Long COVID or Post COVID-19 Syndrome

Patients who present with persisting symptoms after an acute COVID-19 illness may be experiencing Long COVID.  

Definitions

  • Acute COVID-19: signs and symptoms of COVID-19 for up to 4 weeks since acute infection.
  • Ongoing symptomatic COVID-19: signs and symptoms of COVID-19 from 4 to 12 weeks since acute infection.
  • Long COVID or Post COVID-19 Syndrome: a condition that occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19, with symptoms lasting for at least 2 months and cannot be explained by an alternative diagnosis.
    • Common symptoms include fatigue, shortness of breath and cognitive dysfunction but also others and generally have an impact on everyday functioning.
    • Severity of initial COVID-19 infection does not predict development of Post COVID-19 Syndrome. Symptoms may be new onset following initial recovery from an acute COVID-19 episode of persist from the initial illness. Symptoms may also fluctuate or relapse over time.
    • This definition is applicable for adults from 18 years of age. A clinical case definition for Post COVID-19 Syndrome in children and young people continues to be researched globally.
    • ‘Long COVID’ is the patient preferred term for Post COVID-19 Syndrome.  Also may be referred to as Post-Acute Sequelae of COVID-19 (PASC).

Symptoms of Long COVID

Most common symptoms:

  • Fatigue
  • Shortness of breath
  • Cognitive dysfunction or ‘brain fog’
  • Impact on everyday function

Further symptoms associated with Long COVID include:

  • Cough
  • Fatigue, headache, cognitive dysfunction, sleep disturbance, neurological symptoms
  • Post-exertional malaise (the worsening of symptoms following even minor physical or mental exertion)
  • Chest pains
  • Sleep disturbance, anxiety, depression, mood changes
  • Hair loss
  • Loss of smell or taste, ‘anosmia’
  • Skin conditions
  • Myalgias, musculoskeletal or joint pains, generalised weakness
  • Low grade fevers
  • Reduced activity level, reduced ability to function or continue with day-to-day activities

Patients with complications of COVID-19 infection may also present in this post-acute phase with symptoms related to:

  • Myocarditis or pericarditis
  • Cardiac arrythmias, microvascular angina
  • Thromboembolic disease
  • Dysautonomia, including POTS
  • Mast cell activation syndrome
  • Renal impairment
  • Interstitial lung disease
  • Myelopathy, neuropathy, and neurocognitive disorders
  • new onset diabetes and thyroiditis
  • hepatitis and abnormal liver enzymes
  • new onset allergies and anaphylaxis or Mast Cell Activation Syndrome
  • Post-Intensive Care Syndrome
  • Multi-system Inflammatory Syndrome for children.

Latest research focusing on the development of Long COVID after COVID-19 with the Omicron strain, suggests a lower prevalence rate than previously thought - approximately 5% of COVID-19 patients.

Long COVID in children

The prevalence, symptoms, and definition of Long COVID in children and young people is under investigation.

Consider Multi-System Inflammatory Syndrome when assessing children with ongoing COVID-19 symptoms.

  • Paediatric Inflammatory Multisystem Syndrome (PIMS-TS) occurs 2 to 6 weeks after infection with COVID-19.
  • The initial COVID-19 infection may have been asymptomatic and undetected.
  • Consider PIMS-TS in any unwell child with fever for a minimum of 3 days, gastrointestinal symptoms (abdominal pain, diarrhoea, and vomiting), rash, conjunctival injection, or tachycardia.
  • Children with suspected PIMS-TS need urgent assessment as outlined here.

Assessment of Long COVID for GPs:

  • Consider the diagnosis in adults who have symptoms and are more than 4 weeks since their acute COVID-19 infection
  • The key assessment points are:
    • History - details of the acute COVID-19 infection, positive PCR or RAT details, vaccination status, symptoms and their impact on function, red flags.
    • Understanding, validation, and empathy for patient’s symptoms
    • Examination including vital signs, targeted to patient’s symptoms.
    • Consider and exclude red flags, especially in the early 4–6-week period post-acute COVID-19 illness, including:
      • new or increasing dyspnoea or hypoxia
      • syncope
      • palpitations or arrythmias
      • unexplained cardiac chest pain
      • suspected VTE
      • new focal neurological signs or symptoms
      • new confusion
      • multi-system inflammatory syndrome in children
      • rule out organic disease in these patients (e.g. PE, MI, stroke or relevant disease for the relevant presenting symptom)
    • Investigations, which may include bloods, ECG, Chest X-ray, or others, guided by the patient’s symptoms.
  • More detailed assessment guide is available on Health Pathways under Post COVID-19 Condition.

Management of Long COVID for GPs:

  • Validating the patient’s experience – multiple studies have demonstrated prolonged persistence of immune system markers, supporting the pathophysiological basis of this condition. The exact pathophysiology remains uncertain, but may involve microvascular clotting and damage, viral persistence, or immune system dysregulation.
  • Encouraging patients to use symptom diaries to track and monitor symptoms - example diary in the RACGP Post COVID-19 resource
  • Symptom-based management ideas – outlined in the WHO Self Rehabilitation resource
  • Advise rest, pacing and prioritisation of activities for patients with fatigue – see the World Physiotherapy handout
  • Advise patients of Long COVID peer-support groups are available via podcasts, social media or through the Lung Foundation
  • Consider a GP Chronic Disease Management Plan item 721 with Team Care Arrangement item 732 to involve Allied Health for a multidisciplinary approach – for example, physiotherapy, pulmonary rehabilitation, occupational therapist, dietician, or others
  • Optimise medical management of pre-existing conditions
  • Encourage uptake of COVID-19 vaccinations where safe and other preventative measures to reduce risk of Long COVID from future COVID-19 infections
  • Consider referral to Long COVID Clinics – details below
  • Pathophysiology and future treatments for Post COVID-19 Syndrome remain uncertain and are being researched currently.

For further information regarding referrals relating to Long COVID management please see HealthPathways.

Additional resources