al</a>). Amongst patients with prior hospitalization these are much higher: Patients were seen a mean of 60 days days after onset of symptoms. Only 12.6% of patients reported being asymptomatic, with particularly high rates of ongoing fatigue (53.1%), dyspnea (43.4%), joint pain (27.3%), and chest pain (21.7%) (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recsTzckhoPojIWWx" rel="noopener noreferrer" target="_blank">Carfi et al</a>). PACS is more common in people displaying a wider array of initial symptoms (&gt;5 symptoms at time of diagnosis) (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recZugyYT6Qf1QvKy" rel="noopener noreferrer" target="_blank">Sudre et al</a>). It also appears to be more common in breakthrough cases (19% experience symptoms &gt;6wks) <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2109072" rel="noopener noreferrer" target="_blank">(Bergwerk et al)</a>. </p>
15466<p></p>
15467<p><span style="font-weight:700">Demographics:</span></p>
15468<p>Longer term effects have been seen in persons of all demographic groups, though appear to be more common in women (14.9%) compared with men (9.5%), and older populations (ranging from 9.9% in 18–49 year olds to 21.9% in ≥70 year olds) (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recZugyYT6Qf1QvKy" rel="noopener noreferrer" target="_blank">Sudre et al</a>).</p>
15469<p></p>
15470<p><span style="font-weight:700">Tool</span>: <a href="https://www.nature.com/articles/s41591-021-01283-z/tables/1" rel="noopener noreferrer" target="_blank">Table of Reported Prevalence of PACS </a>(Nature Article, as of March 2021) </p>
15471<h3 id="h.8f2uijkwdqo3">Symptom Patterns<a class="anchor-point" id="symptom-patterns-8f2uijkwdqo3"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15472<p>Common reported symptoms are fatigue and dyspnea, joint pain, and chest pain (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recsTzckhoPojIWWx" rel="noopener noreferrer" target="_blank">Carfi et al</a>) In one survey of over 5000 patients with symptoms lasting &gt;21 days, the most common symptoms were fatigue (79.0%), headache (55.3%), shortness of breath (55.3%), difficulty concentrating (53.6%), cough (49.0%), changed sense of taste (44.9%), diarrhea (43.9%), and muscle or body aches (43.5%). The timing of symptom onset varied and was best described as happening in waves. (<a href="https://www.medrxiv.org/content/10.1101/2021.03.22.21254026v2" rel="noopener noreferrer" target="_blank">Lambert et al</a>)</p>
15473<p></p>
15474<p>One study found two different patterns of symptomatology (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recZugyYT6Qf1QvKy" rel="noopener noreferrer" target="_blank">Sudre et al</a>):</p>
15475<ol class="lst-kix_yqxmwu2qe4f5-0 start level-0" start="1">
15476  <li>Exclusively fatigue, headache and upper respiratory complaints</li>
15477  <li>Multisystem complaints (including fever and gastroenterological symptoms)</li>
15478</ol>
15479<h3 id="h.hbierzjv3014">Pathophysiology<a class="anchor-point" id="pathophysiology-hbierzjv3014"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15480<p>The causes of post-covid syndrome remain unknown at this time and are an area of active research. They include virus-specific pathophysiologic changes, immunologic aberrations and inflammatory damage and expected post-critical illness consequences. (Nalbandian et al) </p>
15481<p></p>
15482<ol class="lst-kix_hy7q99iznadc-0 start level-0" start="1">
15483  <li><span style="font-weight:700">Virus-specific pathophysiologic changes. </span>The virus is known to infect and harm multiple organs, as described 
15483in each subsection here. Further, the <a href="https://covidprotocols.org/en/chapters/specialty-care/#thrombosis-ejke6mrvikhg">endothelial damage and pro-coagulability </a>seen in COVID may cause microangiopathic changes that cause longer-term damage (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec47lnHAIj338za0" rel="noopener noreferrer" target="_blank">Lerner et al</a>). </li>
15484  <li><span style="font-weight:700">Immune and Inflammatory changes. </span>Immune responses may have a role in the etiology of persistent symptoms. One analysis indicated that B-Cell responses may be similar to those described in autoimmune processes (activation of extrafollicular pathways) (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recx04hH6FQnEzuCX" rel="noopener noreferrer" target="_blank">Woodruf et al</a>). T cell dysregulation may also be involved, given their role in acute disease. One study showed that coordinated CD4+ and CD8+ T-cell and antibody responses were associated with milder acute disease (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recBLBAMYmAS3PCkE" rel="noopener noreferrer" target="_blank">Moderbacher et al</a>). The relationship between antibody titers and viral load and post-COVID syndrome is unknown. In one study there was no statistically significant difference between initial viral titres or serial antibody levels between those who did and did not develop long term symptoms (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recvDGQzsoWQAM7mZ" rel="noopener noreferrer" target="_blank">Pereira et al</a>).</li>
15485  <li><span style="font-weight:700">Expected Post-Critical Illness. </span><a href="https://covidprotocols.org/en/chapters/post-covid-care/#post-icu-syndrome-f42ysl6mf4r1">Post ICU syndrome </a>is a constellation of symptoms and sequelae that is common for many people who have been critically ill.</li>
15486</ol>
15487<h2 id="h.6jcumwn5jvke">Outpatient Workup<a class="anchor-point" id="outpatient-workup-6jcumwn5jvke"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15488<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15489<h3 id="h.967bvvjlws">Post-COVID Clinic Visits<a class="anchor-point" id="post-covid-clinic-visits-967bvvjlws"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15490<p>In some locations there are dedicated post-COVID care clinics specializing in care for PACS. However, most patients are still seen by primary care clinicians as well as an array of subspecialists such as pulmonologists, cardiologists, neurologists, and psychiatrists. Generally subspecialty care is not needed, except in patients who have known complications. </p>
15491<p></p>
15492<ol class="lst-kix_c69me314nk6r-0 start level-0" start="1">
15493  <li><span style="font-weight:700">Frequency of Visits: </span>Acute phase followup is discussed <a href="https://covidprotocols.org/en/chapters/home-and-outpatient-management/#follow-up-visit-schedule-3n9yxykiwy2r">here</a>. Visit frequency depends on many things, including severity of patient symptoms and initial disease, but generally for priorly hospitalized patients out of the acute phase and for those with ongoing symptoms we recommend a virtual check-in at<span style="font-weight:700"> 3 days</span> after discharge, and again at <span style="font-weight:700">4-6 weeks</span>. They should be seen in person at <span style="font-weight:700">12 weeks</span> where possible. (Nalbandian et al) </li>
15494  <li><span style="font-weight:700">Infection control:</span> Patients who are seen in a clinic should be cleared based on infection control practices at the institution before an appointment is made. Generally <a href="https://covidprotocols.org/en/chapters/infection-prevention-and-control/#releasing-patients-from-isolation-wl31srbzeqab">time-based clearance criteria</a> are acceptable, though those at risk for persistent infection or reinfection may need retesting. </li>
15495</ol>
15496<h3 id="h.65b4xw7f0sv5">Work-Up<a class="anchor-point" id="work-up-65b4xw7f0sv5"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15497<p>Clinical testing is not always needed. If performed, testing should target evaluation for non-COVID etiologies as well as serious sequelae of disease. Clinicians need to distinguish between non-life-threatening symptoms such as persistent dyspnea, fatigue, and neurocognitive issues and serious sequelae such as VTE and heart failure (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recBqoCIyeSJPKe7J" rel="noopener noreferrer" target="_blank">Greenhaigh et al</a>).</p>
15498<p></p>
15499<ol class="lst-kix_ss5ljp98o3oi-0 start level-0" start="1">
15500  <li><span style="font-weight:700">Screen for “red flag” symptoms: </span></li>
15501</ol>
15502<ol class="lst-kix_ss5ljp98o3oi-1 start level-1" start="1">
15503  <li>New or worsening dyspnea</li>
15504  <li>Unexplained chest pain</li>
15505  <li>New confusion</li>
15506  <li>Focal weakness</li>
15507  <li>New or worsening lower extremity edema</li>
15508</ol>
15509<ol class="lst-kix_ss5ljp98o3oi-0 level-0" start="2">
15510  <li><span style="font-weight:700">Screen for common neurocognitive symptoms:</span> </li>
15511</ol>
15512<ol class="lst-kix_ss5ljp98o3oi-1 start level-1" start="1">
15513  <li>Anxiety</li>
15514  <li>Depression</li>
15515  <li>PTSD</li>
15516  <li>Sleep disturbances</li>
15517  <li>Cognitive impairment</li>
15518</ol>
15519<ol class="lst-kix_ss5ljp98o3oi-0 level-0" start="3">
15520  <li><span style="font-weight:700">COVID Testing</span>: SARS-CoV-2 PCR is discouraged as it can be positive for months (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recvfIpIygHkfJyat" rel="noopener noreferrer" target="_blank">Katz</a>
15520). <a href="https://covidprotocols.org/en/chapters/covid-overview/#reinfection-and-durable-immunity-cqg6stdn1rou">Reinfection</a> is rare and generally there is not an indication for repeat testing. However if the patient has new<a href="https://covidprotocols.org/en/chapters/covid-overview/#symptoms-baul6ognghnh"> symptoms of COVID</a> or a concern for reinfection, it may be indicated in select cases. See here for <a href="https://covidprotocols.org/en/chapters/covid-testing/#testing-previously-infected-patients-daxyn5juz1xb">guidance on repeat testing</a>. Generally there is not an indication for serology, unless the initial diagnosis was not clear. </li>
15521  <li><span style="font-weight:700">Imaging and Pulmonary Testing.</span> See <a href="https://covidprotocols.org/en/chapters/post-covid-care/#radiographic-abnormalities-ye9weoy15eem">Radiographic Abnormalities</a> and <a href="https://covidprotocols.org/en/chapters/post-covid-care/#pulmonary-function-tests-z1e3k92fxgq7">Pulmonary Function Tests</a>. Adapted from the British Thoracic Society’s followup algorithms (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec6igXazvY4PcHvV" rel="noopener noreferrer" target="_blank">George et al</a>).</li>
15522</ol>
15523<ol class="lst-kix_ss5ljp98o3oi-1 start level-1" start="1">
