Mumbai: It is quite clear now that the impact of COVID-19 lies way beyond influenza-like conditions, even for the majority who are not much affected by this dreaded disease. It is also evident that this disease affects many more organs beyond the lungs and the respiratory tract including the heart, kidney, brain, and the gastrointestinal tract. What more do we know and how can we be alert about these conditions, particularly since some of that impact can be long-term?
We speak with S. Chatterjee, senior consultant, internal medicine, Apollo Hospital, New Delhi, and Jeenam Shah, consultant chest physician and interventional pulmonologist at Saifee, Wockhardt and Bhatia Hospitals in Mumbai.
Dr Chatterjee, how have you seen the disease play out, particularly in patients who have recovered from COVID, but face other kinds of problems?
SC: There are minor problems, and there are moderate to major problems that we are seeing in patients who have supposedly recovered from COVID and tested negative for COVID (when repeat testing was allowed) around day 14 or 15.
The most common thing that they are facing--the smallest problem--is that they continue to have a low-grade fever for a much longer time than we expected. They would have fever for about four to five weeks, and without any other cause being found. That really troubles the patients and their relatives. That also confuses us, because we also start looking at other causes of fever. Weakness is a feature, which is variable; it is seen in quite a few people. They have gastrointestinal upsets--like loose motions and vomiting continuing even after the active illness is over.
But [one of] the major things that I have seen is the heart being affected. I have seen patients developing myocarditis [inflammation of the heart tissue]. The degree could vary from mild to moderate, and it is the right side of the heart that is getting involved more than the left. Although none of the patients have become very serious with myocarditis, it is a feature we are seeing in follow-up patients.
The other two things that I have seen are people presenting with a postural drop of blood pressure [when blood pressure drops with change of bodily posture] and having giddiness. And at the moment, I am treating a patient who has developed a nervous involvement--what we call as a GB syndrome [Guillain-Barré syndrome]--developed after almost three to four weeks. I do not know whether it is exactly post-COVID, but the patient suffered from COVID a few weeks back and she has [now] come with that [GB syndrome], and we have not found any other cause for it.
Dr Shah, what have you been seeing? Have people come back, and with what?
JS: I have been seeing a lot of lung fibrosis [damage to the lung tissue] in my outpatient department (OPD) practice. When patients who have been on a ventilator or had required very high oxygen levels during their hospital stay come back to the OPD, most of them have lower oxygen than normal. This is because of a condition known as lung fibrosis. So, any damage to the lung leads to fibrosis, and it is an irreversible damage. So many patients are coming to the OPD practice hypoxic, with low oxygen concentration, and they are requiring home oxygen also. So, they are somewhat bedridden, if at all home-bound. That is the most important complication that I have seen. And it happens in quite a few patients.
It is not that the virus goes away, you are cured, and you are “happily ever after”. You see a lot of lung fibrosis. I currently have at least 20-25 patients who are on oxygen therapy at home. That is a cause for worry.
Apart from this, I am seeing a lot of mental changes. Most patients who have been in the hospital for a month--on the ventilator, or on the BiPAP support--are developing a lot of mental complications. They are very worried to go out, they have a lot of emotional stress. They are not able to eat well, they have lost weight. Their family is also affected because of that. So that emotional thing is also a very important component post this recovery of COVID infection.
Apart from that, as Dr Chatterjee has mentioned, a lot of patients who have developed myocardial infarction [a heart attack], some kind of myocarditis, have some residual heart diseases that are prevalent even after the COVID infection settles down.
These three things are the most important complications that I have seen. Obviously, COVID involves a lot of other organs also--kidney issues, GI issues have been persistent post recovery from the viral illness also.
You talked about lung fibrosis. Does that affect people uniformly? You said in some cases it is quite serious. How serious is it? How does it affect life, or the ability to lead a normal life subsequently, at least at this point?
JS: We are still very early into the disease. We still need to follow up those patients [to find out] how severe it is, and how long they are persisting with these kinds of problems. But whatever [I have seen] initially--post one to two months of discharge--the older the patient and the more extensive the disease, the more is the fibrosis. If the patient has gone on a ventilator, if the patient is very elderly, the fibrosis tends to be very severe. And the extent of the severity is that the patient cannot even walk a few steps, cannot even go to the washroom on their own without panting, without taking support or without requiring oxygen. So, this is a very severe debilitating disorder that happens post recovery of COVID.
But obviously, it does not affect all the people. It affects only people who have severe disease, the elderly people, and patients who have been on the ventilator. Patients who have very mild symptoms and patients who do not have many problems have recovered successfully without leaving any residual damage in the lungs.
Across age groups, for 100 patients that you have treated, how many would you say have recovered completely and how many are now showing residual symptoms, including serious ones?
JS: The data I am sharing are biased, because I am only treating moderate to severe patients in the hospital. Most of the mild patients have been home quarantined.
I would say almost 10% of my patients in the ICU have gone home on oxygen therapy. That is a sizable number of patients in the ICU. But if I talk about mild patients who have recovered in the ward, 99% of them have not required oxygen therapy, and have not developed any complications of lung fibrosis post their discharge.
Dr Chatterjee, what are the numbers you are seeing?
