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Xavier de Brito AS, Bronchtein AI, Schaustz EB, Glavam AP, Pinheiro MVT, Secco JCP, Camargo GC, Almeida SA, Quintella TA, Albuquerque DC, Luiz RR, Medei E, Souza OF, Sales ARK, Sousa AS, Rosado-de-Castro PH, Moll-Bernardes RJ. Value of 123I-MIBG SPECT for the assessment of dysautonomia in patients with long COVID. IJC HEART & VASCULATURE 2024; 52:101413. [PMID: 38694270 PMCID: PMC11060949 DOI: 10.1016/j.ijcha.2024.101413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/04/2024]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Denilson C. Albuquerque
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- Cardiology Department, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Ronir R. Luiz
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- Institute for Studies in Public Health—IESC, UFRJ, Rio de Janeiro, Brazil
| | - Emiliano Medei
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- National Center for Structural Biology and Bioimaging, UFRJ, Rio de Janeiro, Brazil
| | - Olga F. Souza
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
| | | | - Andrea S. Sousa
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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2
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Naik H, Cooke E, Boulter T, Dyer R, Bone JN, Tsai M, Cristobal J, McKay RJ, Song X, Nacul L. Low-dose naltrexone for post-COVID fatigue syndrome: a study protocol for a double-blind, randomised trial in British Columbia. BMJ Open 2024; 14:e085272. [PMID: 38740499 PMCID: PMC11097836 DOI: 10.1136/bmjopen-2024-085272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION A significant proportion of individuals suffering from post COVID-19 condition (PCC, also known as long COVID) can present with persistent, disabling fatigue similar to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-viral fatigue syndromes. There remains no clear pharmacological therapy for patients with this subtype of PCC, which can be referred to as post-COVID fatigue syndrome (PCFS). A low dose of the opioid antagonist naltrexone (ie, low-dose naltrexone (LDN)) has emerged as an off-label treatment for treating fatigue and other symptoms in PCC. However, only small, non-controlled studies have assessed LDN in PCC, so randomised trials are urgently required. METHODS AND ANALYSIS A prospective, randomised, double-blind, parallel arm, placebo-controlled phase II trial will be performed to assess the efficacy of LDN for improving fatigue in PCFS. The trial will be decentralised and open to eligible individuals throughout the Canadian province of British Columbia (BC). Participants will be recruited through the province-wide Post-COVID-19 Interdisciplinary Clinical Care Network (PC-ICCN) and research volunteer platform (REACH BC). Eligible participants will be 19-69 years old, have had a confirmed or physician-suspected SARS-CoV-2 infection at least 3 months prior and meet clinical criteria for PCFS adapted from the Institute of Medicine ME/CFS criteria. Individuals who are taking opioid medications, have a history of ME/CFS prior to COVID-19 or history of significant liver disease will be excluded. Participants will be randomised to an LDN intervention arm (n=80) or placebo arm (n=80). Participants in each arm will be prescribed identical capsules starting at 1 mg daily and follow a prespecified schedule for up-titration to 4.5 mg daily or the maximum tolerated dose. The trial will be conducted over 16 weeks, with assessments at baseline, 6, 12 and 16 weeks. The primary outcome will be fatigue severity at 16 weeks evaluated by the Fatigue Severity Scale. Secondary outcomes will include pain Visual Analogue Scale score, overall symptom severity as measured by the Patient Phenotyping Questionnaire Short Form, 7-day step count and health-related quality of life measured by the EuroQol 5-Dimension questionnaire. ETHICS AND DISSEMINATION The trial has been authorised by Health Canada and approved by The University of British Columbia/Children's and Women's Health Centre of British Columbia Research Ethics Board. On completion, findings will be disseminated to patients, caregivers and clinicians through engagement activities within existing PCC and ME/CFS networks. Results will be published in academic journals and presented at conferences. TRIAL REGISTRATION NUMBER NCT05430152.
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Affiliation(s)
- Hiten Naik
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Post-COVID-19 Interdisciplinary Clinical Care Network, Vancouver, British Columbia, Canada
| | - Erin Cooke
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Travis Boulter
- Women's Health Research Institute, Vancouver, British Columbia, Canada
- Complex Chronic Diseases Program, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Roger Dyer
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Melody Tsai
- Women's Health Research Institute, Vancouver, British Columbia, Canada
- Complex Chronic Diseases Program, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Jaymie Cristobal
- Women's Health Research Institute, Vancouver, British Columbia, Canada
- Complex Chronic Diseases Program, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - R Jane McKay
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Xiaowei Song
- Fraser Health Authority, Surrey, British Columbia, Canada
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Luis Nacul
- Women's Health Research Institute, Vancouver, British Columbia, Canada
- Complex Chronic Diseases Program, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
- Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada
- London School of Hygiene and Tropical Medicine, London, UK
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3
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Delogu AB, Aliberti C, Birritella L, De Rosa G, De Rose C, Morello R, Cambise N, Marino AG, Belmusto A, Tinti L, Di Renzo A, Lanza GA, Buonsenso D. Autonomic cardiac function in children and adolescents with long COVID: a case-controlled study. Eur J Pediatr 2024; 183:2375-2382. [PMID: 38446228 PMCID: PMC11035407 DOI: 10.1007/s00431-024-05503-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
Although the mechanisms underlying the pathophysiology of long COVID condition are still debated, there is growing evidence that autonomic dysfunction may play a role in the long-term complications or persisting symptoms observed in a significant proportion of patients after SARS-CoV-2 infection. However, studies focused on autonomic dysfunction have primarily been conducted in adults, while autonomic function has not yet been investigated in pediatric subjects. In this study, for the first time, we assessed whether pediatric patients with long COVID present abnormalities in autonomic cardiac function. Fifty-six long COVID pediatric patients (mean age 10.3 ± 3.8 y) and 27 age-, sex-, and body surface area-matched healthy controls (mean age 10.4 ± 4.5y) underwent a standard 12-lead electrocardiography (ECG) and 24-h ECG Holter monitoring. Autonomic cardiac function was assessed by time-domain and frequency-domain heart rate variability parameters. A comprehensive echocardiographic study was also obtained by two-dimensional echocardiography and tissue Doppler imaging. Data analysis showed that pediatric patients with long COVID had significant changes in HRV variables compared to healthy controls: significantly lower r-MSSD (root mean square of successive RR interval differences, 47.4 ± 16.9 versus 60.4 ± 29.1, p = 0.02), significant higher values VLF (very low frequency, 2077.8 ± 1023.3 versus 494.3 ± 1015.5 ms, p = 0.000), LF (low frequency, 1340.3 ± 635.6 versus 354.6 ± 816.8 ms, p = 0.000), and HF (high frequency, 895.7 ± 575.8 versus 278.9 ± 616.7 ms, p = 0.000). No significant differences were observed between the two groups both in systolic and diastolic parameters by echocardiography. Conclusion: These findings suggest that pediatric patients with long COVID have an imbalance of cardiac autonomic function toward a relative predominance of parasympathetic tone, as already reported in adult patients with long COVID. Further studies are needed to clarify the clinical significance of this autonomic dysfunction and demonstrate its role as a pathophysiological mechanism of long COVID, paving the way for effective therapeutic and preventive strategies. What is Known: • Long Covid in children has been described globally, but studies have mostly focused on collecting the temporal evolution of persisting symptoms. What is New: • Cardiac autonomic imbalance toward a relative predominance of parasympathetic tone is a mechanism underlying Long Covid in children, as also described in adults.
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Affiliation(s)
- A B Delogu
- Institute of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Aliberti
- Institute of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - L Birritella
- Institute of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - G De Rosa
- Institute of Pediatrics, Pediatric Cardiology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - C De Rose
- Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Pediatrics, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - R Morello
- Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Pediatrics, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - N Cambise
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A G Marino
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A Belmusto
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - L Tinti
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - A Di Renzo
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - G A Lanza
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - D Buonsenso
- Università Cattolica del Sacro Cuore, Rome, Italy.
- Institute of Pediatrics, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica Università Cattolica del Sacro Cuore, Largo Agostino Gemelli 8, Rome, 00168, Italy.
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Dixit K, Frishman WH. Postural Tachycardia Syndrome and COVID-19: Focus on Ivabradine Therapy. Cardiol Rev 2024; 32:279-284. [PMID: 36729924 DOI: 10.1097/crd.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In this article we discuss the association of postural orthostatic tachycardia syndrome (POTS) with coronavirus-19 (COVID-19), ivabradine's unique mechanism of action, and its use in POTS patients. We highlight the pathophysiology and common etiologies of POTS, including preceding viral infections, vaccines, trauma, surgeries, and other stressors. COVID-19, a viral illness, has been associated with POTS through a variety of mechanisms that are not yet well understood. The initial management strategy for POTS is largely nonpharmacological, focusing on increasing venous return to the heart through physical therapy or other exercise activities. Ivabradine is a selective inhibitor of the funny sodium channels within the sinoatrial node. This unique mechanism of action allows for the reduction of heart rate without any effect on the heart's ionotropic activity. With an increase in the number of POTS cases, especially during the COVID pandemic, the importance of utilizing new medications and management strategies for POTS becomes imperative. Though ivabradine is currently only approved for the management of patients with coronary artery disease and heart failure by the Food and Drug Administration (FDA), it has also proven to be effective at reducing symptoms among patients with refractory POTS, and thus, should be considered for the management of patients who do not respond to initial treatment strategies.
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Affiliation(s)
- Keshav Dixit
- From the Department of Medicine, ISMMS Mount Sinai Morningside-West, New York, New York
| | - William H Frishman
- Departments of Medicine and Cardiology, New York Medical College and Westchester Medical Center, Valhalla, NY
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Bielecka E, Sielatycki P, Pietraszko P, Zapora-Kurel A, Zbroch E. Elevated Arterial Blood Pressure as a Delayed Complication Following COVID-19-A Narrative Review. Int J Mol Sci 2024; 25:1837. [PMID: 38339115 PMCID: PMC10856065 DOI: 10.3390/ijms25031837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/23/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Arterial hypertension is one of the most common and significant cardiovascular risk factors. There are many well-known and identified risk factors for its development. In recent times, there has been growing concern about the potential impact of COVID-19 on the cardiovascular system and its relation to arterial hypertension. Various theories have been developed that suggest a connection between COVID-19 and elevated blood pressure. However, the precise link between SARS-CoV-2 infection and the long-term risk of developing hypertension remains insufficiently explored. Therefore, the primary objective of our study was to investigate the influence of COVID-19 infection on blood pressure elevation and the subsequent risk of developing arterial hypertension over an extended period. To accomplish this, we conducted a thorough search review of relevant papers in the PubMed and SCOPUS databases up to 3 September 2023. Our analysis encompassed a total of 30 eligible articles. Out of the 30 papers we reviewed, 19 of them provided substantial evidence showing a heightened risk of developing arterial hypertension following COVID-19 infection. Eight of the studies showed that blood pressure values increased after the infection, while three of the qualified studies did not report any notable impact of COVID-19 on blood pressure levels. The precise mechanism behind the development of hypertension after COVID-19 remains unclear, but it is suggested that endothelial injury and dysfunction of the renin-angiotensin-aldosterone system may be contributory. Additionally, changes in blood pressure following COVID-19 infection could be linked to lifestyle alterations that often occur alongside the illness. Our findings emphasize the pressing requirement for thorough research into the relationship between COVID-19 and hypertension. These insights are essential for the development of effective prevention and management approaches for individuals who have experienced COVID-19 infection.
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Affiliation(s)
| | | | | | | | - Edyta Zbroch
- Department of Internal Medicine and Hypertension, Medical University of Bialystok, 15-540 Bialystok, Poland; (E.B.); (P.S.); (P.P.); (A.Z.-K.)
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6
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Gómez-Moyano E, Rodríguez-Capitán J, Gaitán Román D, Reyes Bueno JA, Villalobos Sánchez A, Espíldora Hernández F, González Angulo GE, Molina Mora MJ, Thurnhofer-Hemsi K, Molina-Ramos AI, Romero-Cuevas M, Jiménez-Navarro M, Pavón-Morón FJ. Postural orthostatic tachycardia syndrome and other related dysautonomic disorders after SARS-CoV-2 infection and after COVID-19 messenger RNA vaccination. Front Neurol 2023; 14:1221518. [PMID: 37654428 PMCID: PMC10467287 DOI: 10.3389/fneur.2023.1221518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
The COVID-19 pandemic has caused a challenge for our society due to the post-acute sequelae of the disease. Persistent symptoms and long-term multiorgan complications, known as post-acute COVID-19 syndrome, can occur beyond 4 weeks from the onset of the COVID-19 infection. Postural orthostatic tachycardia syndrome (POTS) is considered a variety of dysautonomia, which is characterized by chronic symptoms that occur with standing and a sustained increase in heart rate, without orthostatic hypotension. POTS can lead to debilitating symptoms, significant disability, and impaired quality of life. In this narrative review, the etiopathogenic basis, epidemiology, clinical manifestations, diagnosis, treatment, prognosis, and socioeconomic impact of POTS, as well as other related dysautonomic disorders, after COVID-19 infection and SARS-CoV-2 postvaccination, were discussed. After a search conducted in March 2023, a total of 89 relevant articles were selected from the PubMed, Google Scholar, and Web of Science databases. The review highlights the importance of recognizing and managing POTS after COVID-19 infection and vaccination, and the approach to autonomic disorders should be known by all specialists in different medical areas. The diagnosis of POTS requires a comprehensive clinical assessment, including a detailed medical history, physical examination, orthostatic vital signs, and autonomic function tests. The treatment of POTS after COVID-19 infection or vaccination is mainly focused on lifestyle modifications, such as increased fluid and salt intake, exercise, and graduated compression stockings. Pharmacotherapy, such as beta-blockers, fludrocortisone, midodrine, and ivabradine, may also be used in selected cases. Further research is needed to understand the underlying mechanisms, risk factors, and optimal treatment strategies for this complication.