15524  <li><span style="font-weight:700">Mild disease without known pneumonia</span>: Generally followup radiograph is not performed in patients with a mild course of disease, no prior positive imaging, and no worsening symptoms. </li>
15525  <li><span style="font-weight:700">Mild disease with persistent dyspnea, or history of mild to moderate pneumonia</span>: Obtain a Chest Xray at 12 weeks. </li>
15526</ol>
15527<ol class="lst-kix_ss5ljp98o3oi-2 start level-2" start="1">
15528  <li>If <span style="font-weight:700">normal</span> and symptoms are resolved, no further workup is needed. </li>
15529  <li>If persistently <span style="font-weight:700">abnormal</span> or <span style="font-weight:700">symptoms</span> persist, obtain full PFTs and consider CTPE for pulmonary embolism. </li>
15530</ol>
15531<ol class="lst-kix_ss5ljp98o3oi-3 start level-3" start="1">
15532  <li>If PFTs are normal and the patient is improving, repeat Chest Xray. </li>
15533  <li>If PFTs are abnormal or the patient is not improving, consider high resolution CT (HRCT). </li>
15534</ol>
15535<ol class="lst-kix_ss5ljp98o3oi-1 level-1" start="3">
15536  <li><span style="font-weight:700">Severe, or ICU- level disease</span>: Obtain a Chest Xray at 12 weeks. Consider full pulmonary function tests and CTPE as well on a case-by-case basis. </li>
15537</ol>
15538<ol class="lst-kix_ss5ljp98o3oi-2 start level-2" start="1">
15539  <li>If Xray is normal and symptoms are resolved, no further workup is needed. </li>
15540  <li>If abnormal, get PFTs and a high resolution CT. Consider Echocardiogram and CTPE as well. </li>
15541</ol>
15542<ol class="lst-kix_ss5ljp98o3oi-0 level-0" start="5">
15543  <li><span style="font-weight:700">Ambulatory saturations </span>including exercise pulse oximetry can be very helpful in determining of a patient has tachycardia on exertion (suggestive of <a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">POTS</a> or arrhythmia) or desaturations on exertion (suggestive of parenchymal or pulmonary vascular disease).</li>
15544</ol>
15545<ol class="lst-kix_ss5ljp98o3oi-1 start level-1" start="1">
15546  <li><span style="font-weight:700">6 minute walk tests</span> may help differentiate etiology of dyspnea in some patients </li>
15547</ol>
15548<ol class="lst-kix_ss5ljp98o3oi-0 level-0" start="6">
15549  <li><span style="font-weight:700">General labs</span> for patients with persistent symptoms &gt;4 weeks after infection, a complete blood count, chemistry panel, and liver function tests are recommended.</li>
15550</ol>
15551<ol class="lst-kix_ss5ljp98o3oi-1 start level-1" start="1">
15552  <li><span style="font-weight:700">Additional labs </span>will depend on symptoms, but could include cardiac enzymes and BNP for cardiac symptoms or prior cardiac concerns; D-dimer for concern for pulmonary embolism (although D-dimer may remain elevated up to four months following acute COVID-19 infection); thyroid function tests for fatigue symptoms CPK and ANA for joint or skin concerns. Routine coagulation markers are not needed. (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec9XlzB8WVbswe2f" rel="noopener noreferrer" target="_blank">Townsend et al.</a>)</li>
15553  <li><span style="font-weight:700">EKGs</span> are done on a case-by-case basis, and should be performed on patients with persistent cardiopulmonary symptoms. </li>
15554  <li><span style="font-weight:700">Echocardiograms</span> are not routine except if concerned for heart failure. Cardiac MRI is typically experimental and not indicated clinically except by specialists for select indications (typically prior myocarditis).</li>
15555</ol>
15556<ol class="lst-kix_ss5ljp98o3oi-0 level-0" start="7">
15557  <li><span style="font-weight:700">Other workup and treatment</span> will depend on the presenting symptoms. See below for: </li>
15558</ol>
15559<ol class="lst-kix_ss5ljp98o3oi-1 start level-1" start="1">
15560  <li>
15560<a href="https://covidprotocols.org/en/chapters/post-covid-care/#dyspnea-or-cough-pl2qtdojlviv">Dyspnea and cough</a></li>
15561  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#interstitial-lung-disease-gsit8cwj3igo">Interstitial lung disease</a> or organizing pneumonia</li>
15562  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#fever-qz4h6r9sxj9q">Fever</a> or <a href="https://covidprotocols.org/en/chapters/post-covid-care/#joint-pain-jx15b6fuan58">joint pain</a></li>
15563  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#anxiety-and-depression-5vtz8ypvr887">Anxiety and depression</a></li>
15564  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#fatigue-and-brain-fog-o5zyvqmfv6no">Fatigue and brain fog</a></li>
15565  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#prolonged-anosmia-and-ageusia-cgwdicgt2ot6">Anosmia and ageusia</a> (difficulty smelling and tasting)</li>
15566  <li>Lightheadedness, sweating, racing heart or other symptoms of <a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">dysautonomia or postural orthostatic tachycardic syndrome (POTS)</a></li>
15567  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#chest-tightness-and-discomfort-wd53c3s0rf76">Chest pain</a> or history of <a href="https://covidprotocols.org/en/chapters/post-covid-care/#cardiac-dysfunction-p1jfjbp8ef8u">cardiac complications/ myocarditis</a></li>
15568  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#delayed-thrombosis-i2adktaazwpp">Deep vein thrombosis</a></li>
15569  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#renal-concerns-lhhoyyv23om1">Kidney dysfunction</a></li>
15570  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#post-icu-syndrome-f42ysl6mf4r1">Post-ICU syndrome</a></li>
15571</ol>
15572<h3 id="h.isih4vy9683v">General Management<a class="anchor-point" id="general-management-isih4vy9683v"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15573<p><span style="font-weight:700"></span></p>
15574<ol class="lst-kix_f8p4itvvgbu7-0 start level-0" start="1">
15575  <li>Optimize comorbidities and health behaviors including sleep hygiene, smoking cessation, and decreased alcohol intake.</li>
15576  <li>If the patient has residual oxygen requirement, have them keep a daily <a href="https://covidprotocols.org/en/chapters/home-and-outpatient-management/#pulse-oximetry-rnlmvdp3jbzk">pulse oximetry</a> journal to monitor for recurrent COVID-19</li>
15577  <li>Encourage gradual increase in exercise (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recBqoCIyeSJPKe7J" rel="noopener noreferrer" target="_blank">Greenhaigh et al</a>). Generally patients should exercise as much as tolerated with Sp02 &gt;90%. If oximetry monitoring is not available, try using an oximeter in the office, and tell them to pay attention to symptoms. Transient desaturations are unlikely to have negative consequences, but persistent desaturation should be avoided.</li>
15578  <li>Please see all the specific subsections below (also linked just above) for specific management recommendations for common specific complaints, as well as indications for subspecialty referral.</li>
15579  <li>Consider early rehabilitation referral for the patient if it is available</li>
15580  <li>Educate patient on the <a href="https://covidprotocols.org/en/chapters/post-covid-care/#course-of-recovery-f2bwlocmt0r5">typical course of recovery</a>.</li>
15581  <li>Consider enrollment in patient studies if available and patient advocacy groups if desired.</li>
15582  <li>Make sure the patient still gets<a href="https://covidprotocols.org/en/chapters/post-covid-care/#vaccination-after-covid-infection-vj4wd4h6w9yn"> vaccinated for COVID.</a></li>
15583  <li>Generally we advise against extended thromboprophylaxis unless it would be otherwise indicated if the patient were hospitalized with an acute illness (see <a href="https://covidprotocols.org/en/chapters/post-covid-care/#delayed-thrombosis-i2adktaazwpp">delayed thrombosis </a>for risk calculators and a more extensive discussion), though this is an area of active research. </li>
15584</ol>
15585<h3 id="h.vj4wd4h6w9yn">Vaccination after COVID Infection<a class="anchor-point" id="vaccination-after-covid-infection-vj4wd4h6w9yn"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15586<p>Vaccination is recommended for patients who have had COVID infection. Vaccine-based immunity may provide immunity against a more conserved part of the virus (e.g. the receptor binding domain) than native immunity, and thus may be more effective. </p>
15587<ol class="lst-kix_sq1mrmbpxwta-0 start level-0" start="1">
15588  <li>Timing of vaccination for already infected patients is not determined, but many institutions recommend waiting 90 days after infection, especially if treated with monoclonal antibodies or convalescent plasma (as these may reduce the effectiveness of vaccines). </li>
15589  <li>Currently most institutions recommend giving both vaccinations for two-shot vaccines, though in the future this may change as there is some evidence that a single dose may provide adequate immunity (An NIH study showed that after a single dose of the Pfizer-BioNTech vaccine, people with prior infection had antibody levels similar to people receiving 2 doses. However we do not know how antibody levels correlate with immunity. (<a href="https://www.nih.gov/news-events/nih-research-matters/immune-response-vaccination-after-covid-19" rel="noopener noreferrer" target="_blank">NIH</a>)</li>
15590  <li>Warn patients that the injections may create more robust immune responses in them than they would in a never-infected patient, and thus they may experience more fevers and fatigue in the days following the injection</li>
15591</ol>
15592<p></p>
15593<p>Anecdotal reports in COVID <a href="https://www.survivorcorps.com/" rel="noopener noreferrer" target="_blank">survivor communities</a> that 30-40% of people may feel improved after COVID vaccination have not yet been empirically studied. </p>
15594<h2 id="h.bknygux3jwb3">Pulmonary Concerns<a class="anchor-point" id="pulmonary-concerns-bknygux3jwb3"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15595<h3 id="h.pl2qtdojlviv">Dyspnea or Cough<a class="anchor-point" id="dyspnea-or-cough-pl2qtdojlviv"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15596<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15597<p></p>
15598<p>Dyspnea is the most common persistent symptom beyond acute COVID-19, ranging from 42–66% prevalence at 60–100 d follow-up (Nalbandian et al). The need for supplemental oxygen due to persistent hypoxemia at 60 days was reported in 6.6 of patients in one US study (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recL1auPGCndeAWVs" rel="noopener noreferrer" target="_blank">Chopra et al</a>).</p>
15599<p><span style="font-weight:700"></span></p>
