Persistent clinical manifestations at 3 and 6 months after severe acute respiratory syndrome coronavirus 2 infection

Dear Editor:

Since the emergence of the severe acute respiratory syndrome type 2 coronavirus (SARS-CoV2) as a pandemic in late 2019 and its significant global impact, more and more data are becoming available regarding its potential clinical sequelae once acute infection has ended,¹ with persistent symptoms described in virtually all organs and systems: neurological, ENT, cardiorespiratory, cutaneous, muscle-joint and digestive. Different terms have been coined to define them, including "persistent coronavirus (COVID) disease" and "post-COVID syndrome", generally to encompass those clinical manifestations that persist beyond 4–12 weeks after the acute illness has subsided.²

Our aim in this work is to evaluate the possible persistent clinical manifestations in patients who have overcome SARS-CoV2 infection, during follow-up in a specialist clinic up to 6 months after the onset of the clinical manifestations.

For this purpose, a retrospective cohort study was conducted on 174 patients admitted to the hospital ward of the Hospital Virgen de las Nieves in Granada between March and October 2020, all of them with confirmed SARS-CoV2 infection by polymerase chain reaction and/or serology, excluding unconfirmed suspects and those who did not require hospital admission. Follow-up was carried out in a specialist clinic with a clinical evaluation, asking about the different signs and symptoms as well as laboratory and radiological assessment.

Of the patients included, 54% were male and 46% female. The mean age was 59.5 years (SD: 14.9). The most commonly reported comorbidities were: hypertension (44.8%), diabetes (19.5%), asthma (13.2%) and COPD (5.2%).

With regard to symptoms present at the acute stage of infection, the most common symptoms found were: fever (87%), cough (74%), dyspnoea (68%) and diarrhoea (64%); followed by arthromyalgia (52%), ageusia (49%), anosmia (45%), headache (37%) and chest pain (34%).

The first post-hospitalisation follow-up visit, after an average of 92 days from the onset of the condition, showed persistence of symptoms in 63% of patients, with dyspnoea (36%), asthenia (30%), anxiety (17%), arthromyalgia (16%) and chest pain (11%) being the most common symptoms. Less common were hair loss (8%), cough (6%), headache (6%), loss of smell (6%), tachycardia with exertion (5.2%) and loss of taste (3%). A small percentage of patients reported odynophagia (1.7%).

After an average of 187 days from the onset of symptoms, the following post-hospitalisation follow-up visit showed persistence of symptoms in 32.75% of patients. The most common persistent symptoms continued to be dyspnoea (32%), asthenia (30%), arthromyalgia (14%) and anxiety (11%). Other less common manifestations were hair loss (7%), loss of smell (4%), headache (4%), tachycardia on exertion (3.4%), loss of taste (2%) and cough (2%).

Most available studies focus on clinical manifestations during acute and short-term infection, usually during the first 3 months, where persistence of clinical manifestations is more common. However, there is increasing evidence on persistent clinical manifestations at 6 months^3,4 and even a year after having overcome the infection,⁵ which is why the definition of “post-COVID syndrome” progressively gains more weight.

In line with other studies,³ our study not only highlights the frequency of persistent dyspnoea and asthenia at 6 months, but also psychological manifestations such as anxiety, in a non-negligible percentage. Hair loss, usually due to telogen effluvium and recoverable in virtually all patients, is a manifestation that usually occurs several weeks after the acute infection. On the other hand, exertional tachycardia, present in 3–5% of the included patients, appears to be due to an autonomic dysfunction secondary to the infection.

There are limitations to this study, such as the inclusion of only hospitalised patients, the clinical assessment based on patient reports without objective tests and the fact that the study was conducted in a single centre. However, the importance of long-term follow-up of these patients is emphasised, as up to one third of patients remain symptomatic 6 months after infection.

Funding

This article has not received any type of funding.