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Affiliation(s)
| | - Jorge Rodríguez-Capitán
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Daniel Gaitán Román
- Department of Cardiology, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | | | | | - Karl Thurnhofer-Hemsi
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Computer Languages and Computer Sciences, University of Malaga, Málaga, Spain
| | - Ana Isabel Molina-Ramos
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Miguel Romero-Cuevas
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Manuel Jiménez-Navarro
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Department of Medicine and Dermatology, University of Malaga, Málaga, Spain
| | - Francisco Javier Pavón-Morón
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Department of Cardiology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
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Schnekenberg L, Sedghi A, Schoene D, Pallesen LP, Barlinn J, Woitek F, Linke A, Puetz V, Barlinn K, Mangner N, Siepmann T. Assessment and Therapeutic Modulation of Heart Rate Variability: Potential Implications in Patients with COVID-19. J Cardiovasc Dev Dis 2023; 10:297. [PMID: 37504553 PMCID: PMC10380874 DOI: 10.3390/jcdd10070297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/02/2023] [Accepted: 07/10/2023] [Indexed: 07/29/2023] Open
Abstract
Cardiac damage has been attributed to SARS-CoV-2-related pathology contributing to increased risk of vascular events. Heart rate variability (HRV) is a parameter of functional neurocardiac integrity with low HRV constituting an independent predictor of cardiovascular mortality. Whether structural cardiac damage translates into neurocardiac dysfunction in patients infected with SARS-CoV-2 remains poorly understood. Hypothesized mechanisms of possible neurocardiac dysfunction in COVID-19 comprise direct systemic neuroinvasion of autonomic control centers, ascending virus propagation along cranial nerves and cardiac autonomic neuropathy. While the relationship between the autonomic nervous system and the cytokine cascade in general has been studied extensively, the interplay between the inflammatory response caused by SARS-CoV-2 and autonomic cardiovascular regulation remains largely unclear. We reviewed the current literature on the potential diagnostic and prognostic value of autonomic neurocardiac function assessment via analysis of HRV including time domain and spectral analysis techniques in patients with COVID-19. Furthermore, we discuss potential therapeutic targets of modulating neurocardiac function in this high-risk population including HRV biofeedback and the impact of long COVID on HRV as well as the approaches of clinical management. These topics might be of particular interest with respect to multimodal pandemic preparedness concepts.
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Affiliation(s)
- Luiz Schnekenberg
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Annahita Sedghi
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Daniela Schoene
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Felix Woitek
- Dresden Heart Center, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Axel Linke
- Dresden Heart Center, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Norman Mangner
- Dresden Heart Center, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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Abbate G, De Iulio B, Thomas G, Priday A, Biondi-Zoccai G, Markley R, Abbate A. Postural Orthostatic Tachycardia Syndrome After COVID-19: A Systematic Review of Therapeutic Interventions. J Cardiovasc Pharmacol 2023; 82:23-31. [PMID: 37094584 DOI: 10.1097/fjc.0000000000001432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/06/2023] [Indexed: 04/26/2023]
Abstract
ABSTRACT Postural orthostatic tachycardia syndrome (POTS) is a clinical syndrome of inappropriate increase in heart rate on standing that has been recently also associated with Coronavirus Disease 2019 (COVID-19) as part of the postacute sequelae of COVID-19 (PASC) or long-COVID. We herein aimed to systematically review reported cases of POTS after COVID-19 and determine the characteristics of the subjects, the diagnostic approach used, and the treatment strategies. We searched the literature according to the following criteria: (1) diagnosis of POTS according to standard definition; (2) timely association with a probable or definite diagnosis of COVID-19; and (3) a description of the individual subject(s). We identified 21 reports meeting criteria between March 2020 and September 2022, including 68 subjects (51 females and 17 males, 3:1 ratio) with a mean age of 34 ± 12 years, with reports deriving from the United States, Norway, Sweden, Israel, Ireland, United Kingdom, Singapore, and Japan. Most cases had mild COVID-19 symptoms. The most common POTS symptoms were palpitations, chest pain, lightheadedness, and debilitating fatigue. The diagnosis was established by means of head-up tilt table or active stand test. Nonpharmacologic treatments (fluids, sodium intake, and compression stockings) were virtually always used, but largely ineffective. Subjects received different treatments, the most common being beta-adrenergic blockers (ie, propranolol), mineral corticosteroids (ie, fludrocortisone), midodrine, and ivabradine. Symptoms tended to improve over time, but most patients remained symptomatic for several months. In conclusion, POTS after COVID-19 is a clinical condition affecting young individuals, and disproportionately young women, occurring as part of PASC-long-COVID, often debilitating, which can be easily diagnosed with a thorough clinical assessment and measuring changes in orthostatic heart rate and blood pressure. POTS after COVID-19 seems to be poorly responsive to nonpharmacological treatments but with symptoms improving with pharmacological interventions. Given the limited data available, additional research is urgently needed with respect to its epidemiology, pathophysiology, and treatments.
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Affiliation(s)
- Gerardina Abbate
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA
| | - Beatrice De Iulio
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA
| | - Georgia Thomas
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Anna Priday
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; and
- Mediterranea Cardiocentro, Napoli, Italy
| | - Roshanak Markley
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Antonio Abbate
- Robert M. Berne Cardiovascular Research Center, University of Virginia, Charlottesville, VA
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Seeley MC, Gallagher C, Ong E, Langdon A, Chieng J, Bailey D, Page A, Lim HS, Lau DH. High incidence of autonomic dysfunction and postural orthostatic tachycardia syndrome in patients with long-COVID: Implications for management and healthcare planning. Am J Med 2023:S0002-9343(23)00402-3. [PMID: 37391116 PMCID: PMC10307671 DOI: 10.1016/j.amjmed.2023.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Autonomic dysfunction including postural orthostatic tachycardia syndrome (POTS) has been reported in individuals with post-acute sequelae of Covid-19 (PASC). However, the degree of dysautonomia in PASC has not been compared to those with POTS and healthy controls. METHODS All participants were prospectively enrolled between 5th August 2021 and 31st October 2022. Autonomic testing included beat-to-beat hemodynamic monitoring to assess respiratory sinus arrhythmia, Valsalva ratio and orthostatic changes during a 10-minute active standing test as well as Sudomotor assessment. The Composite Autonomic Symptom Score (COMPASS-31) was used to assess symptoms and the Euroquol 5-Dimension survey (EQ-5D-5L) was used to assess health-related quality of life (HrQoL) measures. RESULTS A total of 99 participants (n=33 PASC, n=33 POTS and n=33 healthy controls; median age 32 [18], 85.9% females) were included. Compared to healthy controls, the PASC and POTS cohorts demonstrated significantly reduced respiratory sinus arrhythmia (p<0.001), greater heart rate increase during 10-minute active standing test (p<0.001), greater burden of autonomic dysfunction evidenced by higher COMPASS-31 scores across all subdomains (all p<0.001) and poor HrQoL across all EQ-5D-5L domains (all p<0.001), lower median EQ-VAS (p<0.001) and lower utility scores (p<0.001). The majority (79%) of those with PASC met the internationally established criteria for POTS. CONCLUSION The prevalence of autonomic symptomology or POTS was high in those with PASC, leading to poor HrQoL and high health disutility. Autonomic testing should be routinely undertaken in those with PASC to aid diagnosis and direct appropriate management to improve health outcomes. TRIAL REGISTRATION ANZCTR 12621000476831.
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Affiliation(s)
- Marie-Claire Seeley
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; South Australian Health and Medical Research Institute
| | - Celine Gallagher
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; South Australian Health and Medical Research Institute
| | - Eric Ong
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Amy Langdon
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Jonathan Chieng
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide
| | - Danielle Bailey
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide
| | - Amanda Page
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; South Australian Health and Medical Research Institute; College of Medicine and Public Health, Flinders University, South Australia, Australia; The University of Melbourne, Austin and Northern Health, Victoria, Australia
| | - Han S Lim
- The University of Melbourne, Austin and Northern Health, Victoria, Australia
| | - Dennis H Lau
- Australian Dysautonomia and Arrhythmia Research Collaborative, Faculty of Health and Medical Sciences, The University of Adelaide; South Australian Health and Medical Research Institute.
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10
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Day H, Yellman B, Hammer S, Rond C, Bell J, Abbaszadeh S, Stoddard G, Unutmaz D, Bateman L, Vernon SD. Cognitive impairment in post-acute sequelae of COVID-19 and short duration myalgic encephalomyelitis patients is mediated by orthostatic hemodynamic changes. Front Neurosci 2023; 17:1203514. [PMID: 37434760 PMCID: PMC10330752 DOI: 10.3389/fnins.2023.1203514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/19/2023] [Indexed: 07/13/2023] Open
Abstract
Introduction Cognitive impairment is experienced by people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-acute sequelae of COVID-19 (PASC). Patients report difficulty remembering, concentrating, and making decisions. Our objective was to determine whether orthostatic hemodynamic changes were causally linked to cognitive impairment in these diseases. Methods This prospective, observational cohort study enrolled PASC, ME/CFS, and healthy controls. All participants underwent clinical evaluation and assessment that included brief cognitive testing before and after an orthostatic challenge. Cognitive testing measured cognitive efficiency which is defined as the speed and accuracy of subject's total correct responses per minute. General linear mixed models were used to analyze hemodynamics and cognitive efficiency during the orthostatic challenge. Additionally, mediation analysis was used to determine if hemodynamic instability induced during the orthostatic challenge mediated the relationship between disease status and cognitive impairment. Results Of the 276 participants enrolled, 256 were included in this study (34 PASC, 71 < 4 year duration ME/CFS, 69 > 10 year ME/CFS duration, and 82 healthy controls). Compared to healthy controls, the disease cohorts had significantly lower cognitive efficiency scores immediately following the orthostatic challenge. Cognitive efficiency remained low for the >10 year ME/CFS 2 and 7 days after orthostatic challenge. Narrow pulse pressure less than 25% of systolic pressure occurred at 4 and 5 min into the orthostatic challenge for the PASC and ME/CFS cohorts, respectively. Abnormally narrow pulse pressure was associated with slowed information processing in PASC patients compared to healthy controls (-1.5, p = 0.04). Furthermore, increased heart rate during the orthostatic challenge was associated with a decreased procedural reaction time in PASC and < 4 year ME/CFS patients who were 40 to 65 years of age. Discussion For PASC patients, both their disease state and hemodynamic changes during orthostatic challenge were associated with slower reaction time and decreased response accuracy during cognitive testing. Reduced cognitive efficiency in <4 year ME/CFS patients was associated with higher heart rate in response to orthostatic stress. Hemodynamic changes did not correlate with cognitive impairment for >10 year ME/CFS patients, but cognitive impairment remained. These findings underscore the need for early diagnosis to mitigate direct hemodynamic and other physiological effects on symptoms of cognitive impairment.
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Affiliation(s)
- Heather Day
- School of Medicine, The University of Utah, Salt Lake City, UT, United States
| | | | - Sarah Hammer
- Bateman Horne Center, Salt Lake City, UT, United States
| | - Candace Rond
- Bateman Horne Center, Salt Lake City, UT, United States
| | - Jennifer Bell
- Bateman Horne Center, Salt Lake City, UT, United States
| | | | - Greg Stoddard
- School of Medicine, The University of Utah, Salt Lake City, UT, United States
| | - Derya Unutmaz
- Jackson Laboratory for Genomic Medicine, School of Medicine, University of Connecticut, Farmington, CT, United States
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11
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Zanin A, Amah G, Chakroun S, Testard P, Faucher A, Le TYV, Slama D, Le Baut V, Lozeron P, Salmon D, Kubis N. Parasympathetic autonomic dysfunction is more often evidenced than sympathetic autonomic dysfunction in fluctuating and polymorphic symptoms of "long-COVID" patients. Sci Rep 2023; 13:8251. [PMID: 37217645 DOI: 10.1038/s41598-023-35086-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023] Open
Abstract
Several disabling symptoms potentially related to dysautonomia have been reported in "long-COVID" patients. Unfortunately, these symptoms are often nonspecific, and autonomic nervous system explorations are rarely performed in these patients. This study aimed to evaluate prospectively a cohort of long-COVID patients presenting severe disabling and non-relapsing symptoms of potential dysautonomia and to identify sensitive tests. Autonomic function was assessed by clinical examination, the Schirmer test; sudomotor evaluation, orthostatic blood pressure (BP) variation, 24-h ambulatory BP monitoring for sympathetic evaluation, and heart rate variation during orthostatism, deep breathing and Valsalva maneuvers for parasympathetic evaluation. Test results were considered abnormal if they reached the lower thresholds defined in publications and in our department. We also compared mean values for autonomic function tests between patients and age-matched controls. Sixteen patients (median age 37 years [31-43 years], 15 women) were included in this study and referred 14.5 months (median) [12.0-16.5 months] after initial infection. Nine had at least one positive SARS-CoV-2 RT-PCR or serology result. Symptoms after SARS-CoV-2 infection were severe, fluctuating and disabling with effort intolerance. Six patients (37.5%) had one or several abnormal test results, affecting the parasympathetic cardiac function in five of them (31%). Mean Valsalva score was significantly lower in patients than in controls. In this cohort of severely disabled long-COVID patients, 37.5% of them had at least one abnormal test result showing a possible contribution of dysautonomia to these nonspecific symptoms. Interestingly, mean values of the Valsalva test were significantly lower in patients than in control subjects, suggesting that normal values thresholds might not be appropriate in this population.