15600<p><span style="font-weight:700">Differential</span>: The differential for persistent dyspnea after COVID infection includes:</p>
15601<ol class="lst-kix_u7hqbr2olha6-0 start level-0" start="1">
15602  <li>Neuromuscular weakness associated with deconditioning, protein calorie malnutrition, or Post Intensive Care Syndrome including myopathy from corticosteroid or neuromuscular blockade </li>
15603  <li>Post-ARDS pulmonary fibrosis (see below on <a href="https://covidprotocols.org/en/chapter
15603s/post-covid-care/#pulmonary-function-tests-z1e3k92fxgq7">PFT</a> and <a href="https://covidprotocols.org/en/chapters/post-covid-care/#radiographic-abnormalities-ye9weoy15eem">imaging findings</a>)</li>
15604  <li>Pulmonary embolism. Pro-thrombotic effects of COVID infection and hospitalization may increase risk of pulmonary embolism. We do not yet know how long these effects last. </li>
15605  <li>Bacterial superinfection. As with other viral pneumonias, there is a theoretical increased risk of subsequent bacterial superinfection. About 3% of patients with COVID-19 who are admitted have a community acquired bacterial infection (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recuFYVxsE80qVHrB" rel="noopener noreferrer" target="_blank">Garcia-Vidal et al</a>). Patients previously admitted may be at risk for drug-resistance bacterial infections in the future. </li>
15606  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">Dysautonomia</a> or neurologically-caused dyspnea.</li>
15607  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#cardiac-dysfunction-p1jfjbp8ef8u">Cardiac dyspnea</a> including myocarditis and arrhythmias. </li>
15608</ol>
15609<p></p>
15610<p><span style="font-weight:700">Workup</span>: </p>
15611<ol class="lst-kix_xf5zb3gcanjp-0 start level-0" start="1">
15612  <li>In addition to a full <span style="font-weight:700">history</span> for cardiac and pulmonary symptoms, ascertain the patient’s <span style="font-weight:700">tolerance for exertion</span> and whether symptoms are <span style="font-weight:700">worsening</span>. Persistent or worsening symptoms should prompt workup for non-COVID causes. </li>
15613</ol>
15614<ol class="lst-kix_xf5zb3gcanjp-1 start level-1" start="1">
15615  <li>For fever, infectious workup should be performed (see <a href="https://covidprotocols.org/en/chapters/post-covid-care/#fever-qz4h6r9sxj9q">fever</a>)</li>
15616  <li>For signs of heart failure or tachyarrhythmia, see <a href="https://covidprotocols.org/en/chapters/post-covid-care/#cardiac-concerns-81b56iceb3ah">cardiac</a>.</li>
15617  <li>For tachycardia, pleuritic chest pain, or other <span style="font-weight:700">signs of PE </span>consider<span style="font-weight:700"> </span>EKG, D-Dimer, Echocardiogram, or contrast CT.</li>
15618  <li>If features of dysautonomia (orthostatic hypotension, rapid pulse fluctuations, temperature dysregulation, sweating changes, gastrointestinal concerns), workup and treat as <a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">below</a>.</li>
15619</ol>
15620<ol class="lst-kix_xf5zb3gcanjp-0 level-0" start="2">
15621  <li><span style="font-weight:700">Vitals</span> signs for patients that have dyspnea should include:</li>
15622</ol>
15623<ol class="lst-kix_xf5zb3gcanjp-1 start level-1" start="1">
15624  <li>Ambulatory saturations </li>
15625  <li>Orthostatic vitals signs (which could indicate dysautonomia)</li>
15626</ol>
15627<ol class="lst-kix_xf5zb3gcanjp-0 level-0" start="3">
15628  <li><span style="font-weight:700">Chest imaging </span>indications are described <a href="https://covidprotocols.org/en/chapters/post-covid-care/#radiographic-abnormalities-ye9weoy15eem">here</a>. Generally with persistent or worsening symptoms after 3 months imaging is merited. </li>
15629  <li><span style="font-weight:700">Pulmonary Function Tests</span> are indicated as described <a href="https://covidprotocols.org/en/chapters/post-covid-care/#pulmonary-function-tests-z1e3k92fxgq7">here</a>. Generally full PFTs should be considered at 3-6 months for persistent dyspnea. </li>
15630  <li><span style="font-weight:700">6 minute walk tests</span> may help differentiate etiology of COVID in some patients </li>
15631  <li>If despite this workup dyspnea remains unexplained, we recommend a gentle exercise routine as described below. For very complex or ill patients with multiple possible etiologies (e.g. cardiac, pulmonary, and/or dysautonomic), referral to pulmonary for consideration of cardiopulmonary exercise testing may be indicated to help differentiate between these causes, but generally these do not often elucidate a cause of ongoing dyspnea in otherwise well patients and should not be routine. </li>
15632</ol>
15633<p></p>
15634<p><span style="font-weight:700">Treatment:</span></p>
15635<ol class="lst-kix_szji4w8wo8g5-0 start level-0" start="1">
15636  <li>Treatment consists of treating the underlying etiology</li>
15637</ol>
15638<ol class="lst-kix_szji4w8wo8g5-1 start level-1" start="1">
15639  <li>Treatment of pulmonary embolism, secondary infection, <a href="https://covidprotocols.org/en/chapter
15639s/post-covid-care/#interstitial-lung-disease-gsit8cwj3igo">post-ARDS ILD</a>, etc are as they would be for any non-COVID patient</li>
15640  <li>Treatment of breathing concerns related to<span style="font-weight:700"> chest pain on deep inspiration</span> after COVID is covered here. </li>
15641  <li>If the patient has features of <span style="font-weight:700">dysautonomia</span>, see <a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">here</a>. </li>
15642</ol>
15643<ol class="lst-kix_szji4w8wo8g5-0 level-0" start="2">
15644  <li>If workup is normal and the patient had mild COVID we typically focus on physical therapy, breathing exercises, and reassurance. Many of these patients seem anecdotally to improve with time. </li>
15645</ol>
15646<ol class="lst-kix_szji4w8wo8g5-1 start level-1" start="1">
15647  <li>Some specialized breathing-related therapy programs exist, and more are starting to treat post-COVID symptoms. Some online programs are also available for this purpose, such as <a href="https://stasisperformance.com/" rel="noopener noreferrer" target="_blank">Stasis Performance</a>. More will no doubt become available as demand increases.</li>
15648  <li>Symptomatic treatment of dyspnea <a href="https://covidprotocols.org/en/chapters/treatments/#dyspnea-eks98xv429uh">is described here</a></li>
15649  <li>Symptomatic treatment of cough <a href="https://covidprotocols.org/en/chapters/treatments/#cough-7m4jbmg03ntl">is described here</a></li>
15650</ol>
15651<ol class="lst-kix_szji4w8wo8g5-0 level-0" start="3">
15652  <li>Unexplained persistent dyspnea may merit referral to pulmonary or dysautonomia treatment providers</li>
15653</ol>
15654<p></p>
15655<p><span style="font-weight:700;font-style:italic">Tool: </span><span style="font-style:italic;"><a href="https://doi.org/10.1164/ajrccm.166.1.at1102" rel="noopener noreferrer" target="_blank">Information on Six Minute Walk Tests from the American Thoracic Society</a></span></p>
15656<h3 id="h.z1e3k92fxgq7">Pulmonary Function Tests<a class="anchor-point" id="pulmonary-function-tests-z1e3k92fxgq7"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15657<p><span style="font-style:italic">Updated Date: April 19, 2021<br>Literature Review (Pulmonary Function Tests): </span><span style="font-style:italic;"><a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA?filter_Topic=Pulmonary%20Function%20Tests" rel="noopener noreferrer" target="_blank">Gallery View</a></span><span style="font-style:italic">, </span><span style="font-style:italic;"><a href="https://airtable.com/shrpTeICVWxrPb4nn/tbl2bwt3ywyTqJUlA?filter_Topic=Pulmonary%20Function%20Tests" rel="noopener noreferrer" target="_blank">Grid View</a></span></p>
15658<p></p>
15659<p><span style="font-weight:700">Testing options: </span></p>
15660<p>Generally full PFT (spirometry, lung volumes, and DLCO) are not indicated for all patients, but should be performed 3-6 months after infection if there are persistent pulmonary symptoms or persistent radiographic abnormalities after 12 weeks from infection. MIP/MEP in patients who have been ventilated or who have concern for steroid myopathy may help differentiate neuromuscular etiologies, especially in patients with restrictive disease. </p>
15661<p></p>
15662<p><span style="font-weight:700">PFT abnormalities: </span></p>
15663<p>Abnormalities in PFTs, specifically diffusion capacity (DLCO) and TLC, at time of hospital discharge appear to be common and correspond with severity of illness (<a href="https://airtable.com/tbl2bwt3ywyTqJUlA/viwUS7Rm3Irgb45pY/recqg2sFUJ08FBpcJ" rel="noopener noreferrer" target="_blank">Mo X et al</a>). It is unclear how long reductions in pulmonary function persist, though DLCO reductions remain common at 30 days after symptom onset (<a href="https://airtable.com/tbl2bwt3ywyTqJUlA/viwUS7Rm3Irgb45pY/recCP3oLqfaxJxJwi" rel="noopener noreferrer" target="_blank">Frija-Masson et al</a>). </p>
15664<p></p>
15665<ul class="lst-kix_qtp2for02r8j-0 start level-0">
15666  <li>In one study of 57 patients 30 days after hospitalization: “Six (10.5%), 5(8.7%), 25(43.8%) 7(12.3%
15666), and 30 (52.6%) patients had FVC, FEV1, FEV1/FVC ratio, TLC, and DLCO values less than 80% of predicted values, respectively… Compared with non-severe cases, severe patients showed higher incidence of DLCO impairment (75.6%vs42.5%, p = 0.019)” (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recbbS9uvDGcr78GV" rel="noopener noreferrer" target="_blank">Huang et al</a>)</li>
15667  <li>The median 6-min walking distance is low in approximately 1/4 of patients at 6 months. (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recbbS9uvDGcr78GV" rel="noopener noreferrer" target="_blank">Huang et al</a>)</li>
15668</ul>
15669<h3 id="h.ye9weoy15eem">Radiographic Abnormalities<a class="anchor-point" id="radiographic-abnormalities-ye9weoy15eem"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15670<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15671<p></p>
15672<p>Timing of radiographs is described in the general <a href="https://covidprotocols.org/en/chapters/post-covid-care/#work-up-65b4xw7f0sv5">workup</a> section above. </p>
15673<p></p>
15674<p>Persistent radiographic abnormalities from COVID pneumonia may be present. These are likely to improve gradually over several months, but some dysfunction may persist, particularly in patients with ARDS. In a small study of 55 patients 3 months after discharge (64%) had persistent symptoms and 39 (71%) had radiologic abnormalities (interstitial changes or fibrosis) (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recNCZSe5N5SvS8jl" rel="noopener noreferrer" target="_blank">Zhao et al</a>) In a study of 114 patients with severe COVID pneumonia, fibrotic-like changes were found in 35% of patients on 6 month CT scans. The remainder had either complete radiological resolution (38%) or residual ground-glass opacification or interstitial thickening (27%) (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recTI8fxf67MzPaEL" rel="noopener noreferrer" target="_blank">Han et al</a>). </p>
