Hamilton Herald Masthead Hamilton Herald

Editorial


Front Page - Friday, August 14, 2020

The worst might still be ahead for COVID-19 survivors


Heart, lung, brain damage could last a lifetime



Kenneth Fletcher, a Vanderbilt physician who specializes in ear, nose and throat, was one of the first people in Tennessee to contract the COVID-19 virus. - Photos by Michelle Morrow | Hamilton County Herald

Vanderbilt physician Kenneth Fletcher tested positive for COVID-19 back in March, one of the first in Tennessee to contract the virus.

The ear, nose and throat specialist was aware of the new virus and had even talked about it with his doctor at his regular physical, just two days before he was diagnosed. Fletcher, 45, was in good health, an avid runner, swimmer and cyclist. Later that day, he felt “a little bit funny” as he ran but felt fine the next day.

The following day, around lunchtime, he learned in an email that someone at an event he attended March 7 had tested positive for COVID-19. Right away, he shared the information with his Vanderbilt Medical Center colleagues, got tested and went home to wait and see. The next day, March 12, his test came back positive and he quarantined.

COVID-19 symptoms – aches and cold-like symptoms at first, then abdominal pain, severe fatigue, loss of sense of smell, loss of appetite and weight loss, breathing difficulties on some nights – started to kick in.

Fletcher wondered whether his wife and children – and patients and colleagues at Vanderbilt – would also get sick.

“Am I going to be able to run like I want to?” he asked himself. “How much of myself is going to be there when it’s done? It’s not just hurting you now; it’s possibly hurting you forever.”

Fletcher was happy to learn he didn’t pass the coronavirus along to anyone. He’s also back to his pre-COVID fitness levels. But that’s not the end of the story.

“We still don’t know exactly what it means to recover from COVID-19,” says Donald Alcendor, associate professor of microbiology and immunology at Meharry Medical College, where he’s working to develop an antiviral drug for this coronavirus.

“Everyone thought (people with) asymptomatic or moderate COVID-19 would get off scot-free and be 100% recovered. That so-called normal recovery is something that needs to be studied carefully. … (We) have never seen a virus causing the array of clinical symptoms” that this one does.

Studies are documenting longer recovery periods for COVID-19 compared with the regular flu. They’re also finding possible links between the virus and cardiovascular damage, cognitive issues and permanent lung damage.

Will, for example, young, active COVID-19 patients ever have the same lung capacity and stamina?

“Unfortunately, we do not know the answer to this,” says Helen Keipp Talbot, a Vanderbilt physician and associate professor of medicine who also is a member of Vanderbilt’s infectious disease research faculty.

“IF they do fully recover, it will take weeks to months and not days.”

The new coronavirus that causes COVID-19, SARS-CoV-2, attacks cells that line the lungs and some blood vessels. It also replicates in those cells, explains Vanderbilt physician Todd Rice, an associate professor of medicine at Vanderbilt who serves on its allergy pulmonology faculty. (SARS stands for Sudden Acute Respiratory Syndrome.)

In the lungs the new virus causes shortness of breath and low oxygen levels, Rice wrote in an email. In the blood vessels, the virus may be responsible for the blood clotting that has been seen in some COVID-19 patients.

Not only does the virus attack and damage cells, he says, it also creates an inflammation response in the body when the body tries to fight the virus. The inflammation response can be too strong in some patients, causing additional harm to the body.

The evidence suggests the virus has mutated over time, he adds, making it “a bit more infectious and not more severe or deadly,” Rice says. It has continued to affect the same cells in lungs and blood vessels.

Four out of 5 people infected with this coronavirus will be asymptomatic or have, at worst, a case that doesn’t require hospitalization, Alcendor explains. Another 15% will have severe symptoms, and the remaining 5% will have the worst cases.

In mild cases, he says, people might get a fever that goes away quickly, a dry cough he describes as barking and nonproductive, nausea, possible loss of taste or smell, and respiratory issues short of pneumonia.

A moderate case will include the cough, “some small level of lung damage” and pulmonary issues. Mild and moderate cases won’t require hospital care.