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Affiliation(s)
- Adrien Zanin
- INSERM UMR1144, Université Paris Cité, 75018, Paris, France
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Guy Amah
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Sahar Chakroun
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Pauline Testard
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Alice Faucher
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Thi Yen Vy Le
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Dorsaf Slama
- Department of Immunology and Infectious Diseases, APHP, Cochin-Hôtel-Dieu Hospital, Université Paris Cité, 75004, Paris, France
| | - Valérie Le Baut
- Department of Immunology and Infectious Diseases, APHP, Cochin-Hôtel-Dieu Hospital, Université Paris Cité, 75004, Paris, France
| | - Pierre Lozeron
- INSERM UMR1144, Université Paris Cité, 75018, Paris, France
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France
| | - Dominique Salmon
- Department of Immunology and Infectious Diseases, APHP, Cochin-Hôtel-Dieu Hospital, Université Paris Cité, 75004, Paris, France
| | - Nathalie Kubis
- INSERM UMR1144, Université Paris Cité, 75018, Paris, France.
- Service de Physiologie Clinique - Explorations Fonctionnelles, AP-HP, DMU DREAM, Hôpital Lariboisière, Université Paris Cité, 75010, Paris, France.
- Service de Physiologie Clinique - Explorations Fonctionnelles, Hôpital Lariboisière, 2 rue Ambroise Paré, 75475, Paris CEDEX10, France.
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12
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Alabsi H, Emerson K, Lin DJ. Neurorecovery after Critical COVID-19 Illness. Semin Neurol 2023. [PMID: 37168008 DOI: 10.1055/s-0043-1768714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
With the hundreds of millions of people worldwide who have been, and continue to be, affected by pandemic coronavirus disease (COVID-19) and its chronic sequelae, strategies to improve recovery and rehabilitation from COVID-19 are critical global public health priorities. Neurologic complications have been associated with acute COVID-19 infection, usually in the setting of critical COVID-19 illness. Neurologic complications are also a core feature of the symptom constellation of long COVID and portend poor outcomes. In this article, we review neurologic complications and their mechanisms in critical COVID-19 illness and long COVID. We focus on parallels with neurologic disease associated with non-COVID critical systemic illness. We conclude with a discussion of how recent findings can guide both neurologists working in post-acute neurologic rehabilitation facilities and policy makers who influence neurologic resource allocation.
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Affiliation(s)
- Haitham Alabsi
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristi Emerson
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Lin
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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13
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González-Hermosillo G JA, Galarza EJ, Fermín OV, González JMN, Tostado LMFÁ, Lozano MAE, Rabasa CR, Martínez Alvarado MDR. Exaggerated blood pressure elevation in response to orthostatic challenge, a post-acute sequelae of SARS-CoV-2 infection (PASC) after hospitalization. Auton Neurosci 2023; 247:103094. [PMID: 37137186 PMCID: PMC10121145 DOI: 10.1016/j.autneu.2023.103094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Post-acute sequelae of SARS-COV-2 (PASC) are emerging as a major health challenge. Orthostatic intolerance secondary to autonomic failure has been found in PASC patients. This study investigated the effect of COVID-19 after recovery on blood pressure (BP) during the orthostatic challenge. RESEARCH DESIGN AND METHODS Thirty-one out of 45 patients hospitalized due to COVID-19-related pneumonia that developed PASC and did not have hypertension at discharge were studied. They underwent a head-up tilt test (HUTT) at 10.8 ± 1.9 months from discharge. All met the PASC clinical criteria, and an alternative diagnosis did not explain the symptoms. This population was compared with 32 historical asymptomatic healthy controls. RESULTS Exaggerated orthostatic blood pressure response (EOPR)/orthostatic hypertension (OHT) was detected in 8 out of 23 (34.7 %) patients, representing a significantly increased prevalence (7.67-fold increase p = 0.009) compared to 2 out of 32 (6.4 %) asymptomatic healthy controls matched by age, who underwent HUTT and were not infected with SARS-CoV-2. CONCLUSIONS This prospective evaluation in patients with PASC revealed abnormal blood pressure rise during the orthostatic challenge, suggesting of autonomic dysfunction in a third of the studied subjects. Our findings support the hypothesis that EOPR/OHT may be a phenotype of neurogenic hypertension. Hypertension in PASC patients may adversely affect the cardiovascular burden in the world.
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Affiliation(s)
| | - Esteban Jorge Galarza
- Department of Endocrinology, Instituto Nacional de Cardiología Ignacio Chávez, México City 14080, Mexico
| | - Onasis Vicente Fermín
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, México City 14080, Mexico
| | - José Manuel Núñez González
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, México City 14080, Mexico
| | | | - Marco Antonio Estrada Lozano
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, México City 14080, Mexico
| | - Claudia Ruíz Rabasa
- Department of Cardiovascular Dysautonomia, Instituto Nacional de Cardiología Ignacio Chávez, México City 14080, Mexico
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14
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COVID-19 Induced Postural Orthostatic Tachycardia Syndrome (POTS): A Review. Cureus 2023; 15:e36955. [PMID: 37009342 PMCID: PMC10065129 DOI: 10.7759/cureus.36955] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
POTS (Postural Orthostatic Tachycardia Syndrome) is a multisystem disorder characterized by the abnormal autonomic response to an upright posture, causing orthostatic intolerance and excessive tachycardia without hypotension. Recent reports suggest that a significant percentage of COVID-19 survivors develop POTS within 6 to 8 months of infection. Prominent symptoms of POTS include fatigue, orthostatic intolerance, tachycardia, and cognitive impairment. The exact mechanisms of post-COVID-19 POTS are unclear. Still, different hypotheses have been given, including autoantibody production against autonomic nerve fibers, direct toxic effects of SARS-CoV-2, or sympathetic nervous system stimulation secondary to infection. Physicians should have a high suspicion of POTS in COVID-19 survival when presented with symptoms of autonomic dysfunction and should conduct diagnostic tests like the Tilt table and others to confirm it. The management of COVID-19-related POTS requires a comprehensive approach. Most patients respond to initial non-pharmacological options, but when the symptoms become more severe and they do not respond to the non-pharmacological approach, pharmacological options are considered. We have limited understanding and knowledge of post-COVID-19 POTS, and further research is warranted to improve our understanding and formulate a better management plan.
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15
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Daniel M, Charier D, Pereira B, Pachcinski M, Sharshar T, Molliex S. Prognosis value of pupillometry in COVID-19 patients admitted in intensive care unit. Auton Neurosci 2023; 245:103057. [PMID: 36549090 PMCID: PMC9758063 DOI: 10.1016/j.autneu.2022.103057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/26/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION ICU patients with SARS-CoV-2-related pneumonia are at risk to develop a central dysautonomia which can contribute to mortality and respiratory failure. The pupillary size and its reactivity to light are controlled by the autonomic nervous system. Pupillometry parameters (PP) allow to predict outcomes in various acute brain injuries. We aim at assessing the most predictive PP of in-hospital mortality and the need for invasive mechanical ventilation (IV). MATERIAL AND METHODS We led a prospective, two centers, observational study. We recruited adult patients admitted to ICU for a severe SARS-CoV-2 related pneumonia between April and August 2020. The pupillometry was performed at admission including the measurement of baseline pupillary diameter (PD), PD variations (PDV), pupillary constriction velocity (PCV) and latency (PDL). RESULTS Fifty patients, 90 % males, aged 66 (60-70) years were included. Seven (14 %) patients died in hospital. The baseline PD (4.1 mm [3.5; 4.8] vs 2.6 mm [2.4; 4.0], P = 0.009), PDV (33 % [27; 39] vs 25 % [15; 36], P = 0.03) and PCV (3.5 mm.s-1 [2.8; 4.4] vs 2.0 mm.s-1 [1.9; 3.8], P = 0.02) were significantly lower in patients who will die. A PD value <2.75 mm was the most predictive parameter of in-hospital mortality, with an AUC = 0.81, CI 95 % [0.63; 0.99]. Twenty-four (48 %) patients required IV. PD and PDV were significantly lower in patients who were intubated (3.5 mm [2.8; 4.4] vs 4.2 mm [3.9; 5.2], P = 0.03; 28 % [25; 36 %] vs 35 % [32; 40], P = 0.049, respectively). CONCLUSIONS A reduced baseline PD is associated with bad outcomes in COVID-19 patients admitted in ICU. It is likely to reflect a brainstem autonomic dysfunction.
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Affiliation(s)
- Matthieu Daniel
- Medical and Surgical Neurointensive Care Unit, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France; University of Paris, Paris, France.
| | - David Charier
- Anesthesia and Intensive Care Department & Sainbiose INSERM Unité 1059, Université Jean Monnet, Saint-Etienne, France
| | - Bruno Pereira
- Department of Clinical Research and Innovation, CHU of Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Tarek Sharshar
- Medical and Surgical Neurointensive Care Unit, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France,Department of Infection and Epidemiology, Pasteur Institute, University of Paris, Paris, France
| | - Serge Molliex
- Anesthesia and Intensive Care Department & Sainbiose INSERM Unité 1059, Université Jean Monnet, Saint-Etienne, France
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16
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Matsumoto C, Shibata S, Kishi T, Morimoto S, Mogi M, Yamamoto K, Kobayashi K, Tanaka M, Asayama K, Yamamoto E, Nakagami H, Hoshide S, Mukoyama M, Kario K, Node K, Rakugi H. Long COVID and hypertension-related disorders: a report from the Japanese Society of Hypertension Project Team on COVID-19. Hypertens Res 2023; 46:601-619. [PMID: 36575228 PMCID: PMC9793823 DOI: 10.1038/s41440-022-01145-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/28/2022]
Abstract
The coronavirus disease 2019 (COVID-19) affects infected patients even after the acute phase and impairs their health and quality of life by causing a wide variety of symptoms, referred to as long COVID. Although the evidence is still insufficient, hypertension is suspected to be a potential risk factor for long COVID, and the occurrence of cardiovascular diseases seems to be a key facet of multiple conditions observed in long COVID. Nonetheless, there are few reports that comprehensively review the impacts of long COVID on hypertension and related disorders. As a sequel to our previous report in 2020 which reviewed the association of COVID-19 and hypertension, we summarize the possible influences of long COVID on hypertension-related organs, including the cardiovascular system, kidney, and endocrine system, as well as the pathophysiological mechanisms associated with the disorders in this review. Given that the clinical course of COVID-19 is highly affected by age and sex, we also review the impacts of these factors on long COVID. Lastly, we discuss areas of uncertainty and future directions, which may lead to better understanding and improved prognosis of clinical problems associated with COVID-19.
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Affiliation(s)
- Chisa Matsumoto
- Department of Cardiology, Preventive medicine, Tokyo Medical University, Tokyo, Japan.
| | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan.
| | - Takuya Kishi
- Department of Graduate School of Medicine (Cardiology), International University of Health and Welfare, Okawa, Japan
| | - Satoshi Morimoto
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan
| | - Masaki Mogi
- Department of Pharmacology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kazuo Kobayashi
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.,Kobayashi Internal Medicine Clinic, Sagamihara, Japan
| | - Masami Tanaka
- Department of Internal Medicine, Adachi Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kei Asayama
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hironori Nakagami
- Department of Health Development and Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan.,Center for Infectious Disease Education and Research, Osaka University, Osaka, Japan
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Masashi Mukoyama
- Department of Nephrology, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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17
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Crook H, Ramirez A, Hosseini AA, Vavougyios G, Lehmann C, Bruchfeld J, Schneider A, d'Avossa G, Lo Re V, Salmoiraghi A, Mukaetova-Ladinska E, Katshu M, Boneschi FM, Håkansson K, Geerlings M, Pracht E, Ruiz A, Jansen JF, Snyder H, Kivipelto M, Edison P. European Working Group on SARS-CoV-2: Current Understanding, Unknowns, and Recommendations on the Neurological Complications of COVID-19. Brain Connect 2023; 13:178-210. [PMID: 36719785 DOI: 10.1089/brain.2022.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The emergence of COVID-19 was rapidly followed by infection and the deaths of millions of people across the globe. With much of the research and scientific advancement rightly focused on reducing the burden of severe and critical acute COVID-19 infection, the long-term effects endured by those who survived the acute infection has been previously overlooked. Now, an appreciation for the post-COVID-19 condition, including its neurological manifestations, is growing, although there remain many unknowns regarding the aetiology and risk factors of the condition, as well as how to effectively diagnose and treat it. Here, drawing upon the experiences and expertise of the clinicians and academics of the European working group on COVID-19, we have reviewed the current literature to provide a comprehensive overview of the neurological sequalae of the post-COVID-19 condition. In this review, we provide a summary of the neurological symptoms associated with the post-COVID-19 condition, before discussing the possible mechanisms which may underly and manifest these symptoms. Following this, we explore the risk factors for developing neurological symptoms as a result of COVID-19 and the post-COVID-19 condition, as well as how COVID-19 infection may itself be a risk factor for the development of neurological disease in the future. Lastly, we evaluate how the post-COVID condition could be accurately diagnosed and effectively treated, including examples of the current guidelines, clinical outcomes and tools that have been developed to aid in this process, as well as addressing the protection provided by COVID-19 vaccines against post-COVID-19 condition. Overall, this review provides a comprehensive overview of the neurological sequalae of the post-COVID-19 condition.