15675<h3 id="h.gsit8cwj3igo">Interstitial Lung Disease<a class="anchor-point" id="interstitial-lung-disease-gsit8cwj3igo"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15676<p>There are case reports of COVID causing organizing pneumonia and interstitial lung disease, some of which appears to be independent of ARDS or mechanical ventilation (see <a href="https://covidprotocols.org/en/chapters/post-covid-care/#radiographic-abnormalities-ye9weoy15eem">radiographic abnormalities</a> and <a href="https://covidprotocols.org/en/chapters/post-covid-care/#pulmonary-function-tests-z1e3k92fxgq7">pulmonary function tests </a>above). The pathophysiology is likely a viral invasion of epithelial and endothelial cells, as well as immunologic damage, that cause endothelial/epithelial breakdown similar to other forms of ARDS. In history studies and autopsy studies, diffuse alveolar damage in multiple stages is seen, as are myofibroblasts, mural fibrosis, and honeycombing (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recV5mjLaNEBshiku" rel="noopener noreferrer" target="_blank">Carsana et al</a>). Fibrosis may be provoked by cytokines such as IL-6 and TGF-β, which have been found in non-COVID studies to contribute to pulmonary fibrosis.</p>
15677<p></p>
15678<p>There is not yet any consensus about whether treating patients who appear to have an inflammatory ILD or organizing pneumonia with corticosteroids is beneficial. At present, we recommend that clinicians weigh the risks and benefits of protracted corticosteroid treatment for each individualized patient case. There is early evidence to suggest it may help in a subset of cases: One study reviewed 837 patients with ongoing symptoms six weeks after infection. 35 patients were found to have persistent interstitial lung changes, predominantly organizing pneumonia (as reviewed by multidisciplinary specialists). Of these, 30 were offered corticosteroid therapy, resulting in a mean relative increase in transfer factor (DLCO) of 31.6% and forced vital capacity of 9.6% with significant symptomatic and radiological improvement (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec7oBvBrZiS0SKMC" rel="noopener noreferrer" target="_blank">Myall et al</a>). </p>
15679<h2 id="h.wqdtw0vz4asv">Rheumatologic Concerns<a class="anchor-point" id="rheumatologic-concerns-wqdtw0vz4asv"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15680<h3 id="h.qz4h6r9sxj9q">Fever<a class="anchor-point" id="fever-qz4h6r9sxj9q"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15681<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15682<p></p>
15683<p>Persistent fevers can be seen in COVID infection, however fevers after 14 days (or new or severe fevers after improvement) should always prompt an infectious workup as these can be caused by secondary bacterial infections.
15683</p>
15684<ul class="lst-kix_q5vuyidi085b-0 start level-0">
15685  <li>Infectious workup should include (where available) a CBC with differential, LFT, UA, blood culture, procalcitonin, Chest Xray, and sputum culture.</li>
15686</ul>
15687<h3 id="h.jx15b6fuan58">Joint Pain<a class="anchor-point" id="joint-pain-jx15b6fuan58"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15688<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15689<p></p>
15690<p>While there are case reports of reactive arthritis (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/reciUHtoEOaRFHboL" rel="noopener noreferrer" target="_blank">Jali</a>, <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recBjCMAZE67b8vcb" rel="noopener noreferrer" target="_blank">Ono</a>) and rheumatoid arthritis (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/reclooz4WDyYzGGUr" rel="noopener noreferrer" target="_blank">Derksen</a>) triggered by COVID infection, frank arthritis (inflammation of the joints) is very rare after infection with COVID-19. However, persistent polyarthralgias (i.e. joints that are achy but not inflamed on exam or on imaging) are common, as is <a href="https://covidprotocols.org/en/chapters/post-covid-care/#fatigue-and-brain-fog-o5zyvqmfv6no">myalgic encephalitis/ chronic fatigue syndrome</a>. Clinicians should work up joint pain depending on the severity and chronicity, similar to other clinical contexts. </p>
15691<ol class="lst-kix_7wfhnk2rzhpp-0 start level-0" start="1">
15692  <li>Patients with signs of inflammation (swelling, erythema, effusion, etc) in one or more joints should be referred to a rheumatologist for work-up of alternate etiologies, such as septic arthritis, Lyme disease, gout, and rheumatoid arthritis. A joint aspiration can be helpful. If there is any suspicion for septic arthritis (e.g. sudden swelling and effusion, often with fever), joint aspiration should be performed emergently. </li>
15693  <li>Patients with symptoms of less than 3 months’ duration can be managed conservatively with NSAIDS (if not otherwise contraindicated).</li>
15694  <li>In patients with persistent joint pain after 3 months, or particularly debilitating joint pain or red flags such as visibly swollen joints, joint effusions, rashes, or daily fevers or drenching night sweats, we recommend workup with ESR, CRP, appropriate rheumatologic serologies (e.g. ANA, rheumatoid factor, CCP antibodies), a CBC with differential, complete metabolic panel, and urinalysis with sediment (to screen for protein or blood in urine). Patients should be referred to a rheumatologist for consultation.</li>
15695</ol>
15696<h2 id="h.az0llqo38w98">Neurologic and Neuropsychiatric Concerns<a class="anchor-point" id="neurologic-and-neuropsychiatric-concerns-az0llqo38w98"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15697<p><span style="font-style:italic">Updated Date: April 19, 2021<br>Literature Review (Post-COVID Neuropsychiatric Effects): </span><span style="font-style:italic;"><a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA?filter_Topic=Post-COVID%20Neuropsychiatric%20Effects" rel="noopener noreferrer" target="_blank">Gallery View</a></span><span style="font-style:italic">, </span><span style="font-style:italic;"><a href="https://airtable.com/shrpTeICVWxrPb4nn/tbl2bwt3ywyTqJUlA?filter_Topic=%20Post-COVID%20Neuropsychiatric%20Effects" rel="noopener noreferrer" target="_blank">Grid View</a></span></p>
15698<h3 id="h.fbzsdxoch8mt">Incidence<a class="anchor-point" id="incidence-fbzsdxoch8mt"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15699<p>Patients may have sequelae of direct neurologic effects of COVID infection, including encephalitis or stroke. Prolonged hospital
15699ization, particularly ICU admission, can lead to cognitive deficits (<a href="https://covidprotocols.org/en/chapters/post-covid-care/#post-icu-syndrome-f42ysl6mf4r1">see post-ICU syndrome</a>). In addition, prolonged illness can manifest different psychiatric and neurologic sequelae. In a study of over 200,000 patients, the estimated incidence of a neurological or psychiatric diagnosis in the 6 months following a COVID diagnosis was 33.62%, for 12.84% it was their first such diagnosis. These effects were more common in COVID-19 than in those who had influenza (hazard ratio [HR] 1.44, 1.78 for first diagnosis. (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recsuAzj5X7PID40s" rel="noopener noreferrer" target="_blank">Taquet et al</a>). The incidence of several neuropsychiatric complications are provided below. Please see <a href="https://covidprotocols.org/en/chapters/post-covid-care/#fatigue-and-brain-fog-o5zyvqmfv6no">‘Fatigue’</a> for discussion of chronic fatigue syndrome.</p>
15700<ul class="lst-kix_4t51vvbsrxok-0 start level-0">
15701  <li>0.56% for intracranial haemorrhage and 2.10% for ischaemic stroke (these are covered <a href="https://covidprotocols.org/en/chapters/specialty-care/#stroke-k8vj306xrg53">here</a>)</li>
15702  <li>0.11% for parkinsonism and 0.67% for dementia</li>
15703  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#anxiety-and-depression-5vtz8ypvr887">Mood disorder </a>13.66%; first diagnosis 4.22%</li>
15704  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#anxiety-and-depression-5vtz8ypvr887">Anxiety disorder</a> 17.39%; first diagnosis 7.11% </li>
15705  <li>Psychotic disorder 1.40%; first diagnosis 0.42%</li>
15706  <li><a href="https://covidprotocols.org/en/chapters/psychosocial-support/#addiction-pgi8h6rkmnb2">Substance use disorder</a> 6.58%; first diagnosis 1.92%</li>
15707</ul>
15708<p><span style="font-weight:700">Workup and treatment:  </span>Patients with known neurologic and/or psychiatric complications of COVID-19 should be followed by a neurologist and/or psychiatrist where available. Management of these complications following COVID-19 should be the same as it is in patients who have these disorders independent of COVID19. </p>
15709<h3 id="h.o5zyvqmfv6no">Fatigue and “Brain Fog”<a class="anchor-point" id="fatigue-and-brain-fog-o5zyvqmfv6no"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15710<p><span style="font-style:italic">Updated Date: May 9, 2021</span></p>
15711<p><span style="font-style:italic"></span></p>
15712<p>Fatigue is by far one of the most common PACS symptoms. Half of patients in one study reported ongoing fatigue, a median of 10 weeks after infection, with 32% reporting symptoms &gt;12 weeks after (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recAo8Jexl2LbUCtE" rel="noopener noreferrer" target="_blank">Townsend et al</a>). Most patients' symptoms resolve on their own, though it may take many months. If symptoms last more than six months, some of these patients may meet criteria for Myalgic encephalitis/chronic fatigue syndrome (ME/CFS), which has been documented with many severe viral syndromes including COVID. More information about diagnosis of ME/CFS is available in the <a href="https://www.nap.edu/resource/19012/MECFScliniciansguide.pdf" rel="noopener noreferrer" target="_blank">Institute of Medicine Clinician’s Report</a>. There is some relationship between ME/CFS symptoms and <a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">dysautonomia/ POTS.</a> For ME/CFS specifically: </p>
15713<ol class="lst-kix_qxcj2qgnj7k-0 start level-0" start="1">