SC: I would agree with Dr Shah, because we both work with a tertiary care centre and we handle the same sort of patients. I actually forgot to mention we are seeing lung fibrosis and hypoxia very frequently in severe patients who are getting discharged, who were on a ventilator, or who require high flow oxygen for recovery. The percentage, as he said, is the same because we are seeing patients in a big hospital.
But only time will tell us, and we will see as to what percentage of patients really recover or really require long-term oxygen therapy, because lung fibrosis is not totally reversible and it can remain irreversible for a long time.
If you look at the kind of patients who have come back, are you seeing, for instance, that people who you thought had recovered completely, and also were maybe healthier, showing some signs of longer term damage?
SC: Obviously, people who have comorbidities and the elderly people are the patients who have suffered major illness. But [we did see this] even the younger patients. Patients, especially male patients, in the 50- to 60-year age group and even above 45, I [would] put them in the high-risk category even if they have a bit of comorbidities, because that is the age when we are losing quite a few people. I really am very upset when I lose a patient who is between 50 and 60 years, because that is the age when you are almost at the top of your career and everything. And we are seeing a lot of patients being lost even in this age group.
I would totally agree that people who have comorbidities, people who are elderly have more complications, but anybody and everybody who has gone on to a ventilator and has required several empirical treatment or modalities have had more complications than the people who have been mildly symptomatic. But I have seen people who were asymptomatic or mildly symptomatic when they were diagnosed coming back even one or two weeks later with several neurological problems--numbness, pain, tingling, weakness, lethargy--which I do not think are major problems but are troubling people in the long term.
Are you able to cure this or at least attempt to treat these symptoms?
SC: Quite a few people actually are recovering with time. But as I said, we are treating it only for the last three to four months. So only time would tell us as to how much of these people recover. People with weakness and the GI symptoms or other like giddiness and postural drop and all that are recovering in two to four weeks’ time. But quite a few people are not recovering also, and only time would tell us as to what their long-term implication is.
Dr Shah, if you were to compare COVID and non-COVID patients who have been treated in the ICU, is there some similarity? Or do COVID patients who have gone into ICU or intubation come out with deeper residual symptoms?
JS: Whatever I have seen in my practice, I would definitely say that COVID patients who have been in the ICU and the ventilator have come out with deeper symptoms--because the amount of lung fibrosis that the COVID infection is leaving behind is much more than the rest of the lung infection that we have been seeing in so many years. We do not know the exact pathophysiology as to why it is happening.
Apart from that, because the patients are in the hospital for at least a month, a lot of muscle wasting, and other GI complications are also leaving behind much more residual symptoms than routinely expected.
You also talked about mental health. All other factors constant, is this higher in patients who have emerged from COVID treatments as compared to non-COVID patients?
JS: Some amount of mental changes do happen in patients who are in the ICU. Another problem in the ICU is that all the people--doctors, nurses, and ward boys--are wearing the same uniform, everyone is just white [personal protective equipment kits]. You cannot see their expressions, you cannot talk to them.
Generally, an ICU is a very friendly atmosphere, we try to talk to the patients, we try to cheer them up. But in a COVID situation, everyone--including doctors and support staff--is very tense. So, there is absolutely no healthy communication with the patients which is possible. The patients have not spoken to their relatives, or to anyone nearby. So the mental changes are much more than you would expect with normal ICU patients.
I have seen even in moderate to mild patients who are treated in the ward or the rooms, they also tend to develop a lot of mental changes that are not routinely expected because there is so much fear related to corona--that once the patients get corona, they think it is doomsday, that they are not going to come out. They wonder what will happen when they go back home, whether the society will accept them, whether they will be able to move out of the house again, whether they will get infected again, whether they will infect their close ones and the elderly in the family. So many mental factors are going on in the patients’ mind.
SC: As Dr Shah said, mental illness is a major issue we are finding even [in the wards]. I do not go into the ICU that much, because I am an internist. But I see all these mild to moderate cases in the floors, and they are going into depression, anxiety.
Since the last two weeks, in our hospitals, we have psychologists talking to the patient, they telephonically consult because what is also happening is that the relatives are not allowed to visit patients who are mild to moderately sick because they are in a COVID ward. So, they are all alone and that is pushing them into anxiety and depression. When we go for our rounds, [if] we find a patient not doing too well mentally, we make a psychologist speak with them and we have seen the benefits of being proactive about it.
Dr Chatterjee, as you look ahead, knowing all of this, how can we be more careful?
SC: We have to be mentally strong. Even yoga and meditation actually builds up your mentally stability and your physical health. We have to have a healthy lifestyle, exercise, have the right food, have strong mental health, and yoga and meditation and all that does add to overcoming this illness much more. If you are mentally and physically weak, if you have comorbidities, obviously that makes you more prone to all these after-effects of the illness, which are more common.
Dr Shah, how do we as potential patients or citizens be more prepared for what lies beyond COVID?
JS: It is not the end of the game. We are still not done with COVID as of now. We should not lower our guard. We still need to continue the same precautions that we have been taking over the last four odd months. The virus is still looming very large nearby us.
And one thing that we have not realised is that the doctors are gradually going into exhaustion. If you ask about me, after three months of rigorous practice, there are a lot of difficulties for us also. So, it is upon us the citizens now to take utmost care and not overburden our healthcare system because it is also not in a healthy state right now. Even healthcare can crumble any time.
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