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Affiliation(s)
- Harry Crook
- Imperial College London, 4615, Brain Sciences, London, London, United Kingdom of Great Britain and Northern Ireland;
| | - Alfredo Ramirez
- University of Cologne, 14309, Department of Psychiatry and Psychotherapy, Koln, Nordrhein-Westfalen, Germany
- University of Bonn, 9374, Department of Neurodegenerative diseases and Geriatric Psychiatry, Bonn, Nordrhein-Westfalen, Germany
- Glenn Biggs Institute for Alzheimer's and Neurodegenerative Diseases, Department of Psychiatry , San Antonio, Texas, United States
- German Centre for Neurodegenerative Diseases, 172279, Bonn, Nordrhein-Westfalen, Germany;
| | - Akram A Hosseini
- Nottingham University Hospitals NHS Trust, 9820, Department of Neurology, Nottingham, Nottingham, United Kingdom of Great Britain and Northern Ireland;
| | - Georgios Vavougyios
- University of Cyprus, 54557, Department of Neurology, Nicosia, Nicosia, Cyprus;
| | - Clara Lehmann
- University of Cologne, 14309, Department of Internal Medicine, Koln, Nordrhein-Westfalen, Germany
- University of Cologne, 14309, Center for Molecular Medicine Cologne (CMMC), Koln, Nordrhein-Westfalen, Germany
- German Centre for Infection Research, 459706, Braunschweig, Niedersachsen, Germany;
| | - Judith Bruchfeld
- Karolinska University Hospital, 59562, Department of Infectious Diseases, Stockholm, Sweden;
| | - Anja Schneider
- University Hospital Bonn, 39062, Department of Neurodegenerative diseases and Geriatric Psychiatry, Bonn, Nordrhein-Westfalen, Germany
- German Centre for Neurodegenerative Diseases, 172279, Bonn, Nordrhein-Westfalen, Germany;
| | - Giovanni d'Avossa
- Bangor University, 1506, School of Psychology, Bangor, Gwynedd, United Kingdom of Great Britain and Northern Ireland;
| | | | - Alberto Salmoiraghi
- Betsi Cadwaladr University Health Board, 1507, Bangor, Gwynedd, United Kingdom of Great Britain and Northern Ireland
- Glyndwr University, 8725, Wrexham, Clwyd, United Kingdom of Great Britain and Northern Ireland;
| | - Elizabeta Mukaetova-Ladinska
- University of Leicester, 4488, Neuroscience, Psychology and Behaviour, University Road, Leicester, United Kingdom of Great Britain and Northern Ireland, LE1 7RH;
| | - Mohammad Katshu
- University of Nottingham, 6123, School of Medicine, Nottingham, Nottinghamshire, United Kingdom of Great Britain and Northern Ireland;
| | - Filippo M Boneschi
- University of Milan, 9304, Division of Neuroscience and INSPE, San Raffaele Scientific Institute, Milano, Lombardia, Italy;
| | - Krister Håkansson
- Karolinska Institute, 27106, Department of Neurobiology, Care Sciences and Society, Stockholm, Stockholm, Sweden;
| | - Mirjam Geerlings
- Utrecht University, 8125, University Medical Center Utrecht, Utrecht, Utrecht, Netherlands;
| | - Elisabeth Pracht
- University of Cologne, 14309, Department of Psychiatry and Psychotherapy, Koln, Nordrhein-Westfalen, Germany;
| | - Agustín Ruiz
- Universitat Internacional de Catalunya, 16760, Institut Català de Neurociències Aplicades, Barcelona, Catalunya, Spain;
| | - Jacobus Fa Jansen
- Maastricht University Medical Centre+, 199236, Department of Radiology and Nuclear Medicine, Maastricht, Limburg, Netherlands;
| | - Heather Snyder
- Alzheimer's Association, 44027, Chicago, Illinois, United States;
| | - Miia Kivipelto
- Karolinska Institute, 27106, Department of Neurobiology, Care Sciences and Society, Stockholm, Stockholm, Sweden;
| | - Paul Edison
- Imperial College London, 4615, Brain Sciences, Neurology Imaging Unit, 1st Floor, B - Block, Hammersmith Hospital Campus, Du Cane Road, London, United Kingdom of Great Britain and Northern Ireland, SW7 2AZ;
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18
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Autonomic Nerve Involvement in Post-Acute Sequelae of SARS-CoV-2 Syndrome (PASC). J Clin Med 2022; 12:jcm12010073. [PMID: 36614874 PMCID: PMC9821608 DOI: 10.3390/jcm12010073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
The novel SARS-CoV-2 virus and resulting COVID-19 global pandemic emerged in 2019 and continues into 2022. While mortality from COVID-19 is slowly declining, a subset of patients have developed chronic, debilitating symptoms following complete recovery from acute infection with COVID-19. Termed as post-acute sequelae of SARS-CoV-2 syndrome (PASC), the underlying pathophysiology of PASC is still not well understood. Given the similarity between the clinical phenotypes of PASC and postural orthostatic tachycardia syndrome (POTS), it has been postulated that dysautonomia may play a role in the pathophysiology of PASC. However, there have been only a few studies that have examined autonomic function in PASC. In this retrospective study, we performed an analysis of autonomic nerve function testing in PASC patients and compared the results with those of POTS patients and healthy controls. Our results suggest that a significant number of PASC patients have abnormal autonomic function tests, and their clinical features are indistinguishable from POTS.
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19
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Mohammad KO, Lin A, Rodriguez JBC. Cardiac Manifestations of Post-Acute COVID-19 Infection. Curr Cardiol Rep 2022; 24:1775-1783. [PMID: 36322364 PMCID: PMC9628458 DOI: 10.1007/s11886-022-01793-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW There is emerging evidence that the post-acute and chronic phases of COVID-19 infection are associated with various significant cardiovascular sequelae. RECENT FINDINGS Long COVID has been shown to be associated with multiple cardiovascular sequelae including direct myocardial injury, arrhythmias, and cardiomyopathies. Hypotheses on the mechanism of myocardial injury include direct viral infiltration and autoimmune dysregulation. Long COVID is associated with persistent cardiac ischemia in patients with no previous history of coronary disease, atrial and ventricular arrhythmias, and the development of new-onset heart failure in previously healthy patients. Onset of long COVID may be related to severity of the initial SARS-CoV2 infection. Cardiac MRI is a valuable tool in assessing myocarditis and the development of cardiomyopathies in the setting of long COVID. Both patients with and without pre-existing cardiovascular disease are at risk of developing myocardial injury in the setting of long COVID. Future studies will elucidate both cardiovascular mortality and cardiac rehabilitation in the post-acute and chronic phases of COVID-19.
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Affiliation(s)
- Khan O. Mohammad
- Department of Internal Medicine, Dell Medical School at The University of Texas, 1500 Red River St., Austin, TX 78701 USA
| | - Andrew Lin
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, CA USA
| | - Jose B. Cruz Rodriguez
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, San Diego, CA USA
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20
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Potential Therapeutic Benefits of Metformin Alone and in Combination with Sitagliptin in the Management of Type 2 Diabetes Patients with COVID-19. Pharmaceuticals (Basel) 2022; 15:ph15111361. [PMID: 36355535 PMCID: PMC9699540 DOI: 10.3390/ph15111361] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is a potential risk factor for the development of COVID-19 and is associated with higher severity and mortality rates. T2DM patients are commonly treated with metformin monotherapy or metformin plus sitagliptin. In the present case-control, single-center cohort study, a total number of 112 T2DM patients suffering from COVID-19 and aged 44−62 years old were compared with 78 T2DM patients without COVID-19 and aged 42−56 years old. Both the patient group and the control group were allocated into four groups. Group A: T2DM patients with COVID-19 on metformin treatments plus standard therapy (n = 60); group B: T2DM patients with COVID-19 on metformin plus sitagliptin plus standard therapy (n = 52); group C: T2DM patients without COVID-19 on metformin treatments (n = 40); and group D: T2DM patients without COVID-19 on metformin plus sitagliptin (n = 38). The investigation duration was 2−3 weeks. Anthropometric measurements, serological and biochemical investigations, pulmonary radiological findings, and clinical outcomes were evaluated. Only 101 T2DM patients with COVID-19 continued the study, 71 (70.29%) with mild-moderate COVID-19 and 30 (29.7%) with severe COVID-19 were compared with 78 T2DM patients as a control. Inflammatory biomarkers (C reactive protein, ferritin, and procalcitonin), a lung injury biomarker (lactate dehydrogenase), and a coagulopathy biomarker (D-dimer) were elevated in severe COVID-19 patients compared with mild-moderate COVID-19 (p < 0.05) and T2DM patients (p < 0.05). However, metformin plus sitagliptin was more effective than metformin monotherapy in T2DM patients with COVID-19, as evidenced by the mitigation of oxidative stress, CT scan score, and clinical outcomes. The present study confirmed the protective effects of this combination against the development of COVID-19 severity, as most T2DM COVID-19 patients develop mild-moderate forms. Herein, the combination of metformin and sitagliptin may lead to more beneficial effects than metformin monotherapy.
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21
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Al-Kuraishy HM, Al-Gareeb AI, Alexiou A, Batiha GES. Central Effects of Ivermectin in Alleviation of Covid-19-induced Dysauto-nomia. Curr Drug Targets 2022; 23:1277-1287. [PMID: 35950254 DOI: 10.2174/1389450123666220810102406] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/17/2022] [Accepted: 03/03/2022] [Indexed: 01/25/2023]
Abstract
Covid-19 may be associated with various neurological disorders, including dysautonomia, a dysfunction of the autonomic nervous system (ANS). In Covid-19, hypoxia, immunoinflammatory abnormality, and deregulation of the renin-angiotensin system (RAS) may increase sympathetic discharge with dysautonomia development. Direct SARS-CoV-2 cytopathic effects and associated inflammatory reaction may lead to neuroinflammation, affecting different parts of the central nervous system (CNS), including the autonomic center in the hypothalamus, causing dysautonomia. High circulating AngII, hypoxia, oxidative stress, high pro-inflammatory cytokines, and emotional stress can also provoke autonomic deregulation and high sympathetic outflow with the development of the sympathetic storm. During SARS-CoV-2 infection with neuro-invasion, GABA-ergic neurons and nicotinic acetylcholine receptor (nAChR) are inhibited in the hypothalamic pre-sympathetic neurons leading to sympathetic storm and dysautonomia. Different therapeutic modalities are applied to treat SARS-CoV-2 infection, like antiviral and anti-inflammatory drugs. Ivermectin (IVM) is a robust repurposed drug widely used to prevent and manage mild-moderate Covid-19. IVM activates both GABA-ergic neurons and nAChRs to mitigate SARS-CoV-2 infection- induced dysautonomia. Therefore, in this brief report, we try to identify the potential role of IVM in managing Covid-19-induced dysautonomia.
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Affiliation(s)
- Hayder M Al-Kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, AL-Mustansiriyiah University, Baghdad, Iraq
| | - Ali I Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, AL-Mustansiriyiah University, Baghdad, Iraq
| | - Athanasios Alexiou
- Department of Science and Engineering, Novel Global Community Educational Foundation, Hebersham, Australia.,AFNP Med, Wien, Austria
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour 22511, AlBeheira, Egypt
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22
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COVID-19, cardiac involvement and cardiac rehabilitation: Insights from a rehabilitation perspective - State of the Art. Turk J Phys Med Rehabil 2022; 68:317-335. [DOI: 10.5606/tftrd.2022.11435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022] Open
Abstract
Since the beginning of the pandemic, many novel coronavirus disease 2019 (COVID-19) patients have experienced multisystem involvement or become critically ill and treated in intensive care units, and even died. Among these systemic effects, cardiac involvement may have very important consequences for the patient’s prognosis and later life. Patients with COVID-19 may develop cardiac complications such as heart failure, myocarditis, pericarditis, vasculitis, acute coronary syndrome, and cardiac arrhythmias or trigger an accompanying cardiac disease. The ratio of COVID-19 cardiac involvement ranges between 7 and 28% in hospitalized patients with worse outcomes, longer stay in the intensive care unit, and a higher risk of death. Furthermore, deconditioning due to immobility and muscle involvement can be seen in post-COVID-19 patients and significant physical, cognitive and psychosocial impairments may be observed in some cases. Considering that the definition of health is “a state of complete physical, mental and social well-being”, individuals with heart involvement due to COVID-19 should be rehabilitated by evaluating all these aspects of the disease effect. In the light of the rehabilitation perspective and given the increasing number of patients with cardiac manifestations of COVID-19, in this review, we discuss the rehabilitation principles in this group of patients.