15714  <li>Diagnosis requires the following three symptoms <span class="tooltip-wrapper"><span class="tooltip-content"><span style="text-decoration-skip-ink:none;-webkit-text-decoration-skip:none;">Frequency and severity of symptoms should be assessed. The diagnosis of ME/CFS (SEID) should be questioned if patients do not have these symptoms at least half of the time with moderate, substantial, or severe intensity. </span></span></span>: </li>
15715</ol>
15716<ol class="lst-kix_qxcj2qgnj7k-1 start level-1" start="1">
15717  <li>A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest and </li>
15718  <li>Post-exertional malaise, and </li>
15719  <li>Unrefreshing sleep</li>
15720</ol>
15721<ol class="lst-kix_qxcj2qgnj7k-0 level-0" start="2">
15722  <li>At least one of the two following manifestations is also required: </li>
15723</ol>
15724<ol class="lst-kix_qxcj2qgnj7k-1 start level-1" start="1">
15725  <li>Cognitive impairment or </li>
15726  <li>Orthostatic intolerance</li>
15727</ol>
15728<p></p>
15729<p><span style="font-weight:700">Management: </span></p>
15730<p>There is no cure or medical treatment for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Some patients, but not all, achieve some degree of relief with symptom management. There is some overlap between ME/CFS and <a href="https://covidprotocols.org/en/chapter
15730s/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">dysautonomia</a> (treatment is covered here). </p>
15731<ul class="lst-kix_xcuaa655ryb9-0 start level-0">
15732  <li><span style="font-weight:700">Post-exertional malaise </span>can be managed by pacing training (or activity management). Many patients describe a push/crash cycle where they feel exhausted after physical or mental exertion, and take a long time to recover and thus avoid exercise. However, gentle exercise anecdotal improves patients tolerance over time and improves quality of life. Pacing management is generally targeted at increasing mental and physical exertion slowly, but staying within an “exertion envelope” to avoid exceeding personal limits. See <a href="http://www.cfsselfhelp.org/pacing-tutorial" rel="noopener noreferrer" target="_blank">this tool.</a> </li>
15733</ul>
15734<ul class="lst-kix_xcuaa655ryb9-1 start level-1">
15735  <li>Rehabilitation specialists or exercise physiologists with experience with ME/CFS can help develop strategies.</li>
15736</ul>
15737<ul class="lst-kix_xcuaa655ryb9-0 level-0">
15738  <li>For treating <span style="font-weight:700">insomnia</span>, <a href="https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.html" rel="noopener noreferrer" target="_blank">good sleep habits </a>and medications are helpful</li>
15739  <li><span style="font-weight:700">Pain</span> should be managed with over the counter medications (generally NSAIDs and acetaminophen), gentle movement, gentle massage and other supportive treatments.</li>
15740  <li><span style="font-weight:700">Memory and concentration </span>problems can be hard to treat. Some patients may benefit from stimulant medications such as those used to treat ADHD. However, not all patients derive benefit from these, and they often can worsen the push/crash cycles described above. Medications such as those used for Alzheimer's Disease are not recommended. </li>
15741  <li><span style="font-weight:700;"><a href="https://covidprotocols.org/en/chapters/post-covid-care/#anxiety-and-depression-5vtz8ypvr887">Depression and anxiety</a></span> are covered here.</li>
15742  <li><span style="font-weight:700">Lightheadedness and orthostasis</span> are covered <a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">here. </a></li>
15743  <li><span style="font-weight:700">Disability</span> from ME/CFS is complicated. In the USA, more information is available from the <a href="https://www.cdc.gov/me-cfs/resources/disability.html" rel="noopener noreferrer" target="_blank">CDC website</a>. </li>
15744</ul>
15745<p></p>
15746<p><span style="font-weight:700">Tool:</span> <a href="https://www.nap.edu/resource/19012/MECFScliniciansguide.pdf" rel="noopener noreferrer" target="_blank">Institute of Medicine Clinician’s Report</a> for ME/CFS diagnosis and treatment</p>
15747<p><span style="font-weight:700">Tool:</span> <a href="http://www.cfsselfhelp.org/pacing-tutorial" rel="noopener noreferrer" target="_blank">Pacing Tutorial</a> </p>
15748<h3 id="h.5vtz8ypvr887">Anxiety and Depression<a class="anchor-point" id="anxiety-and-depression-5vtz8ypvr887"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15749<p><span style="font-style:italic">Updated Date: May 9, 2021</span></p>
15750<p></p>
15751<p>Recovered COVID patients are at increased risk of mood disorders including depression and anxiety, as well as consequences of isolation and social stigma. It is unclear as yet whether mood changes arise from increased stress, isolation, and trauma or whether there is an additional direct neurocognitive effect of the virus. </p>
15752<ul class="lst-kix_ev2zqzxtx3tv-0 start level-0">
15753  <li>In a study of analyzing health records of more than 236,000 patients with COVID-19 found that six months after being diagnosed with COVID-19, 1 in 3 patients had experienced a psychiatric or neurological illness (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recsuAzj5X7PID40s" rel="noopener noreferrer" target="_blank">Taquet et al</a>). While anxiety, mood, and substance use disorders were most common, concern was raised about rates of serious neurological complications, especially in patients who had been severely ill with Covid-19. <span style="font-style:italic">The data also indicated that compared to control groups of people who had the flu or other non-Covid respiratory infections, first-ever neuropsychiatric diagnoses were almost twice as high. </span></li>
15754  <li>The presence of a mood disorder prior to admission is associated with greater likelihood of discharge to a skilled nursing facility or other rehabilitation facility rather than home (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recXwlUIdcV9siUBZ" rel="noopener noreferrer" target="_blank">Castro et al</a>). </li>
15755  <li>Hospitalized individuals with a history of mood disorder may be at risk for greater COVID-19 morbidity and mortality and are at increased risk of need for postacute care. Further studies should investigate the mechanism by which these disorders may confer elevated risk. </li>
15756  <li>ICU patients are at particular risk of post-traumatic stress disorder. See <a href="https://covidprotocols.org/en/chapter
15756s/post-covid-care/#post-icu-syndrome-f42ysl6mf4r1">Post-ICU syndrome</a> </li>
15757  <li><a href="https://covidprotocols.org/en/chapters/post-covid-care/#fatigue-and-brain-fog-o5zyvqmfv6no">ME/CFS</a> can also be associated with mood changes. </li>
15758</ul>
15759<p></p>
15760<p><span style="font-weight:700">Management:</span></p>
15761<p>In general, these are not treated differently than patients suffering with anxiety or depression from other etiologies (see here for<a href="https://covidprotocols.org/en/chapters/psychosocial-support/#anxiety-and-depression-kwrwdi877m9d"> treatment recommendations</a>).</p>
15762<h3 id="h.cgwdicgt2ot6">Prolonged Anosmia and Ageusia<a class="anchor-point" id="prolonged-anosmia-and-ageusia-cgwdicgt2ot6"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15763<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15764<p>Loss of smell and taste have been observed to be prolonged, often many months. See <a href="https://covidprotocols.org/en/search/?q=anosmia#anosmia-and-ageusia-decreased-smell-and-taste-a95n9lid66r7">anosmia and ageusia</a> for a review of this topic. Some patients have phantom smells (parosmia). Overall, the loss of smell persists for more than 4 weeks in about 10% of patients (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recVgJDL0OkuVF8I5" rel="noopener noreferrer" target="_blank">Walker et al</a>). </p>
15765<p></p>
15766<p><span style="font-weight:700">Management: </span></p>
15767<ul class="lst-kix_ai9yxiah8lil-0 start level-0">
15768  <li>Confirm that the olfactory disturbance is COVID-19 related. People with progressive smell loss/disturbance that does not line up chronologically with COVID-19 infection need to go through the typical workup for olfactory disturbance so that nothing is missed (typically nasal endoscopy and MRI if endoscopy is normal). Similarly, patients with anosmia associated with other neurological findings should be worked up for alternate causes. </li>
15769  <li>There is currently no definitive recommendation for medical treatment of these effects. A synthesis of ENTUK and BRS expert guidance and recommends (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recVgJDL0OkuVF8I5" rel="noopener noreferrer" target="_blank">Walker et al</a>, <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recEqiCDHz9DVE6br" rel="noopener noreferrer" target="_blank">Hopkins et al</a>): </li>
15770</ul>
15771<ul class="lst-kix_ai9yxiah8lil-1 start level-1">
15772  <li>Olfactory (smell) training for patients with symptoms over 2 weeks. Training is available at<a href="https://abscent.org/learn-us/smell-training" rel="noopener noreferrer" target="_blank"> AbScent</a> and<a href="https://www.fifthsense.org.uk/" rel="noopener noreferrer" target="_blank"> Fifth Sense</a>. </li>
15773  <li>Topical corticosteroid nasal drops (fluticasone or betamethasone typically) can be tried in patients with symptoms lasting more than 2 weeks. These tend to be low-risk, but efficacy is not yet proven, and they likely help mostly with nasal obstruction.</li>
15774  <li>Oral steroids have minimal data, except some case reports (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recJprdq66nAwpvOh" rel="noopener noreferrer" target="_blank">Le Bon et al</a>). Do not offer oral corticosteroids within 2 weeks of infection unless otherwise indicated as the chance of spontaneous recovery is high, and they may cause delayed viral clearance. We do not recommend using these in patients who are still symptomatic. They are optional in patients with no other symptoms more than 2 weeks after infection. </li>
15775</ul>
15776<ul class="lst-kix_ai9yxiah8lil-0 level-0">
15777  <li>Monitor patients’ weight, as smelling and tasting changes can trigger weight loss</li>
15778  <li>Ensure loss-of smell safety measures: smoke detectors should be functional, if there is natural gas in the household then it should be removed or detectors obtained, and food safety should be assured with adequate refrigerator/freezer temperatures and expiration date checks</li>
15779  <li>For patients with symptoms persisting after 3 months, consider referral to ear, nose, and throat physician. </li>
15780</ul>