Severe symptoms in the 15% include hypoxia (insufficient supply of oxygen to the body) and lung problems that appear in a CT scan. These patients need hospital care that includes oxygen but not intensive care or a ventilator, Alcendor says.

In the very worst cases, the 5%, patients will have shortness of breath and great difficulty breathing. Injury is also possible to multiple organ systems. These patients will most likely need intensive care and mechanical ventilation, possibly for weeks. Long-term effects may require rehabilitation therapy, Alcendor notes.

Recovery scenarios are “incredibly variable,” says Jonathan Moorman, a physician and Division Chief of Infectious, Inflammatory and Immunologic Diseases at East Tennessee State University Health. “We have people who had a mild disease describing prolonged symptoms. We don’t know what really drives that. It may be a prolonged immune response but we don’t know.”

Those who have the most severe cases and who are placed on a ventilator, however, “can expect a long recovery,” he says.

“Recovery can mean lots of different things,” Rice acknowledges. It can mean being released from the hospital or seeing symptoms improve after quarantining and self-treating at home.

“For many patients, recovery means the patient is no longer infectious, which is usually 10 days after symptoms start and (having) no fever for three straight days and feeling better if you had symptoms. Patients that are considered recovered are often not entirely back to their baseline before they got the virus,” Rice adds.

Residual symptoms can include fatigue, weakness, cough and even some residual shortness of breath, he says. “These symptoms continue to get better as time goes by, but it can be a slow process.”

“Some patients can have permanent scarring in their lungs – the lungs can heal slowly over time and patients may continue to have healing (and improvement in their lung function) over at least a year after they are discharged from the hospital,” Rice continues. “But in some patients, the lungs do not heal entirely and they are left with some residual scarring and some chronic respiratory problems.

“We do not yet know what percentage of patients will have long-term residual effects from the virus, since we have dealt with it (for) four months,” Rice says. “We know from other diseases that make patients this sick that a considerable number of them have prolonged fatigue, weakness and difficulty concentrating on things.”

One recent study, a telephone survey of COVID-19 patients in which Vanderbilt participated, found 35% of respondents still had symptoms two to three weeks after testing positive. Even in ages 18-34, 20% still had symptoms when contacted. Follow-ups with these patients are planned.

By comparison, someone with seasonal flu usually has fully recovered within two weeks.

Vanderbilt scientists also are following COVID-19 patients who were hospitalized to see if they develop long-term cognitive impairment or other mental issues.

“There is emerging evidence that COVID-19 affects the brain and leads to a wide range of neurological complications such as delirium,” the principal investigator in the study, Jin Han, M.D., M.Sc., associate professor of Emergency Medicine, wrote in a statement. “Because it affects the brain and causes delirium, we hypothesize that a disproportionate number of patients might develop long-term cognitive impairment, PTSD and depression.”

The study of COVID patients is based on prior studies of ICU patients hospitalized for Acute Respiratory Distress Syndrome.

“In a broad group of ICU survivors closely resembling COVID-19 patients, 33-50% have acquired dementia, 10-20%, Post Traumatic Stress Disorder and 33%, major depression,” Vanderbilt reports.

“There are some good publications that show being critically ill and requiring long hospital stays is associated with functional and cognitive declines,” Vanderbilt’s Talbot says. “Since (COVID-19) is so severe, we will unfortunately see a lot of cognitive and functional decline even in young adults.”

STAT (statnews.com), a health-industry online news site, reported in late July on studies in Germany that examined the cardiac effects of COVID-19.

One study showed the cardiac MRIs of 100 people who recovered from COVID-19 differed from those of 100 similar people who didn’t get it. Two out of three of those who had COVID-19 had recovered at home.

“Seventy-eight patients showed structural changes to their hearts, 76 had evidence of a biomarker signaling cardiac injury typically found after a heart attack and 60 had signs of inflammation,” STAT reported.

The lead researcher on the MRI study told STAT a majority of COVID-19 patients have heart issues, even if they do not exhibit classic heart symptoms.