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23
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Understanding the Pivotal Role of the Vagus Nerve in Health from Pandemics. Bioengineering (Basel) 2022; 9:bioengineering9080352. [PMID: 36004877 PMCID: PMC9405360 DOI: 10.3390/bioengineering9080352] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 11/22/2022] Open
Abstract
The COVID-19 pandemic seems endless with the regular emergence of new variants. Is the SARS-CoV-2 virus particularly evasive to the immune system, or is it merely disrupting communication between the body and the brain, thus pre-empting homeostasis? Retrospective analysis of the COVID-19 and AIDS pandemics, as well as prion disease, emphasizes the pivotal but little-known role of the 10th cranial nerve in health. Considering neuroimmunometabolism from the point of view of the vagus nerve, non-invasive bioengineering solutions aiming at monitoring and stimulating the vagal tone are subsequently discussed as the next optimal and global preventive treatments, far beyond pandemics.
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24
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Lehmann HC. Neuromuskuläre Manifestationen beim Long-COVID-Syndrom. DER NERVENARZT 2022; 93:761-768. [PMID: 35852546 PMCID: PMC9294793 DOI: 10.1007/s00115-022-01321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 12/15/2022]
Abstract
Unter dem Long-COVID(„coronavirus disease“)-Syndrom werden Beschwerden zusammengefasst, die nach einer akuten SARS-CoV-2(„severe acute respiratory syndrome coronavirus type 2“)-Infektion auftreten, über einen Zeitraum von mehreren Wochen anhalten und nicht durch eine andere Diagnose erklärt werden können. Long-COVID wird als Multiorganmanifestation aufgefasst. In diesem Übersichtsartikel wird die Datenlage hinsichtlich neuromuskulärer Manifestationen des Long-COVID-Syndroms summiert und anhand von Kriterien wie Effektstärke, Plausibilität, Kohärenz und experimentelle Evidenz bewertet. Bisher sind vor allem Myalgien und eine autonome Dysfunktion (u. a. das posturale Tachykardiesyndrom) als neuromuskuläre Symptome von Long-COVID beschrieben worden. Die bisherige Evidenz ist allerdings gering: Neben einer sehr heterogenen Methodik und unterschiedlichen Definitionen in den klinischen Long-COVID-Studien fehlen schlüssige experimentelle Daten, die die beschriebenen Symptome als spezifische Langzeitfolge von COVID-19 belegen.
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25
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Sodagar A, Javed R, Tahir H, Razak SIA, Shakir M, Naeem M, Yusof AHA, Sagadevan S, Hazafa A, Uddin J, Khan A, Al-Harrasi A. Pathological Features and Neuroinflammatory Mechanisms of SARS-CoV-2 in the Brain and Potential Therapeutic Approaches. Biomolecules 2022; 12:biom12070971. [PMID: 35883527 PMCID: PMC9313047 DOI: 10.3390/biom12070971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/03/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
The number of deaths has been increased due to COVID-19 infections and uncertain neurological complications associated with the central nervous system. Post-infections and neurological manifestations in neuronal tissues caused by COVID-19 are still unknown and there is a need to explore how brainstorming promoted congenital impairment, dementia, and Alzheimer’s disease. SARS-CoV-2 neuro-invasion studies in vivo are still rare, despite the fact that other beta-coronaviruses have shown similar properties. Neural (olfactory or vagal) and hematogenous (crossing the blood–brain barrier) pathways have been hypothesized in light of new evidence showing the existence of SARS-CoV-2 host cell entry receptors into the specific components of human nerve and vascular tissue. Spike proteins are the primary key and structural component of the COVID-19 that promotes the infection into brain cells. Neurological manifestations and serious neurodegeneration occur through the binding of spike proteins to ACE2 receptor. The emerging evidence reported that, due to the high rate in the immediate wake of viral infection, the olfactory bulb, thalamus, and brain stem are intensely infected through a trans-synaptic transfer of the virus. It also instructs the release of chemokines, cytokines, and inflammatory signals immensely to the blood–brain barrier and infects the astrocytes, which causes neuroinflammation and neuron death; and this induction of excessive inflammation and immune response developed in more neurodegeneration complications. The present review revealed the pathophysiological effects, molecular, and cellular mechanisms of possible entry routes into the brain, pathogenicity of autoantibodies and emerging immunotherapies against COVID-19.
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Affiliation(s)
- Aisha Sodagar
- Department of Botany, Faculty of Sciences, University of Agriculture, Faisalabad 38040, Pakistan;
| | - Rasab Javed
- Institute of Microbiology, University of Agriculture, Faisalabad 38040, Pakistan;
| | - Hira Tahir
- Department of Botany, Government College Women University Faisalabad, Faisalabad 38000, Pakistan;
| | - Saiful Izwan Abd Razak
- Bioinspired Device and Tissue Engineering Research Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, Johor Bahru 81310, Johor, Malaysia;
- Sports Innovation & Technology Centre, Institute of Human Centred Engineering, Universiti Teknologi Malaysia, Johor Bahru 81310, Johor, Malaysia
| | - Muhammad Shakir
- School of Life Sciences, Northeast Normal University, Changchun 130024, China;
| | - Muhammad Naeem
- College of Life Science, Hebei Normal University, Shijiazhuang 050024, China;
| | - Abdul Halim Abdul Yusof
- School of Chemical and Energy Engineering, Faculty of Engineering, Universiti Teknologi Malaysia, Johor Bahru 81310, Johor, Malaysia;
| | - Suresh Sagadevan
- Nanotechnology & Catalysis Research Centre, University of Malaya, Kuala Lumpur 50603, Kuala Lumpur, Malaysia;
| | - Abu Hazafa
- Department of Biochemistry, Faculty of Sciences, University of Agriculture, Faisalabad 38040, Pakistan
- Correspondence: or (A.H.); (A.K.); (A.A.-H.)
| | - Jalal Uddin
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Khalid University, Abha 62529, Saudi Arabia;
| | - Ajmal Khan
- Natural and Medical Sciences Research Center, University of Nizwa, Birkat Al Mauz, Nizwa 616, Oman
- Correspondence: or (A.H.); (A.K.); (A.A.-H.)
| | - Ahmed Al-Harrasi
- Natural and Medical Sciences Research Center, University of Nizwa, Birkat Al Mauz, Nizwa 616, Oman
- Correspondence: or (A.H.); (A.K.); (A.A.-H.)
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26
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Scala I, Rizzo PA, Bellavia S, Brunetti V, Colò F, Broccolini A, Della Marca G, Calabresi P, Luigetti M, Frisullo G. Autonomic Dysfunction during Acute SARS-CoV-2 Infection: A Systematic Review. J Clin Med 2022; 11:jcm11133883. [PMID: 35807167 PMCID: PMC9267913 DOI: 10.3390/jcm11133883] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 02/04/2023] Open
Abstract
Although autonomic dysfunction (AD) after the recovery from Coronavirus disease 2019 (COVID-19) has been thoroughly described, few data are available regarding the involvement of the autonomic nervous system (ANS) during the acute phase of SARS-CoV-2 infection. The primary aim of this review was to summarize current knowledge regarding the AD occurring during acute COVID-19. Secondarily, we aimed to clarify the prognostic value of ANS involvement and the role of autonomic parameters in predicting SARS-CoV-2 infection. According to the PRISMA guidelines, we performed a systematic review across Scopus and PubMed databases, resulting in 1585 records. The records check and the analysis of included reports’ references allowed us to include 22 articles. The studies were widely heterogeneous for study population, dysautonomia assessment, and COVID-19 severity. Heart rate variability was the tool most frequently chosen to analyze autonomic parameters, followed by automated pupillometry. Most studies found ANS involvement during acute COVID-19, and AD was often related to a worse outcome. Further studies are needed to clarify the role of autonomic parameters in predicting SARS-CoV-2 infection. The evidence emerging from this review suggests that a complex autonomic nervous system imbalance is a prominent feature of acute COVID-19, often leading to a poor prognosis.
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Affiliation(s)
- Irene Scala
- School of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy; (I.S.); (P.A.R.); (S.B.); (F.C.); (A.B.); (G.D.M.); (P.C.)
| | - Pier Andrea Rizzo
- School of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy; (I.S.); (P.A.R.); (S.B.); (F.C.); (A.B.); (G.D.M.); (P.C.)
| | - Simone Bellavia
- School of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy; (I.S.); (P.A.R.); (S.B.); (F.C.); (A.B.); (G.D.M.); (P.C.)
| | - Valerio Brunetti
- Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e Della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (V.B.); (G.F.)
| | - Francesca Colò
- School of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy; (I.S.); (P.A.R.); (S.B.); (F.C.); (A.B.); (G.D.M.); (P.C.)
| | - Aldobrando Broccolini
- School of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy; (I.S.); (P.A.R.); (S.B.); (F.C.); (A.B.); (G.D.M.); (P.C.)
- Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e Della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (V.B.); (G.F.)
| | - Giacomo Della Marca
- School of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy; (I.S.); (P.A.R.); (S.B.); (F.C.); (A.B.); (G.D.M.); (P.C.)
- Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e Della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (V.B.); (G.F.)
| | - Paolo Calabresi
- School of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy; (I.S.); (P.A.R.); (S.B.); (F.C.); (A.B.); (G.D.M.); (P.C.)
- Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e Della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (V.B.); (G.F.)
| | - Marco Luigetti
- School of Medicine and Surgery, Catholic University of Sacred Heart, Largo Francesco Vito, 1, 00168 Rome, Italy; (I.S.); (P.A.R.); (S.B.); (F.C.); (A.B.); (G.D.M.); (P.C.)
- Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e Della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (V.B.); (G.F.)
- Correspondence: ; Tel.: +39-06-30154435
| | - Giovanni Frisullo
- Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e Della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (V.B.); (G.F.)
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27
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COVID-19 Vaccination Might Induce Postural Orthostatic Tachycardia Syndrome: A Case Report. Vaccines (Basel) 2022; 10:vaccines10070991. [PMID: 35891154 PMCID: PMC9323926 DOI: 10.3390/vaccines10070991] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/14/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023] Open
Abstract
We report a case of new-onset postural orthostatic tachycardia syndrome in a healthy 46-year-old female after a single dose of the BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 vaccine. There have been three prior reports of new-onset postural orthostatic tachycardia syndrome after COVID-19 vaccination. Predominant symptoms noted included fatigue, brain fog, headache, sinus tachycardia, and dizziness. Management includes noninvasive therapies, behavioral approaches, and pharmacologic regimens. Here, the patient presented with fatigue, palpitations, dizziness, and presyncope, with symptoms beginning 7 days after vaccination. Presenting vitals included temperature within normal limits, inappropriate tachycardia, up to 120 beats per minute, blood pressure of 128/87 mm of mercury, and 100% saturation in room air. Her management included lifestyle changes, dietary supplements, and ivabradine. Further studies are needed to evaluate prevalence, etiology, and optimal management.
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28
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Park J, Kim S, Lee J, An JY. A case of transient POTS following COVID-19 vaccine. Acta Neurol Belg 2022; 122:1081-1083. [PMID: 35725868 PMCID: PMC9208536 DOI: 10.1007/s13760-022-02002-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/07/2022] [Indexed: 01/02/2023]
Affiliation(s)
- Jeonghyun Park
- Department of Neurology, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Republic of Korea
| | - Sanghyun Kim
- Department of Neurology, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Republic of Korea
| | - Jusuck Lee
- Department of Neurology, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Republic of Korea
| | - Jae Young An
- Department of Neurology, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon, Gyeonggi-do, 442-723, Republic of Korea.
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29
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Hajiasgharzadeh K, Jafarlou M, Mansoori B, Dastmalchi N, Baradaran B, Khabbazi A. Inflammatory reflex disruption in COVID-19. CLINICAL & EXPERIMENTAL NEUROIMMUNOLOGY 2022; 13:CEN312703. [PMID: 35600135 PMCID: PMC9111569 DOI: 10.1111/cen3.12703] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 12/13/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified in Wuhan, China, in late 2019 and caused coronavirus disease 2019 (COVID-19), which is still a global pandemic. In most infected people, SARS-CoV-2 can only cause moderate symptoms, while in other patients, it leads to severe illness and eventually death. Although the main clinical manifestation of COVID-19 is often seen in the lungs, this disease affects almost all body organs. The excessive and prolonged release of inflammatory cytokines that may occur in COVID-19 patients, known as cytokine storms, stimulates undesired immune responses and can cause various tissues damage. In the current review article, we focus on the potential advantages of the intrinsic cholinergic anti-inflammatory pathway (CAP) as the efferent arm of inflammatory reflex in COVID-19 management. Considering this endogenous protective mechanism against chronic inflammation, we focused on the effects of SARS-CoV-2 in the destruction of this anti-inflammatory system. Several studies indicated the interaction of SARS-CoV-2 with the alpha7 subtype of the nicotinic acetylcholine receptor as the effector molecule of the inflammatory reflex. On the other hand, neurological manifestations have increasingly been identified as significant extrapulmonary manifestations of COVID-19. The rational connection between these findings and COVID-19 pathogenesis may be an important issue in both our understanding and dealing with this disease. COVID-19 is deeply rooted in our daily life and requires an urgent need for the establishment of effective therapeutic options, and all the possible treatments must be considered for the control of such inflammatory conditions.