15781<h3 id="h.jdzvelbxg9wq">Headache<a class="anchor-point" id="headache-jdzvelbxg9wq"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15782<p>Migraine-like headaches are relatively common, and late-onset headaches may be do to high cytokine levels. Many times these headaches are refractory to typical analgesics. About 38% of patients in one study had ongoing headaches after 6 weeks (<a href="https://www.ahshighlights.com/summaries-podcasts/article/headache-covid-19-a-short-term-challenge-with-long-term-insights" rel="noopener noreferrer" target="_blank">Pozo-Rosich et al</a>). Management of headache is the same as for non-COVID patients, and is covered in <a href="https://bwh.covidprotocols.org/protocols/neurology/#headache">BWH’s COVID guidelines</a>.</p>
15783<h3 id="h.e9h9w1nhepmd">Dysautonomia and POTS<a class="anchor-point" id="dysautonomia-and-pots-e9h9w1nhepmd"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15784<p><span style="font-style:italic">Updated Date: March 15, 2021</span></p>
15785<p>After COVID, some patients develop disorders of the autonomic nervous system, which most commonly include orthostatic hypotension, postural tachycardia of either CNS or peripheral etiology, gastrointestinal disorders, and sweating abnormalities, as well as other rarer symptoms. Evidence-based treatments exist for autonomic dysfunction, particularly for the cardiovascular manifestations.</p>
15786<ul class="lst-kix_yywi7t5w7kas-0 start level-0">
15787  <li>Autonomic dysfunction has been associated with post-infectious syndromes in the past, and is thought to occur most likely either through direct viral sequelae or through autoimmune mechanisms (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/reczDgbchH4CaRvTu" rel="noopener noreferrer" target="_blank">Dani et al</a>).</li>
15788  <li>In a retrospective study of all 841 COVID patients admitted to two Spanish hospitals in March 2020 (the ALBACOVID registry), 2.5% developed dysautonomia (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recMNOOFF87Yv8jlV" rel="noopener noreferrer" target="_blank">Romero-Sanchez et al</a>).</li>
15789  <li>The literature includes multiple case reports and small case series of patients developing autonomic intolerance (most commonly postural orthostatic tachycardia syndrome (POTS), but also orthostatic hypotension, hyperhidrosis, nausea/constipation/dyspepsia, and pupillary abnormalities such as accommodation defects) after COVID infection (see e.g. <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recbnzwSo0VF00gkU" rel="noopener noreferrer" target="_blank">Umapathi et al</a>). </li>
15790</ul>
15791<h4 id="h.9kooxpsclkr9">Diagnosis<a class="anchor-point" id="diagnosis-9kooxpsclkr9"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h4>
15792<ul class="lst-kix_qzia4xobt84a-0 start level-0">
15793  <li><span style="font-weight:700">Vitals</span>: Initial steps include orthostatic vital signs, thorough cardiopulmonary and neurologic exams, and EKG.</li>
15794</ul>
15795<ul class="lst-kix_qzia4xobt84a-1 start level-1">
15796  <li>POTS is diagnosed by an increase in HR by at least 30 bpm from supine to standing or by an increase to a HR of &gt;120 within ten minutes of standing. Further testing can help distinguish a central etiology, which is generally accompanied by a hyperadrenergic state, from a peripheral autonomic neuropathy.</li>
15797  <li>Orthostatic hypotension is diagnosed by a drop in blood pressure by &gt;20 mmHg systolic or 10 mmHg diastolic within three minutes of standing.</li>
15798</ul>
15799<ul class="lst-kix_qzia4xobt84a-0 level-0">
15800  <li><span style="font-weight:700">Differential</span>: Autonomic symptoms can overlap with other pathologies. For instance, patients can have shortness or breath (often orthostatic), palpitations, and poor exercise tolerance. Thus, investigating other etiologies with targeted testing such as outpatient rhythm monitoring, echocardiogram, chest imaging, pulmonary function tests, etc. is often warranted.</li>
15801  <li><span style="font-weight:700">Laboratory tests</span> to consider (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recv90zM7aLMBLpGZ" rel="noopener noreferrer" target="_blank">Benarroch et al</a>, <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recnWGrHg6iN6RADM" rel="noopener noreferrer" target="_blank">Zadourian et al</a>).</li>
15802</ul>
15803<ul class="lst-kix_qzia4xobt84a-1 start level-1">
15804  <li>CBC to rule out significant anemia, chemistry panel for electrolyte disturbances, TSH, Early morning cortisol, Hemoglobin A1c, ANA, with subserologies if elevated</li>
15805  <li>Supine/seated/standing plasma catecholamine levels (marked increases can point towards a central hyperadrenergic state as a cause of POTS, rather than peripheral nerve pathology)</li>
15806  <li>Urinary catecholamines and metanephrines</li>
15807  <li>If available, serum paraneoplastic antibody panel (Through Mayo Clinic in the U.S.)</li>
15808</ul>
15809<ul class="lst-kix_qzia4xobt84a-0 level-0">
15810  <li>Additional diagnostic tests to consider in select patients (most of these are not widely available outside of select centers, and often do not change management) </li>
15811</ul>
15812<ul class="lst-kix_qzia4xobt84a-1 start level-1">
15813  <li>Skin biopsy for epidermal axonal density, as evidence for small fiber autonomic neuropathy </li>
15814  <li>Non invasive and invasive cardiopulmonary exercise testing </li>
15815  <li>Tilt table testing</li>
15816  <li>24-hour blood pressure monitoring</li>
15817  <li>Formal autonomic testing (including cardiovagal and sudomotor testing, sometimes thermoregulatory testing as well) </li>
15818  <li>Urodynamic testing, gastrointestinal motility testing, or ophthalmologic exam if indicated by symptoms</li>
15819</ul>
15820<h4 id="h.md4o6xf44lpr">Treatment:<a class="anchor-point" id="treatment-md4o6xf44lpr"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h4>
15821<p>Common treatment options for postural orthostatic tachycardia and orthostatic hypotension include the following:</p>
15822<ul class="lst-kix_8a9e37jpst1h-0 start level-0">
15823  <li>Lifestyle measures (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recyN1346EVSboPnw" rel="noopener noreferrer" target="_blank">Mar et al</a>):</li>
15824</ul>
15825<ul class="lst-kix_8a9e37jpst1h-1 start level-1">
15826  <li>Elevation of head of bed</li>
15827  <li>Avoiding prolonged recumbent position</li>
15828  <li>Copious fluid intake (2-3 L daily)</li>
15829  <li>Plenty of salt intake (10-12g daily)</li>
15830  <li>Graded exercise regimen - can start with recumbent exercise such as seated bike/rowing machine)</li>
15831  <li>Compression pants such as running compression pants, and/or abdominal binders</li>
15832  <li>Small frequent meals</li>
15833  <li>Avoid exacerbating factors such as dehydration, overheating, alcohol, prolonged standing</li>
15834</ul>
15835<ul class="lst-kix_8a9e37jpst1h-0 level-0">
15836  <li>Pharmacologic therapy (most common therapies; others exist as well) (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recnWGrHg6iN6RADM" rel="noopener noreferrer" target="_blank">Zadourian et al</a>, <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec4vXP3m9LJtqhHW" rel="noopener noreferrer" target="_blank">Fedorowski</a>):</li>
15837</ul>
15838<ul class="lst-kix_8a9e37jpst1h-1 start level-1">
15839  <li>Salt tablets - e.g. 1g TID, though dietary salt preferable</li>
15840  <li>Beta blockers - best evidence for propranolol, 10-40 mg three times daily, start at lower end of dosage range </li>
15841  <li>Fludrocortisone - For volume expansion. Start with 0.1 mg PO daily, then increase up to 0.2 mg PO daily, monitoring after initiation and titration for hypokalemia</li>
15842  <li>Pyridostigmine - Acetylcholinesterase inhibitor to facilitate cholinergic ganglionic nerve transmission and increase sympathetic vascular tone, particularly in patients suspected of autonomic neuropathy as primary etiology. 30-60 mg two to three times daily. Start at 30 mg twice daily.</li>
15843  <li>Midodrine - For orthostatic hypotension. 2.5-10 mg three times daily, start at 2.5 mg three times daily during daytime hours. Note that some patients with POTS may have hypertension, and that midodrine can cause severe supine hypertension, so use in select patients, avoid &lt;4 hours before bedtime, and monitor blood pressure after initiation/titration. </li>
15844  <li>Clonidine - As a sympatholytic, especially in patients with elevated standing catecholamines. 0.1-0.4 mg PO twice daily, start at 0.1 mg at night and can titrate up by 0.1 mg each week</li>
15845  <li>Ivabradine, a negative chronotropic, may be indicated in patients with hyperadrenergic POTS (plasma NE &gt;600 pg/ml and abnormal tilt table test). (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recHPKtcmqBeJPm9x" rel="noopener noreferrer" target="_blank">Taub et al</a>)</li>
15846</ul>
15847<ul class="lst-kix_8a9e37jpst1h-0 level-0">
15848  <li>Some data, particularly for small fiber autonomic neuropathy, exists for IVIG (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec3p6kIS3jNimdiS" rel="noopener noreferrer" target="_blank">Oaklander</a>) and/or immunosuppression in cases with strong suspicion for autoimmune etiology. This should be pursued only in consultation with neurology.</li>
15849  <li>Appropriate referrals include cardiology and neurology. Specialist autonomic neurologists exist as well.</li>
15850  <li>There is inadequate data at present to assess the course of post-COVID autonomic dysfunction, though some patients have shown recovery (see e.g. <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recbnzwSo0VF00gkU" rel="noopener noreferrer" target="_blank">Umpathi et al</a>).</li>
15851</ul>
15852<h2 id="h.w34oxzt914mq">Hematologic Concerns<a class="anchor-point" id="hematologic-concerns-w34oxzt914mq"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15853<h3 id="h.i2adktaazwpp">Delayed Thrombosis<a class="anchor-point" id="delayed-thrombosis-i2adktaazwpp"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15854<p><span style="font-style:italic">Updated Date: May 9, 2021</span></p>
15855<p></p>
15856<p>