The second German study examined autopsy results on 39 elderly people who died early in the pandemic. Twenty-four of those had high levels of the virus in their hearts, STAT reported.

The STAT article says it’s too early to say if damage to the hearts of those recovering from COVID-19 will be permanent, or whether the conditions will improve over time. If damage is permanent, STAT concluded, it might mean the health system will have to absorb a spike in coronary issues over time.

Informal accounts from people who have had COVID-19 indicate that it’s nothing like seasonal flu and that lingering symptoms do occur.

Nashville musician John England first experienced COVID-19 symptoms in late June. He was tested the next day and began isolating and self-treating at home that day, even though he didn’t receive his test results – positive – until four days later.

“I suspect my case would be considered ‘mild’ or ‘moderate,’ since I never went to the hospital, but it was plenty bad enough, for me,” he explains. He still feels tired and has a cough, even though he has been cleared of the virus.

Diana Berrent, a New York mother and founder of an online COVID-19 support group and Facebook page called Survivor Corps, says she got sick in March with an “average” case of COVID-19. She says she was “pretty miserable for a couple of weeks with some GI and fatigue issues that linger four and a-half months later.” Her blood iron and vitamin D levels also have been low, she says.

Rick Davis, a Survivor Corps member who works in Nashville’s hospitality industry, was diagnosed with COVID-19 March 12. He says he tested negative for seasonal flu at two walk-in clinics before being tested for coronavirus at a third. He was one of the first in Tennessee to be diagnosed, he says, adding he felt terrible for about two weeks, losing his sense of smell and taste and losing 22 pounds.

At his regular physical recently, he told his doctor he seemed to get winded more easily than usual. A chest X-ray came back fine, he recounts, and he’ll be exercising more to get back into shape. He said he had no other lingering symptoms.

Fletcher, the Vanderbilt physician who was diagnosed in March, says having COVID-19 places him in a “very humbling position.”

“I have to say it wasn’t that bad, but it was a little bit (of a) scare.” He says, adding many other people have had worse problems with COVID-19 than he.

It took him until around Day 13 before he started feeling better, he adds, but “way out of gas.” On Day 17, he decided to go outside and walk up a hill in his neighborhood, one he used to sprint up.

“I didn’t even want to walk up the hill,” he recalls. It took perhaps another month before he started feeling close to normal.

Since he caught the virus early, other health care providers at Vanderbilt were interested in his situation, and he says he benefited from that. He’s been part of a COVID-19 taste and smell study at Vanderbilt and has been told he’s still pretty close to not being able to smell anything, even though the sense has begun to come back.

“I think there’s been a lot of positive things about being through it,” he says. “We as a family were enrolled in a study at Vanderbilt. They’ve had blood drawn. They feel like they’re part of the way to figure out this for the world. It’s nice they get to be actively involved.”

Many of those who attended the event where he caught COVID-19 also caught it. “We’ve almost had this little community. We’ve all had it. It was bad that we got sick, but it created this interesting community around it,” he points out.

COVID-19 “seems to be the disease of fear,” he says, and when people are afraid they act in unpredictable ways. “It makes me try to understand why.

“… The mental part (of the virus) was fascinating,” he says. “Even more than the physical it’s the mental anguish. When you have it it’s significant.”

Fletcher also knows it’s hard for non-scientists to understand that researchers – including those studying COVID-19 – rarely get instant results, even though that’s what the public wants.

“I’m surprised we know as much as we do,” he says. People’s emotions and what he calls the American independent spirit are often at odds with the pace of the scientific process.

“I feel super fortunate,” he says. “(I feel) nothing but joy with being done with it. It could (have been) so much worse.

“…My feeling is that humans if anything have the ability to mold and adapt,” Fletcher wrote in a later email. “There have been other viruses, plagues, and wars that people have lived through that I am sure seemed overwhelming and daunting in the same way.

“The virus will find an equilibrium with people either through vaccination, natural immunity or probably a bit of both, but in the middle we all need to be patient and realize that doing our best to protect and respect each other is important.”