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Affiliation(s)
- Khalil Hajiasgharzadeh
- Immunology Research CenterTabriz University of Medical SciencesTabrizIran
- Connective Tissue Diseases Research CenterTabriz University of Medical SciencesTabrizIran
| | - Mahdi Jafarlou
- Immunology Research CenterTabriz University of Medical SciencesTabrizIran
| | - Behzad Mansoori
- Cellular and Molecular Oncogenesis ProgramThe Wistar InstitutePhiladelphiaPennsylvaniaUSA
| | | | - Behzad Baradaran
- Immunology Research CenterTabriz University of Medical SciencesTabrizIran
- Pharmaceutical Analysis Research CenterTabriz University of Medical SciencesTabrizIran
| | - Alireza Khabbazi
- Connective Tissue Diseases Research CenterTabriz University of Medical SciencesTabrizIran
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30
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Durstenfeld MS, Peluso MJ, Kelly JD, Win S, Swaminathan S, Li D, Arechiga VM, Zepeda VA, Sun K, Shao SJ, Hill C, Arreguin MI, Lu S, Hoh R, Tai VW, Chenna A, Yee BC, Winslow JW, Petropoulos CJ, Kornak J, Henrich TJ, Martin JN, Deeks SG, Hsue PY. Role of antibodies, inflammatory markers, and echocardiographic findings in post-acute cardiopulmonary symptoms after SARS-CoV-2 infection. JCI Insight 2022; 7:157053. [PMID: 35389890 PMCID: PMC9220849 DOI: 10.1172/jci.insight.157053] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/06/2022] [Indexed: 12/15/2022] Open
Abstract
Shortness of breath, chest pain, and palpitations occur as postacute sequelae of COVID-19, but whether symptoms are associated with echocardiographic abnormalities, cardiac biomarkers, or markers of systemic inflammation remains unknown. In a cross-sectional analysis, we assessed symptoms, performed echocardiograms, and measured biomarkers among adults more than 8 weeks after confirmed SARS-CoV-2 infection. We modeled associations between symptoms and baseline characteristics, echocardiographic findings, and biomarkers using logistic regression. We enrolled 102 participants at a median of 7.2 months following COVID-19 onset; 47 individuals reported dyspnea, chest pain, or palpitations. Median age was 52 years, and 41% of participants were women. Female sex, hospitalization, IgG antibody against SARS-CoV-2 receptor binding domain, and C-reactive protein were associated with symptoms. Regarding echocardiographic findings, 4 of 47 participants (9%) with symptoms had pericardial effusions compared with 0 of 55 participants without symptoms; those with effusions had a median of 4 symptoms compared with a median of 1 symptom in those without effusions. There was no strong evidence for a relationship between symptoms and echocardiographic functional parameters or other biomarkers. Among adults more than 8 weeks after SARS-CoV-2 infection, SARS-CoV-2 RBD antibodies, markers of inflammation, and, possibly, pericardial effusions are associated with cardiopulmonary symptoms. Investigation into inflammation as a mechanism underlying postacute sequelae of COVID-19 is warranted.
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Affiliation(s)
- Matthew S Durstenfeld
- Division of Cardiology, University of California, San Francisco, San Francisco, United States of America
| | - Michael J Peluso
- University of California, San Francisco, San Francisco, United States of America
| | - J Daniel Kelly
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, United States of America
| | - Sithu Win
- Division of Cardiology, University of California, San Francisco, San Francisco, United States of America
| | - Shreya Swaminathan
- Division of Cardiology, University of California, San Francisco, San Francisco, United States of America
| | - Danny Li
- Division of Cardiology, University of California, San Francisco, San Francisco, United States of America
| | - Victor M Arechiga
- Division of Cardiology, University of California, San Francisco, San Francisco, United States of America
| | - Victor Antonio Zepeda
- Division of Cardiology, University of California, San Francisco, San Francisco, United States of America
| | - Kaiwen Sun
- Department of Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Shirley J Shao
- School of Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Christopher Hill
- School of Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Mireya I Arreguin
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Scott Lu
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Rebecca Hoh
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Viva W Tai
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Ahmed Chenna
- Oncology Group, Monogram Biosciences, South San Francisco, United States of America
| | - Brandon C Yee
- Monogram Biosciences, South San Francisco, United States of America
| | - John W Winslow
- Oncology Group, Monogram Biosciences, South San Francisco, United States of America
| | | | - John Kornak
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, United States of America
| | - Timothy J Henrich
- Division of Experimental Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Jeffrey N Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, United States of America
| | - Steven G Deeks
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, United States of America
| | - Priscilla Y Hsue
- Division of Cardiology, University of California, San Francisco, San Francisco, United States of America
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Orendáčová M, Kvašňák E. Possible Mechanisms Underlying Neurological Post-COVID Symptoms and Neurofeedback as a Potential Therapy. Front Hum Neurosci 2022; 16:837972. [PMID: 35431842 PMCID: PMC9010738 DOI: 10.3389/fnhum.2022.837972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/26/2022] [Indexed: 12/13/2022] Open
Abstract
Theoretical considerations related to neurological post-COVID complications have become a serious issue in the COVID pandemic. We propose 3 theoretical hypotheses related to neurological post-COVID complications. First, pathophysiological processes responsible for long-term neurological complications caused by COVID-19 might have 2 phases: (1) Phase of acute Sars-CoV-2 infection linked with the pathogenesis responsible for the onset of COVID-19-related neurological complications and (2) the phase of post-acute Sars-CoV-2 infection linked with the pathogenesis responsible for long-lasting persistence of post-COVID neurological problems and/or exacerbation of another neurological pathologies. Second, post-COVID symptoms can be described and investigated from the perspective of dynamical system theory exploiting its fundamental concepts such as system parameters, attractors and criticality. Thirdly, neurofeedback may represent a promising therapy for neurological post-COVID complications. Based on the current knowledge related to neurofeedback and what is already known about neurological complications linked to acute COVID-19 and post-acute COVID-19 conditions, we propose that neurofeedback modalities, such as functional magnetic resonance-based neurofeedback, quantitative EEG-based neurofeedback, Othmer's method of rewarding individual optimal EEG frequency and heart rate variability-based biofeedback, represent a potential therapy for improvement of post-COVID symptoms.
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Affiliation(s)
- Mária Orendáčová
- Department of Medical Biophysics and Medical Informatics, Third Faculty of Medicine, Charles University in Prague, Prague, Czechia
| | - Eugen Kvašňák
- Department of Medical Biophysics and Medical Informatics, Third Faculty of Medicine, Charles University in Prague, Prague, Czechia
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32
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Long-Term COVID 19 Sequelae in Adolescents: the Overlap with Orthostatic Intolerance and ME/CFS. CURRENT PEDIATRICS REPORTS 2022; 10:31-44. [PMID: 35287333 PMCID: PMC8906524 DOI: 10.1007/s40124-022-00261-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 12/13/2022]
Abstract
Purpose of Review To discuss emerging understandings of adolescent long COVID or post-COVID-19 conditions, including proposed clinical definitions, common symptoms, epidemiology, overlaps with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and orthostatic intolerance, and preliminary guidance on management. Recent Findings The recent World Health Organization clinical case definition of post-COVID-19 condition requires a history of probable or confirmed SARS-CoV-2 infection, with symptoms starting within 3 months of the onset of COVID-19. Symptoms must last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms of the post-COVID-19 condition include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction. These symptoms generally have an impact on everyday functioning. The incidence of prolonged symptoms following SARS-CoV-2 infection has proven challenging to define, but it is now clear that those with relatively mild initial infections, without severe initial respiratory disease or end-organ injury, can still develop chronic impairments, with symptoms that overlap with conditions like ME/CFS (profound fatigue, unrefreshing sleep, post-exertional malaise, cognitive dysfunction, and orthostatic intolerance). Summary We do not yet have a clear understanding of the mechanisms by which individuals develop post-COVID-19 conditions. There may be several distinct types of long COVID that require different treatments. At this point, there is no single pharmacologic agent to effectively treat all symptoms. Because some presentations of post-COVID-19 conditions mimic disorders such as ME/CFS, treatment guidelines for this and related conditions can be helpful for managing post-COVID-19 symptoms. Supplementary Information The online version contains supplementary material available at 10.1007/s40124-022-00261-4.
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Abstract
Purpose Autonomic dysfunction in patients with viral infections has been described before. In this study, we aimed to evaluate autonomic functions in patients with the coronavirus infectious disease 2019 (COVİD-19). Methods In this cross-sectional study, we compared 112 patients who had recovered from COVID-19 and 106 healthy controls. Symptoms of autonomic dysfunction were assessed with the SCOPA-AUT scale. Results Pupillomotor, urinary and sudomotor subscores of SCOPA-AUT scale were significantly higher in the COVID-19 patient group (p = 0.03, p = 0,006, p = 0.0001, respectively). There were no significant difference in terms of gastrointestinal, cardiovascular, sexual subscores and total SCOPA-AUT scores between the patient and control groups. The presence of fatigue symptom in the acute phase of COVID-19 increased the total SCOPA-AUT score by 2.2 points (p = 0.04) whereas the presence of smell loss (OR = 5.82, p = 0.01) and dyspnea (OR = 5.8, p = 0.03) were significant risk factors for pupillomotor dysfunction. The urinary, cardiovascular, sexual subscores and the total score of SCOPA-AUT scale were positively correlated with the age of the patient group. Conclusion Our study suggests that many patients might have prolonged symptoms of autonomic dysfunction after the acute phase of COVID-19 that might worsen the clinical recovery.
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Agnihotri SP, Luis CVS, Kazamel M. Autonomic neuropathy as post-acute sequela of SARS-CoV-2 infection: a case report. J Neurovirol 2022; 28:158-161. [PMID: 35181863 PMCID: PMC8856878 DOI: 10.1007/s13365-022-01056-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/13/2022] [Accepted: 01/27/2022] [Indexed: 01/01/2023]
Abstract
Symptoms of autonomic dysfunction, particularly those of orthostatic intolerance, continue to represent a major component of the currently recognized post-acute sequelae of SARS-CoV-2 infections. Different pathophysiologic mechanisms can be involved in the development of orthostatic intolerance including hypovolemia due to gastrointestinal dysfunction, fatigue-associated deconditioning, and hyperadrenergic state due to pandemic-related anxiety. Additionally, there has been a well-established association of a common primary autonomic disorder like postural orthostatic tachycardia syndrome, a subtype of orthostatic intolerance, with antecedent viral infections. Here we report a case of neuropathic type postural orthostatic tachycardia syndrome as a form of autonomic neuropathy that developed following COVID-19 infection.
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Affiliation(s)
- Shruti P Agnihotri
- Department of Neurology, University of Alabama at Birmingham, 1720 2nd Ave. South, SC271, Birmingham, AL, 35294-0017, USA
| | - Carmela V San Luis
- Department of Neurology, University of Alabama at Birmingham, 1720 2nd Ave. South, SC271, Birmingham, AL, 35294-0017, USA
| | - Mohamed Kazamel
- Department of Neurology, University of Alabama at Birmingham, 1720 2nd Ave. South, SC271, Birmingham, AL, 35294-0017, USA.
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35
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Dotan A, David P, Arnheim D, Shoenfeld Y. The autonomic aspects of the post-COVID19 syndrome. Autoimmun Rev 2022; 21:103071. [PMID: 35182777 PMCID: PMC8848724 DOI: 10.1016/j.autrev.2022.103071] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 01/04/2023]
Abstract
The SARS-CoV-2 outbreak, responsible for the widespread COVID-19, led to one of the most rogue pandemics in modern time, yet the major effects of the pandemic may still be ahead of us. SARS-CoV-2 had been found to possess autoimmune properties. Close to 20 distinct autoantibodies which target GPCR of the nervous system and renin-angiotensin system-related molecules were found significantly associated with the clinical severity of COVID-19. The new on-set of more than 10 various autoimmune disorders were documented as well. Additionally, clinical presentations of persisted symptoms were triggered in numerous recently recovered COVID-19 patients, which led to the formulation of the novel term “post-COVID19 syndrome”. Manifestations related to post-COVID-19 syndrome exist among approximately 50–80% of symptomatic COVID-19 patients who recovered, and among patients reported more than 50 different long-term effects of the SARS-CoV-2 infection. Many of the common symptoms of the post-COVID19 syndrome are not explained by the virus-related injury alone. Similarly to chronic fatigue syndrome and fibromyalgia, autoimmune-mediated autonomic nervous system dysfunction may play a significant part in the pathogenesis of such symptoms, including chronic fatigue, cognitive impairment, mood related disorders, and numerous more. Importantly, therapeutic options such as immunomodulatory and immunosuppressive therapy may favor some post-COVID19 patients, while plasmapheresis and IVIG could be considered in severe cases. Nevertheless, as physical exercise has been found to stabilize the autonomic nervous system, exercise therapy might be a safer and more effective remedy for the post-COVID19 syndrome.