15856The <a href="https://covidprotocols.org/en/chapters/specialty-care/#thrombosis-ejke6mrvikhg">pro-thrombotic state of acute COVID</a> is well-described, but the duration of this state is unclear. Retrospective studies to date suggest that the rates of VTE following hospitalization for COVID-19 are similar to rates for other acute medical illnesses (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recforOUvIsofTwAU" rel="noopener noreferrer" target="_blank">Patell et al</a> and <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rechNoW2d3apx3Glv" rel="noopener noreferrer" target="_blank">Roberts et al</a>). One study of 163 patients suggested a 2.5% incidence of thrombosis by 30 days, with mean occurrence at 23 days. However, there was a 3.7% incidence of bleeding, mostly due to fall (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recforOUvIsofTwAU" rel="noopener noreferrer" target="_blank">Patell et al</a>). One registry study of COVID patients indicated that the 90 day post-discharge venous and arterial thromboembolism and all-cause mortality rates were 1.55%, 1.71%, and 4.83% respectively (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recEn6VgBaCR2ywf4" rel="noopener noreferrer" target="_blank">Giannis et al</a>). Delayed VTE events, even in patients who were never hospitalized, have been reported. </p>
15857<p></p>
15858<p><span style="font-weight:700">Extended </span><span style="font-weight:700;"><a href="https://covidprotocols.org/en/chapters/treatments/#prophylactic-dosing-8qpojiljj6p8">thromboprophylaxis</a></span><span style="font-weight:700">. </span> Generally we do not recommend extended thromboprophylaxis past hospitalization for COVID patients, unless it would otherwise be indicated for non-COVID factors related to acute illness (such as protracted immobility). We recommend the <a href="https://www.mdcalc.com/improvedd-risk-score-venous-thromboembolism-vte" rel="noopener noreferrer" target="_blank">IMPROVEDD</a> score (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/reck4h7RJIurEjNCz" rel="noopener noreferrer" target="_blank">Spyropoulous et al</a>) to assess 42- and 77-day VTE risk, and to weigh this risk against bleeding risk when determining if extended prophylaxis is indicated. Some centers do recommend extended prophylaxis (generally up to 6 weeks after discharge). This remains an area of active investigation, and shared decision-making is appropriate. </p>
15859<p><span style="font-weight:700"></span></p>
15860<p><span style="font-weight:700">Acute COVID-related VTE treatment after hospitalization. </span>For thromboses associated with acute COVID infection, these are considered “provoked” thromboses and are treated with the same duration of anticoagulation as for non-COVID associated clots of a similar type (typically 3-6 months depending on resolution of the initial provocation, residual vein thrombosis, elevated inflammatory markers, other VTE risks including obesity, known inherited thrombophilia, or past VTE). </p>
15861<p></p>
15862<p><span style="font-weight:700">Delayed VTE.</span> The duration of the hypercoagulable state from COVID is unknown. For patients who present later than 8-12 weeks after an COVID infection with a <span style="font-weight:700;font-style:italic">new</span> VTE we would recommend considering this “unprovoked” and working up accordingly for hypercoagulable states. There is no data behind this specific time cutoff for post-COVID syndrome, this recommendation is based on the analogy of delayed VTE after surgery and may change in the future as more is learned. There is some evidence that antiphospholipid autoantibodies may be found in some cases (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recf229Bhz98c8xp3" rel="noopener noreferrer" target="_blank">Zuo et al</a>). </p>
15863<p></p>
15864<p><span style="font-weight:700">Arterial Thrombosis.</span> For arterial clots without obvious structural abnormalities, cardioembolic source, or catheter-associated thromboses, hypercoagulability workup is generally warranted, regardless of COVID status or timing (for arterial 
15864clot workup and treatment see <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recXF0eHnDCJdlXMY" rel="noopener noreferrer" target="_blank">May et al</a>).</p>
15865<h2 id="h.81b56iceb3ah">Cardiac Concerns<a class="anchor-point" id="cardiac-concerns-81b56iceb3ah"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15866<h3 id="h.wd53c3s0rf76">Chest Tightness and Discomfort<a class="anchor-point" id="chest-tightness-and-discomfort-wd53c3s0rf76"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15867<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15868<p></p>
15869<p>Persistent chest discomfort following recovery is common (21.7%, <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recmYf2HKqv4KlDeX" rel="noopener noreferrer" target="_blank">Carfi et al</a>) and can take quite some time to abate. The etiology is unknown but is hypothesized to be a combination of pleuritic or pericardial inflammation, costochondritis, musculoskeletal pain from coughing, or microvascular cardiac injury. Of course, more serious causes of chest pain are also possible, including myocarditis, myocardial infarction, spontaneous coronary artery dissection (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/receUJZKH2UfMSlyI" rel="noopener noreferrer" target="_blank">Cannata et al</a>), pulmonary embolism, new bacterial pneumonia, pleural effusion, and pneumothorax. Palpitations are also reported in about 9% of patients. These can be due to arrhythmias, but are often due to a debilitating but challenging to diagnose condition called <a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">Postural Orthostatic Tachycardia Syndrome (POTS)</a> (which is addressed under dysautonomia). Frustrating for the provider and the patient is that standard testing, encompassing ECG, ECHO, stress test, heart rate monitors, and cardiac magnetic resonance imaging, tend to be normal in the majority of patients. </p>
15870<p></p>
15871<p>Management: </p>
15872<ol class="lst-kix_h9h6a4rh1gdn-0 start level-0" start="1">
15873  <li><span style="font-weight:700">New and worsening </span>chest pain should always prompt workup for the above etiologies according to the nature and timeline of the pain. An exhaustive summary of the workup of chest pain is beyond the scope of this site, but generally include ECG, Echocardiogram, stress testing, Holter or event monitors, and cardiac MR depending on the indication. </li>
15874  <li><span style="font-weight:700">Ongoing but improving</span> chest pain after concerning etiologies have been ruled out generally does not require treatment if it is not interfer
15874ing with life. However, NSAIDs may be considered in the absence of contraindications. Colchicine (in half dose) can be used NSAIDs are ineffective. We do not recommend opiates. </li>
15875  <li>For Postural Orthostatic Tachycardia Syndrome see <a href="https://covidprotocols.org/en/chapters/post-covid-care/#dysautonomia-and-pots-e9h9w1nhepmd">Dysautonomia and POTS. </a></li>
15876</ol>
15877<h3 id="h.p1jfjbp8ef8u">Cardiac Dysfunction<a class="anchor-point" id="cardiac-dysfunction-p1jfjbp8ef8u"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15878<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15879<p></p>
15880<p>Many patients who have recovered from COVID infection have signs of cardiac damage (see <a href="https://covidprotocols.org/en/chapters/specialty-care/#myocarditis-n57f104f4od7">myocarditis</a>). In individuals with no known cardiac involvement or specific complaints, studies of recovered COVID patients have documented changes in systolic function and elevated troponin (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec0r0m0PQTNpMVQG" rel="noopener noreferrer" target="_blank">Puntmann et al</a>; <a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recQlRVOAnR0i5gZO" rel="noopener noreferrer" target="_blank">Huang et al</a>). The long term implications of documented inflammation remain unknown. Patients with viral myocarditis will likely have some recovery over time, as is seen in other forms of virally-induced inflammation, but the extent of recovery is not yet known</p>
15881<ul class="lst-kix_u78xwmlh6opl-0 start level-0">
15882  <li>In one study of 100 patients undergoing cardiac MRI 69-92 days after diagnosis, 78% of patients who had recovered had some signs of cardiac damage, and 60% had ongoing myocardial inflammation. Troponins were elevated in 76% of these patients, but cardiac function was preserved. This was independent of severity, pre-existing conditions, and the time of diagnosis (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec0r0m0PQTNpMVQG" rel="noopener noreferrer" target="_blank">Puntmann et al</a>). </li>
15883  <li>This is true even among patients without prior cardiac disease. In one study of 26 college athletes diagnosed with COVID (none hospitalized, most asymptomatic), 46% showed evidence of myocarditis or prior myocardial injury by cardiac MRI ranging 12-53 days after diagnosis. (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec694z7AhzVNIzLE" rel="noopener noreferrer" target="_blank">Rajpal et al</a>)</li>
15884</ul>
15885<p></p>
15886<p>Management: </p>
15887<ol class="lst-kix_b22uvd2azowp-0 start level-0" start="1">
15888  <li>Whether <span style="font-weight:700">screenings</span> to detect cardiovascular damage should become a routine part of follow-up care for COVID-19 patients remains unclear. </li>
15889</ol>
15890<ol class="lst-kix_b22uvd2azowp-1 start level-1" start="1">
15891  <li><span style="font-weight:700">Patients with ongoing chest pain, palpitations, or signs of heart failure</span> should be worked up for active disease as <a href="https://covidprotocols.org/en/chapters/post-covid-care/#chest-tightness-and-discomfort-wd53c3s0rf76">above</a>. </li>
15892  <li>Completely <span style="font-weight:700">asymptomatic patients with a history of mild disease</span> likely do not need any post-COVID workup, though this may change as we learn more.</li>
15893  <li><span style="font-weight:700">Completely asymptomatic patients with underlying cardiac conditions </span>or a <span style="font-weight:700">history of</span> <span style="font-weight:700">severe COVID infection</span>, comparing a pre-COVID and a post-COVID EKG is reasonable, as is obtaining troponin/ Nt-proBNP. If any abnormalities, work up as above. </li>
15894</ol>
15895<ol class="lst-kix_b22uvd2azowp-0 level-0" start="2">
15896  <li>Patients who experienced a <span style="font-weight:700">known cardiac injury</span> (including MI, cardiac arrest, arrhythmia, or symptomatic myocarditis) due to COVID should be followed by a cardiologist. </li>
15897</ol>
15898<ol class="lst-kix_b22uvd2azowp-1 start level-1" start="1">
15899  <li>Serial echocardiogram and electrocardiogram at weeks 4-12 is generally indicated (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec6igXazvY4PcHvV" rel="noopener noreferrer" target="_blank">George et al</a>).</li>
15900  <li>Management of arrhythmia is covered in this article (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recu0MmBQ1yldohUR" rel="noopener noreferrer" target="_blank">Desai et al)</a>.</li>
15901  <li>