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Affiliation(s)
- Arad Dotan
- Ariel University, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Paula David
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel; Department of Medicine B, Sheba Medical Center, Tel Hashomer, Israel
| | - Dana Arnheim
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Shoenfeld
- Ariel University, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel; Laboratory of the Mosaics of Autoimmunity, Saint Petersburg University, 199034, Russia
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36
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Gemignani F. Small Fiber Neuropathy and SARS-CoV-2 Infection. Another piece in the long COVID puzzle? Muscle Nerve 2022; 65:369-370. [PMID: 35014706 DOI: 10.1002/mus.27495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/09/2022]
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37
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Mbonu C, Molokwu N, Matelski A. A COVID Constellation: A Case of Transverse Myelitis and Acquired von Willebrand Syndrome. J Investig Med High Impact Case Rep 2022; 10:23247096221109205. [PMID: 35927967 PMCID: PMC9358551 DOI: 10.1177/23247096221109205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic revealed a myriad of postinfectious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequelae, many of which remain poorly understood. We describe a rare presentation of a patient developing 2 simultaneous COVID-19 sequelae: transverse myelitis and acquired von Willebrand syndrome (AVWS). There have been numerous published case reports of patients developing transverse myelitis after a diagnosis of COVID-19. However, none have described AVWS as an observed complication from SARS-CoV-2 infection. To our knowledge, this case report is the first to describe AVWS as a result of COVID-19 infection, suggesting that patients with a prior diagnosis of COVID-19 are susceptible to developing this rare bleeding disorder.
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Affiliation(s)
- Collins Mbonu
- Emory University School of Medicine, Atlanta, GA, USA
| | - Nneka Molokwu
- Emory University School of Medicine, Atlanta, GA, USA
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Shah B, Kunal S, Bansal A, Jain J, Poundrik S, Shetty MK, Batra V, Chaturvedi V, Yusuf J, Mukhopadhyay S, Tyagi S, Meenahalli Palleda G, Gupta A, Gupta MD. Heart rate variability as a marker of cardiovascular dysautonomia in post-COVID-19 syndrome using artificial intelligence. Indian Pacing Electrophysiol J 2022; 22:70-76. [PMID: 35101582 PMCID: PMC8800539 DOI: 10.1016/j.ipej.2022.01.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 12/29/2021] [Accepted: 01/20/2022] [Indexed: 01/03/2023] Open
Abstract
Introduction Cardiovascular dysautonomia comprising postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH) is one of the presentations in COVID-19 recovered subjects. We aim to determine the prevalence of cardiovascular dysautonomia in post COVID-19 patients and to evaluate an Artificial Intelligence (AI) model to identify time domain heart rate variability (HRV) measures most suitable for short term ECG in these subjects. Methods This observational study enrolled 92 recently COVID-19 recovered subjects who underwent measurement of heart rate and blood pressure response to standing up from supine position and a 12-lead ECG recording for 60 s period during supine paced breathing. Using feature extraction, ECG features including those of HRV (RMSSD and SDNN) were obtained. An AI model was constructed with ShAP AI interpretability to determine time domain HRV features representing post COVID-19 recovered state. In addition, 120 healthy volunteers were enrolled as controls. Results Cardiovascular dysautonomia was present in 15.21% (OH:13.04%; POTS:2.17%). Patients with OH had significantly lower HRV and higher inflammatory markers. HRV (RMSSD) was significantly lower in post COVID-19 patients compared to healthy controls (13.9 ± 11.8 ms vs 19.9 ± 19.5 ms; P = 0.01) with inverse correlation between HRV and inflammatory markers. Multiple perceptron was best performing AI model with HRV(RMSSD) being the top time domain HRV feature distinguishing between COVID-19 recovered patients and healthy controls. Conclusion Present study showed that cardiovascular dysautonomia is common in COVID-19 recovered subjects with a significantly lower HRV compared to healthy controls. The AI model was able to distinguish between COVID-19 recovered patients and healthy controls.
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Affiliation(s)
- Bhushan Shah
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India
| | - Shekhar Kunal
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India
| | - Ankit Bansal
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India
| | - Jayant Jain
- SBILab, Department of ECE, IIIT, Delhi, India
| | | | - Manu Kumar Shetty
- Department of Pharmacology, Maulana Azad Medical College, Delhi, India
| | - Vishal Batra
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India
| | - Vivek Chaturvedi
- Senior Consultant Cardiologist and Director Cardiac Electrophysiology, Narayana Superspeciality Hospital, Gurugram, India
| | - Jamal Yusuf
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India
| | - Saibal Mukhopadhyay
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India
| | - Sanjay Tyagi
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India
| | - Girish Meenahalli Palleda
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India
| | | | - Mohit Dayal Gupta
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Delhi, India.
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Long-COVID Syndrome and the Cardiovascular System: A Review of Neurocardiologic Effects on Multiple Systems. Curr Cardiol Rep 2022; 24:1711-1726. [PMID: 36178611 PMCID: PMC9524329 DOI: 10.1007/s11886-022-01786-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Long-COVID syndrome is a multi-organ disorder that persists beyond 12 weeks post-acute SARS-CoV-2 infection (COVID-19). Here, we provide a definition for this syndrome and discuss neuro-cardiology involvement due to the effects of (1) angiotensin-converting enzyme 2 receptors (the entry points for the virus), (2) inflammation, and (3) oxidative stress (the resultant effects of the virus). RECENT FINDINGS These effects may produce a spectrum of cardio-neuro effects (e.g., myocardial injury, primary arrhythmia, and cardiac symptoms due to autonomic dysfunction) which may affect all systems of the body. We discuss the symptoms and suggest therapies that target the underlying autonomic dysfunction to relieve the symptoms rather than merely treating symptoms. In addition to treating the autonomic dysfunction, the therapy also treats chronic inflammation and oxidative stress. Together with a full noninvasive cardiac workup, a full assessment of the autonomic nervous system, specifying parasympathetic and sympathetic (P&S) activity, both at rest and in response to challenges, is recommended. Cardiac symptoms must be treated directly. Cardiac treatment is often facilitated by treating the P&S dysfunction. Cardiac symptoms of dyspnea, chest pain, and palpitations, for example, need to be assessed objectively to differentiate cardiac from neural (autonomic) etiology. Long-term myocardial injury commonly involves P&S dysfunction. P&S assessment usually connects symptoms of Long-COVID to the documented autonomic dysfunction(s).
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Rienks R, Holdsworth D, Davos CH, Halle M, Bennett A, Parati G, Guettler N, Nicol ED. OUP accepted manuscript. Eur J Prev Cardiol 2022; 29:1724-1730. [PMID: 35266533 PMCID: PMC8992320 DOI: 10.1093/eurjpc/zwac041] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/17/2021] [Accepted: 02/23/2022] [Indexed: 11/20/2022]
Abstract
This article provides an overview of the recommendations of the Aviation and Occupational Cardiology Task Force of the European Association of Preventive Cardiology on returning individuals to work in high-hazard occupations (such as flying, diving, and workplaces that are remote from healthcare facilities) following symptomatic Coronavirus Disease 2019 (COVID-19) infection. This process requires exclusion of significant underlying cardiopulmonary disease and this consensus statement (from experts across the field) outlines the appropriate screening and investigative processes that should be undertaken. The recommended response is based on simple screening in primary healthcare to determine those at risk, followed by first line investigations, including an exercise capacity assessment, to identify the small proportion of individuals who may have circulatory, pulmonary, or mixed disease. These individuals can then receive more advanced, targeted investigations. This statement provides a pragmatic, evidence-based approach for those (in all occupations) to assess employee health and capacity prior to a return to work following severe disease, or while continuing to experience significant post-COVID-19 symptoms (so-called ‘long-COVID’ or post-COVID-19 syndrome).
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Affiliation(s)
- Rienk Rienks
- Central Military Hospital, University Hospital, Lundlaan 1, 3584 EZ Utrecht, The Netherlands
| | - David Holdsworth
- Defence COVID-19 Recovery Service, Defence Medical Rehabilitation Centre, Stanford Hall, Stanford Hall Estate, Stanford On Soar, Loughborough, Leicestershire, LE12 5QW, UK
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, UK
| | - Constantinos H Davos
- Biomedical Research Foundation, Academy of Athens, 4 Soranou Ephessiou St., 115 27 Athens, Greece
| | - Martin Halle
- Department of Prevention, Rehabilitation and Sports Medicine, Medical Faculty, University Hospital, Technical University Munich, Georg-Brauchle-Ring 56, Munchen, Germany
| | - Alexander Bennett
- Defence COVID-19 Recovery Service, Defence Medical Rehabilitation Centre, Stanford Hall, Stanford Hall Estate, Stanford On Soar, Loughborough, Leicestershire, LE12 5QW, UK
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Stanford on Soar, Loughborough LE12 5QN, UK
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, Milan, Province of Milan 20126, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Mosè Bianchi Street, 90 - 20149 Milan, Italy
| | - Norbert Guettler
- Air Force Centre of Aerospace Medicine, Fuerstenfeldbruck, Germany
| | - Edward D Nicol
- Defence COVID-19 Recovery Service, Defence Medical Rehabilitation Centre, Stanford Hall, Stanford Hall Estate, Stanford On Soar, Loughborough, Leicestershire, LE12 5QW, UK
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- School of Biomedical Engineering and Imaging Sciences, Kings College, London, Strand London, WC2R 2LS, UK
- Corresponding author. Tel: +44 207 352 8121,
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41
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Alranini I, Kashour T, Al-Hersi A, Alqarawi W. Syncope and COVID-19: Case series and literature review. JOURNAL OF NATURE AND SCIENCE OF MEDICINE 2022. [DOI: 10.4103/jnsm.jnsm_134_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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42
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Balcom EF, Nath A, Power C. Acute and chronic neurological disorders in COVID-19: potential mechanisms of disease. Brain 2021; 144:3576-3588. [PMID: 34398188 PMCID: PMC8719840 DOI: 10.1093/brain/awab302] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 12/15/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a global pandemic caused by SARS-CoV-2 infection and is associated with both acute and chronic disorders affecting the nervous system. Acute neurological disorders affecting patients with COVID-19 range widely from anosmia, stroke, encephalopathy/encephalitis, and seizures to Guillain-Barré syndrome. Chronic neurological sequelae are less well defined although exercise intolerance, dysautonomia, pain, as well as neurocognitive and psychiatric dysfunctions are commonly reported. Molecular analyses of CSF and neuropathological studies highlight both vascular and immunologic perturbations. Low levels of viral RNA have been detected in the brains of few acutely ill individuals. Potential pathogenic mechanisms in the acute phase include coagulopathies with associated cerebral hypoxic-ischaemic injury, blood-brain barrier abnormalities with endotheliopathy and possibly viral neuroinvasion accompanied by neuro-immune responses. Established diagnostic tools are limited by a lack of clearly defined COVID-19 specific neurological syndromes. Future interventions will require delineation of specific neurological syndromes, diagnostic algorithm development and uncovering the underlying disease mechanisms that will guide effective therapies.
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Affiliation(s)
- Erin F Balcom
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Avindra Nath
- Section of Infections of the Nervous System, NINDS-NIH, Bethesda, MD, USA
| | - Christopher Power
- Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
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43
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Yong SJ, Liu S. Proposed subtypes of post-COVID-19 syndrome (or long-COVID) and their respective potential therapies. Rev Med Virol 2021; 32:e2315. [PMID: 34888989 DOI: 10.1002/rmv.2315] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 12/12/2022]
Abstract
The effects of coronavirus disease 2019 (COVID-19), a highly transmissible infectious respiratory disease that has initiated an ongoing pandemic since early 2020, do not always end in the acute phase. Depending on the study referred, about 10%-30% (or more) of COVID-19 survivors may develop long-COVID or post-COVID-19 syndrome (PCS), characterised by persistent symptoms (most commonly fatigue, dyspnoea, and cognitive impairments) lasting for 3 months or more after acute COVID-19. While the pathophysiological mechanisms of PCS have been extensively described elsewhere, the subtypes of PCS have not. Owing to its highly multifaceted nature, this review proposes and characterises six subtypes of PCS based on the existing literature. The subtypes are non-severe COVID-19 multi-organ sequelae (NSC-MOS), pulmonary fibrosis sequelae (PFS), myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS), postural orthostatic tachycardia syndrome (POTS), post-intensive care syndrome (PICS) and medical or clinical sequelae (MCS). Original studies supporting each of these subtypes are documented in this review, as well as their respective symptoms and potential interventions. Ultimately, the subtyping proposed herein aims to provide better clarity on the current understanding of PCS.
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Affiliation(s)
- Shin Jie Yong
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Selangor, Malaysia
| | - Shiliang Liu
- Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Silva-Hernández L, Cabal-Paz B, Mayo-Canalejo D, Horga A. Post-COVID symptoms of potential peripheral nervous and muscular origin. NEUROLOGY PERSPECTIVES 2021; 1:S25-S30. [PMID: 38620983 PMCID: PMC8669717 DOI: 10.1016/j.neurop.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 11/05/2022]
Abstract
Many patients report persistent symptoms attributable to dysfunction of the peripheral nervous and muscular systems after acute COVID-19. These symptoms may constitute part of the so-called post-acute COVID-19 syndrome (PACS), or may result from neuromuscular complications of hospitalisation in intensive care units (ICUs). This article provides an updated review of symptoms of potential neuromuscular origin in patients with PACS, differentiating symptoms according to muscle, peripheral nerve, or autonomic nervous system involvement, and analyses the forms of neuromuscular involvement in patients who were admitted to the ICU due to severe COVID-19.