15901Competitive athletes with cardiac damage should abstain from competitive sports or aerobic activity for 3–6 months until resolution of myocardial inflammation (by MRI or troponin). (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recTyrmchrCH9IaCa" rel="noopener noreferrer" target="_blank">Maron et al</a>)</li>
15902  <li>Adhere to guideline-directed medical therapy. Despite initial concerns, <a href="https://covidprotocols.org/en/chapters/treatments/#raas-inhibitors-t81x9z51xnjr">RAAS inhibitors</a> are considered safe to use in COVID patients.</li>
15903  <li>Standard lifestyle modifications are always recommended including</li>
15904</ol>
15905<ol class="lst-kix_b22uvd2azowp-2 start level-2" start="1">
15906  <li>Ensure daily physical activity, ideally following the American Heart Association Guidelines of at least 30 minutes of exercise per day for at least 6 days per week</li>
15907  <li>Smoking and alcohol cessation</li>
15908  <li>Lipid lowering medications if indicated</li>
15909  <li>Weight loss management for obese patients</li>
15910</ol>
15911<h2 id="h.lhhoyyv23om1">Renal Concerns<a class="anchor-point" id="renal-concerns-lhhoyyv23om1"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15912<p><span style="font-style:italic">Updated Date: March 15, 2021</span></p>
15913<p></p>
15914<p><span style="font-weight:700">Incidence</span>: Up to 40% of the hospitalized COVID-19 patients develop acute kidney injury (AKI) and 6.6% require renal replacement therapy (RRT). (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recfChQs4kuxigOSn" rel="noopener noreferrer" target="_blank">Ng et al</a>) Interestingly, one study found that 13% of patients in a cohort of hospitalized patients from Wuhan had normal eGFR on admission and no AKI while in hospital had reduced eGFR at 6 month follow up, suggesting a longer-term insult. (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recXbTE7EL1m3sNJZ" rel="noopener noreferrer" target="_blank">Huang et al</a>). </p>
15915<p></p>
15916<p><span style="font-weight:700">Pathophysiology: </span>The mechanism of renal injury is generally acute tubular necrosis on renal biopsies and autopsies. Microthrombi may play a role as well. A new entity, COVID-19-associated nephropathy (COVAN), is also possible. COVAN is characterized by a collapsing variant of focal segmental glomerulosclerosis with involution of the glomerular tuft. COVAN likely emerges from interferon and chemokine activation, with APOL1 risk alleles as a risk factor (similar to HIV) (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recfs2Meyq14LL3n5" rel="noopener noreferrer" target="_blank">Velez et al</a>). </p>
15917<p></p>
15918<p><span style="font-weight:700">Management</span></p>
15919<p></p>
15920<ol class="lst-kix_2k84ncmqobst-0 start level-0" start="1">
15921  <li><span style="font-weight:700">No known renal injury</span>: Given the Huang et al study suggesting a possible late presentation of decreased eGFR, we recommend that where possible post-COVID patients who have not received a BMP get their eGFR tested prior to the prescription of renally-cleared medications. Similarly, patients with symptoms past 4 weeks or prior hospitalization may benefit from a basic metabolic panel on <a href="https://covidprotocols.org/en/chapters/post-covid-care/#post-covid-clinic-visits-967bvvjlws">followup</a>. </li>
15922  <li><span style="font-weight:700">Known renal injury unresolved at the time of discharge</span>: AKI patients who do not recover to baseline kidney function should be followed by nephrology where possible after their discharge from the hospital for potential residual CKD. </li>
15923  <li><span style="font-weight:700">For patients on Renal Replacement Therapy (RRT): </span>Although mortality is significantly higher in RRT requiring patients, 66% of the survivors have renal recovery to become RRT-independent (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recfChQs4kuxigOSn" rel="noopener noreferrer" target="_blank">Ng et al</a>) in the first month. Recovery rate rises to 92% with longer follow up at 150 days (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recrNI83FrgkzeLin" rel="noopener noreferrer" target="_blank">Stockmann et al</a>). Hence, these patients should be monitored closely by the dialysis units for signs of renal recovery such as lower pre-dialysis serum creatinine levels and increasing urine output. Hemodialysis patients should be directed into the dialysis units accepting COVID-19 patients until completion of COVID-19 quarantine peri
15923od, whereupon they can return to their original units. These practices highly vary depending on location, available dialysis units and logistics.</li>
15924  <li><span style="font-weight:700">Transplant patients</span> who had reduction in their immunosuppression regimen during COVID-19 pneumonia should have close follow up after recovery. If the immunosuppression was reduced during the infection, it can be increased back to pre-infection level cautiously within weeks to months depending on their clinical course (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/rec3rE8QhHQZuHTwf" rel="noopener noreferrer" target="_blank">Kataria et al</a>). However, clear data and guidelines remain absent about how to manage the immunosuppression in patients with COVID-19. </li>
15925</ol>
15926<h2 id="h.f42ysl6mf4r1">Post-ICU Syndrome<a class="anchor-point" id="post-icu-syndrome-f42ysl6mf4r1"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15927<p><span style="font-style:italic">Updated Date: April 19, 2021</span></p>
15928<p></p>
15929<p>Patients admitted to ICU are at risk of post-ICU syndrome, a diverse constellation of physical, cognitive, and psychiatric deficits. In one study of 45 patients in New York 91% met criteria for post-ICU syndrome (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recgTvYKbr2FKmaUj" rel="noopener noreferrer" target="_blank">Martillo et al</a>).</p>
15930<ul class="lst-kix_7qvy9vcgq8k1-0 start level-0">
15931  <li>86.7 % had impairments in the physical domain</li>
15932</ul>
15933<ul class="lst-kix_7qvy9vcgq8k1-1 start level-1">
15934  <li>58% had some degree of mobility impairment</li>
15935</ul>
15936<ul class="lst-kix_7qvy9vcgq8k1-0 level-0">
15937  <li>48% reported impairments in the psychiatric domain. 38% exhibited at least mild depression, and 18 % moderate to severe depression. 18% met criteria for PTSD. </li>
15938</ul>
15939<ul class="lst-kix_7qvy9vcgq8k1-1 start level-1">
15940  <li>This is also supported by a much larger study where post-ICU patients had a six-month estimated incidence of a neurologic or psychiatric diagnosis of 46%. This was the first such diagnosis for 25%. (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recsuAzj5X7PID40s" rel="noopener noreferrer" target="_blank">Taquet et al</a>). </li>
15941</ul>
15942<ul class="lst-kix_7qvy9vcgq8k1-0 level-0">
15943  <li>8% had impairments on cognitive screening.</li>
15944</ul>
15945<p></p>
15946<p><span style="font-weight:700">Tracheostomy and Chronic ventilation: </span>In a study of 1,800 patients requiring tracheostomies, only 52% were successfully weaned from mechanical ventilation after a month in a national cohort study from Spain (<a href="https://airtable.com/shrotaa0TOXrHFFsk/tbl2bwt3ywyTqJUlA/viwpH1Ug3JBR5zW0Q/recfXRp83kBhg1qBm" rel="noopener noreferrer" target="_blank">Martin-Villars et al</a>). </p>
15947<p></p>
15948<p><span style="font-weight:700">Diagnostic Evaluation: </span></p>
15949<p> </p>
15950<ul class="lst-kix_9rsfsdwlqzu2-0 start level-0">
15951  <li><span style="font-weight:700">Cognitive</span>: Patients with suspected PICS can undergo an assessment in the clinic, with referral to neuropsychiatry – if available – for further testing depending on results. It is not known to what extent results on this testing following hospital discharge predicts long-term impairment. </li>
15952</ul>
15953<ul class="lst-kix_9rsfsdwlqzu2-1 start level-1">
15954  <li>Montreal Cognitive Assessment (MOCA). This is a more sensitive test for cognitive impairment. Modified Mini-Mental State Examination (MMSE) </li>
15955  <li>Mini-Cog </li>
15956</ul>
15957<ul class="lst-kix_9rsfsdwlqzu2-0 level-0">
15958  <li><span style="font-weight:700">Mental health:  </span></li>
15959</ul>
15960<ul class="lst-kix_9rsfsdwlqzu2-1 start level-1">
15961  <li>Hospital Anxiety and Depression Scale (HADS) </li>
15962  <li>Impact of Events Scale-Revised (IES-R) for PTSD </li>
15963</ul>
15964<p></p>
15965<p><span style="font-weight:700">Management:</span></p>
15966<p>Treatment for post-ICU syndrome is largely targeted at the specific physical and psychological needs of the individual. Some additional information is available at<a href="https://www.aftertheicu.org" rel="noopener noreferrer" target="_blank"> </a><a href="https://www.aftertheicu.org" rel="noopener noreferrer" target="_blank">AfterTheICU</a>.</p>
15967<p></p>
15968<h2 id="h.l7nafbusssgt">Gastrointestinal Concerns<a class="anchor-point" id="gastrointestinal-concerns-l7nafbusssgt"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h2>
15969<p>Updated Date: October 1, 2021</p>
15970<h3 id="h.bmxuw3jmud8h">Functional GI Disorders<a class="anchor-point" id="functional-gi-disorders-bmxuw3jmud8h"></a><span class="copy-link-wrapper"><span class="copy-link-content">Copy Link!</span></span></h3>
15971<p>Like other infections that are associated with transient gut inflammation, COVID-19 patients may experience persistent GI dysfunction after resolution of the acute infection, consistent with a post-infectious functional gastrointestinal disorder (FGIDs) / disorder of the gut-brain interaction (DGBI).<a href="https://doi.org/10.14309/ajg.0000000000001062" rel="noopener noreferrer" target="_blank"> </a></p>
15972<ol class="lst-kix_op1aqp67ffp9-0 start level-0" start="1">
15973  <li><a href="https://doi.org/10.14309/ajg.0000000000001062" rel="noopener noreferrer" target="_blank">Proposed criteria for diagnosis of post-COVID-19 FGID/DGBI can be found here in Table 2: </a><a href="https://doi.org/10.14309/ajg.0000000000001062" rel="noopener noreferrer" target="_blank">Schmulson, </a><span style="font-style:italic;"><a href="https://doi.org/10.14309/ajg.0000000000001062" rel="noopener noreferrer" target="_blank">The American Journal of Gastroenterology</a></span><a href="https://doi.org/10.14309/ajg.0000000000001062" rel="noopener noreferrer" target="_blank">, 2021</a><a href="https://doi.org/10.14309/ajg.0000000000001062" rel="noopener noreferrer" target="_blank">. </a></li>
15974  <li><a href="https://doi.org/10.14309/ajg.0000000000001062" rel="noopener noreferrer" target="_blank">Treatment is based on symptoms. </a></li>
15975</ol>
15976<p></p>
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