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Affiliation(s)
- L Silva-Hernández
- Grupo de Estudio de Enfermedades Neuromusculares, Servicio de Neurología, Hospital Universitario Puerto de Hierro de Majadahonda, Majadahonda, Spain
| | - B Cabal-Paz
- Servicio de Neurología, Hospital Universitario Puerto de Hierro de Majadahonda, Majadahonda, Spain
| | - D Mayo-Canalejo
- Servicio de Neurología, Hospital Universitario de Móstoles, Móstoles, Spain
| | - A Horga
- Unidad de Enfermedades Neuromusculares, Servicio de Neurología, Hospital Clínico San Carlos e Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
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45
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Post-Acute Sequelae of COVID-19 and Cardiovascular Autonomic Dysfunction: What Do We Know? J Cardiovasc Dev Dis 2021; 8:jcdd8110156. [PMID: 34821709 PMCID: PMC8621226 DOI: 10.3390/jcdd8110156] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
Post-acute sequelae of SARS-CoV-2 (PASC), or long COVID syndrome, is emerging as a major health issue in patients with previous SARS-CoV-2 infection. Symptoms commonly experienced by patients include fatigue, palpitations, chest pain, dyspnea, reduced exercise tolerance, and “brain fog”. Additionally, symptoms of orthostatic intolerance and syncope suggest the involvement of the autonomic nervous system. Signs of cardiovascular autonomic dysfunction appear to be common in PASC and are similar to those observed in postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia. In this review, we report on the epidemiology of PASC, discuss current evidence and possible mechanisms underpinning the dysregulation of the autonomic nervous system, and suggest nonpharmacological and pharmacological interventions to treat and relieve symptoms of PASC-associated dysautonomia.
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Al-Kuraishy HM, Al-Gareeb AI, Qusti S, Alshammari EM, Gyebi GA, Batiha GES. Covid-19-Induced Dysautonomia: A Menace of Sympathetic Storm. ASN Neuro 2021; 13:17590914211057635. [PMID: 34755562 PMCID: PMC8586167 DOI: 10.1177/17590914211057635] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Among the plethora of debilitating neurological disorders of COVID-19 syndrome in survivors, the scope of SARS-CoV-2-induced dysautonomia (DNS) is yet to be understood, though the implications are enormous. Herein, we present an inclusive mini-review of SARS-CoV-2-induced DNS and its associated complications. Although, the direct link between Covid-19 and DSN is still speculative, the hypothetical links are thought to be either a direct neuronal injury of the autonomic pathway or a para/post-infectious immune-induced mechanism. SARS-CoV-2 infection-induced stress may activate the sympathetic nervous system (SNS) leading to neuro-hormonal stimulation and activation of pro-inflammatory cytokines with further development of sympathetic storm. Sympathetic over-activation in Covid-19 is correlated with increase in capillary pulmonary leakage, alveolar damage, and development of acute respiratory distress syndrome. Furthermore, SARS-CoV-2 can spread through pulmonary mechanoreceptors and chemoreceptors to medullary respiratory center in a retrograde manner resulting in sudden respiratory failure. Taken together, DSN in Covid-19 is developed due to sympathetic storm and inhibition of Parasympathetic nervous system-mediated anti-inflammatory effect with development of cytokine storm. Therefore, sympathetic and cytokine storms together with activation of Renin-Angiotensin-System are the chief final pathway involved in the development of DSN in Covid-19.
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Affiliation(s)
- Hayder M Al-Kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, Almustansiriyia University
| | - Ali I Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, Almustansiriyia University
| | - Safaa Qusti
- Biochemistry Department, Faculty of Science, 37848King Abdulaziz University, Jeddah, Saudi Arabia
| | - Eida M Alshammari
- Department of Chemistry, College of Sciences, University of Ha'il, Ha'il, Saudi Arabia
| | - Gideon Ampoma Gyebi
- Department of Biochemistry, 236312Faculty of Science and Technology Bingham University, Karu, Nasarawa, Nigeria
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, 289643Damanhour University, AlBeheira, Egypt
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Cassar MP, Tunnicliffe EM, Petousi N, Lewandowski AJ, Xie C, Mahmod M, Samat AHA, Evans RA, Brightling CE, Ho LP, Piechnik SK, Talbot NP, Holdsworth D, Ferreira VM, Neubauer S, Raman B. Symptom Persistence Despite Improvement in Cardiopulmonary Health - Insights from longitudinal CMR, CPET and lung function testing post-COVID-19. EClinicalMedicine 2021; 41:101159. [PMID: 34693230 PMCID: PMC8527025 DOI: 10.1016/j.eclinm.2021.101159] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The longitudinal trajectories of cardiopulmonary abnormalities and symptoms following infection with coronavirus disease (COVID-19) are unclear. We sought to describe their natural history in previously hospitalised patients, compare this with controls, and assess the relationship between symptoms and cardiopulmonary impairment at 6 months post-COVID-19. METHODS Fifty-eight patients and thirty matched controls (single visit), recruited between 14th March - 25th May 2020, underwent symptom-questionnaires, cardiac and lung magnetic resonance imaging (CMR), cardiopulmonary exercise test (CPET), and spirometry at 3 months following COVID-19. Of them, forty-six patients returned for follow-up assessments at 6 months. FINDINGS At 2-3 months, 83% of patients had at least one cardiopulmonary symptom versus 33% of controls. Patients and controls had comparable biventricular volumes and function. Native cardiac T1 (marker of fibroinflammation) and late gadolinium enhancement (LGE, marker of focal fibrosis) were increased in patients at 2-3 months. Sixty percent of patients had lung parenchymal abnormalities on CMR and 55% had reduced peak oxygen consumption (pV̇O2) on CPET. By 6 months, 52% of patients remained symptomatic. On CMR, indexed right ventricular (RV) end-diastolic volume (-4·3 mls/m2, P=0·005) decreased and RV ejection fraction (+3·2%, P=0·0003) increased. Native T1 and LGE improved and was comparable to controls. Lung parenchymal abnormalities and peak V̇O2, although better, were abnormal in patients versus controls. 31% had reduced pV̇O2 secondary to symptomatic limitation and muscular impairment. Cardiopulmonary symptoms in patients did not associate with CMR, lung function, or CPET measures. INTERPRETATION In patients, cardiopulmonary abnormalities improve over time, though some measures remain abnormal relative to controls. Persistent symptoms at 6 months post-COVID-19 did not associate with objective measures of cardiopulmonary health. FUNDING The authors' work was supported by the NIHR Oxford Biomedical Research Centre, Oxford British Heart Foundation (BHF) Centre of Research Excellence (RE/18/3/34214), United Kingdom Research Innovation and Wellcome Trust. This project is part of a tier 3 study (C-MORE) within the collaborative research programme entitled PHOSP-COVID Post-hospitalization COVID-19 study: a national consortium to understand and improve long-term health outcomes, funded by the Medical Research Council and Department of Health and Social Care/National Institute for Health Research Grant (MR/V027859/1) ISRCTN number 10980107.
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Affiliation(s)
- Mark Philip Cassar
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Elizabeth M. Tunnicliffe
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
| | - Nayia Petousi
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Adam J. Lewandowski
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
| | - Cheng Xie
- Radcliffe Department of Medicine, British Heart Foundation Centre for Research Excellence, University of Oxford, Oxford, United Kingdom
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Masliza Mahmod
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Azlan Helmy Abd Samat
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Rachael A. Evans
- NIHR Biomedical Research Centre (Respiratory theme), University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Respiratory Science, University of Leicester, Leicester, UK
| | - Christopher E. Brightling
- NIHR Biomedical Research Centre (Respiratory theme), University Hospitals of Leicester NHS Trust, Leicester, UK
- Department of Respiratory Science, University of Leicester, Leicester, UK
| | - Ling-Pei Ho
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Weatherall Institute of Molecular Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Stefan K. Piechnik
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
| | - Nick P. Talbot
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - David Holdsworth
- Department of Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Vanessa M. Ferreira
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine, British Heart Foundation Centre for Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Betty Raman
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), University of Oxford, Oxford, United Kingdom
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Radcliffe Department of Medicine, British Heart Foundation Centre for Research Excellence, University of Oxford, Oxford, United Kingdom
- Corresponding Author: Dr Betty Raman, Oxford Centre for Clinical Magnetic Resonance Research, Level 0, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom, Telephone number: 00441865234580
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Touyz RM, Boyd MO, Guzik T, Padmanabhan S, McCallum L, Delles C, Mark PB, Petrie JR, Rios F, Montezano AC, Sykes R, Berry C. Cardiovascular and Renal Risk Factors and Complications Associated With COVID-19. CJC Open 2021; 3:1257-1272. [PMID: 34151246 PMCID: PMC8205551 DOI: 10.1016/j.cjco.2021.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/28/2021] [Indexed: 01/08/2023] Open
Abstract
The current COVID-19 pandemic, caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus, represents the largest medical challenge in decades. It has exposed unexpected cardiovascular vulnerabilities at all stages of the disease (pre-infection, acute phase, and subsequent chronic phase). The major cardiometabolic drivers identified as having epidemiologic and mechanistic associations with COVID-19 are abnormal adiposity, dysglycemia, dyslipidemia, and hypertension. Hypertension is of particular interest, because components of the renin-angiotensin system (RAS), which are critically involved in the pathophysiology of hypertension, are also implicated in COVID-19. Specifically, angiotensin-converting enzyme-2 (ACE2), a multifunctional protein of the RAS, which is part of the protective axis of the RAS, is also the receptor through which SARS-CoV-2 enters host cells, causing viral infection. Cardiovascular and cardiometabolic comorbidities not only predispose people to COVID-19, but also are complications of SARS-CoV-2 infection. In addition, increasing evidence indicates that acute kidney injury is common in COVID-19, occurs early and in temporal association with respiratory failure, and is associated with poor prognosis, especially in the presence of cardiovascular risk factors. Here, we discuss cardiovascular and kidney disease in the context of COVID-19 and provide recent advances on putative pathophysiological mechanisms linking cardiovascular disease and COVID-19, focusing on the RAS and ACE2, as well as the immune system and inflammation. We provide up-to-date information on the relationships among hypertension, diabetes, and COVID-19 and emphasize the major cardiovascular diseases associated with COVID-19. We also briefly discuss emerging cardiovascular complications associated with long COVID-19, notably postural tachycardia syndrome (POTS).
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Affiliation(s)
- Rhian M. Touyz
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Marcus O.E. Boyd
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Tomasz Guzik
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Sandosh Padmanabhan
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Linsay McCallum
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Patrick B. Mark
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - John R. Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Francisco Rios
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Augusto C. Montezano
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Robert Sykes
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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Buoite Stella A, Furlanis G, Frezza NA, Valentinotti R, Ajcevic M, Manganotti P. Autonomic dysfunction in post-COVID patients with and witfhout neurological symptoms: a prospective multidomain observational study. J Neurol 2021; 269:587-596. [PMID: 34386903 PMCID: PMC8359764 DOI: 10.1007/s00415-021-10735-y] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
The autonomic nervous system (ANS) can be affected by COVID-19, and dysautonomia may be a possible complication in post-COVID individuals. Orthostatic hypotension (OH) and postural tachycardia syndrome (POTS) have been suggested to be common after SARS-CoV-2 infection, but other components of ANS function may be also impaired. The Composite Autonomic Symptom Scale 31 (COMPASS-31) questionnaire is a simple and validated tool to assess dysautonomic symptoms. The aim of the present study was to administer the COMPASS-31 questionnaire to a sample of post-COVID patients with and without neurological complaints. Participants were recruited among the post-COVID ambulatory services for follow-up evaluation between 4 weeks and 9 months from COVID-19 symptoms onset. Participants were asked to complete the COMPASS-31 questionnaire referring to the period after COVID-19 disease. Heart rate and blood pressure were manually taken during an active stand test for OH and POTS diagnosis. One-hundred and eighty participants were included in the analysis (70.6% females, 51 ± 13 years), and OH was found in 13.8% of the subjects. Median COMPASS-31 score was 17.6 (6.9-31.4), with the most affected domains being orthostatic intolerance, sudomotor, gastrointestinal and pupillomotor dysfunction. A higher COMPASS-31 score was found in those with neurological symptoms (p < 0.01), due to more severe orthostatic intolerance symptoms (p < 0.01), although gastrointestinal (p < 0.01), urinary (p < 0.01), and pupillomotor (p < 0.01) domains were more represented in the non-neurological symptoms group. This study confirms the importance of monitoring ANS symptoms as a possible complication of COVID-19 disease that may persist in the post-acute period.
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Affiliation(s)
- Alex Buoite Stella
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Nicolò Arjuna Frezza
- School of Medicine and Surgery, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Romina Valentinotti
- Infectious Diseases, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
| | - Milos Ajcevic
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy
- Department of Engineering and Architecture, University of Trieste, Via Alfonso Valerio 10, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Trieste University Hospital-ASUGI, University of Trieste, Strada di Fiume, 447, 34149, Trieste, Italy.
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50
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Abstract
The article highlights the pathogenesis, clinical manifestations of lesions of the central and peripheral nervous system that have arisen or persist in patients in the postcoid period (Long-COVID-19). Their correct assessment, the use of effective methods of complex treatment, targeted neurorehabilitation contribute to the reversibility of functional disorders, prevention, reduction of disability, improvement of quality of life indicators, prevention of the progression of cognitive, emotional, behavioral disorders initiated by SARS-CoV-2.
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