6 Potential Long-Term Effects of COVID-19
It’s a new virus, and experts are learning more each day about the ways it could affect you in the months following diagnosis.
One great thing modern medicine has given us is the ability to study and record the effects of different diseases in human beings. For the most part, doctors can tell patients what to expect and how to take care of themselves after a new diagnosis, whether it’s a viral infection or an autoimmune disease. But the coronavirus is a brand-new pathogen, and everyone has a lot of questions about it.
As 2020 drags on, experts are learning more about the way COVID-19 affects people – both in the first few weeks and months after their initial diagnosis. And there’s still so much to be discovered. “We are still in the learning phase of this disease,” says Rashid Chotani, M.D., Vice President of Medical Affairs at CareLife Medical in Fairfax, VA. “However, as the disease spreads across the globe, we have observed that the infectivity, symptoms, and severity of COVID-19 varies.”
Essentially, COVID-19 infection looks different for different people, and it’s impossible to predict how your body might react. But here’s what to look out for based on available data, and what you can do to stay safe and healthy.
COVID-19 is thought of primarily as a respiratory disease, characterized by coughing and shortness of breath. So, it’s no surprise that some patients are experiencing lung damage as a result of their initial infection.
A May 2020 study in The Lancet cited evidence from previous coronavirus infections, combined with emerging data on COVID-19, to confirm that significant lung damage is one possible complication of this new virus. In early June, a COVID-19 patient in her twenties, listed as being otherwise healthy, had to get a lung transplant at Northwestern Hospital in Chicago due to severe lung damage. She had spent six weeks on a ventilator prior to the procedure.
“We’re going to be seeing areas of [lung] damage that people are going to be required to be on oxygen,” says Alejandro Comellas, M.D., director of the Institute for Clinical and Translational Science Clinical Research Unit at the University of Iowa in Iowa City. “We’re hoping that those areas are not going to be permanently damaged.”
Even people with asymptomatic COVID-19 infection may shown signs of lung inflammation, according to a May 2020 study published in Nature Research. Blood clotting from COVID-19 could also lead to a pulmonary embolism (blockage of a major artery in the lungs), which is life-threatening and can lead to permanent lung damage.
Panagis Galiatsatos, M.D., pulmonary and critical care physician at Johns Hopkins Medicine in Baltimore, explains that there could be a variety of reasons for post-COVID-19 pulmonary fibrosis (lung damage). The patients could have had underlying lung disease without realizing it.
“Sometimes to have a lung disease manifest with symptoms, you need a trigger,” he says—in this case, that trigger being COVID-19 infection. Or, the damage could be caused by COVID-19 itself. “Our immune systems have to fight off an infection, and at the same time afterwards, they have to help with healing,” he explains.
Think of it, he says, like a house fire: Your priority is to put the fire out, but then you have to rebuild from the damage it caused. This takes time. “Depending on how the pace goes, some parts of the lungs may heal faster than other parts, and that could create symptoms [like] shortness of breath and cough as lungs heal,” Dr. Galiatsatos explains. This process could take weeks or months, depending on your specific severity of illness.
COVID-19 affects more than just your lungs: there is increasing evidence to show that the disease also takes a toll on your heart, with up to one in five COVID-19 patients showing signs of cardiac dysfunction (according to a March 2020 study in JAMA Cardiology).
“We know COVID-19 can infect the heart, can infect the lungs, and can infect the kidneys,” Dr. Galiatsatos says. “This virus seems to be able to impact a variety of organs, and it’s hard to predict how those organs will recover.”
Dr. Chotani echoes this. “This is a very heterogeneous disease, as patients can die not only from lung failure, but also kidney failure, blood clots, liver abnormalities, and neurological manifestations,” he says. Research has increasingly shown that blood clotting associated with COVID-19 can lead to heart attacks or put stress on your heart due to lack of adequate blood flow.
Perhaps the scariest emerging long-term effect of COVID-19 is its potential impact on the brain. A June 2020 study in Neurology found evidence that some patients with severe COVID-19 illness exhibit signs of brain damage or brain injury (though the authors note that this is uncommon).
“It’s difficult to know right now what the cause would be” of brain damage, Dr. Comellas notes. It could be that the virus targets the brain, or that the inflammation caused by the immune reaction is affecting blood flow to the area. In rare cases, serious blood clotting can lead to strokes in COVID-19 patients who are otherwise young and healthy. Or, Dr. Comellas explains, brain damage could occur as a result of hypoxia—low oxygen caused by the respiratory effects of the virus.
In any case, more time and research can help identify the severity to which COVID-19 could put your brain health at risk. “There’s a real interest in understanding the neurocognitive effects in patients who survive COVID-19, especially in these severe cases,” Dr. Comellas explains, in the hope that more proactive steps can be taken to minimize them.
You may have heard of the strange phenomenon called “COVID toes,” where some COVID patients get a painful red rash on their feet. Others report hives-like bumps on various parts of the body, from the chest to the arms to the thighs. While these symptoms usually subside in a few days or weeks, doctors are learning that COVID skin issues can sometimes last for months. “We have patients whose skin symptoms have lasted as long as 150 days after their COVID-19 infection,” says Esther Freeman, M.D., Ph.D., Director of Global Health Dermatology at Massachusetts General Hospital in Boston. And because the skin serves as a “window into the body,” she explains, this could be a sign of underlying chronic inflammation.
Dr. Freeman and her research team presented these findings at the European Academy of Dermatology & Venereology Congress in October, in an effort to educate the public about the variance in appearance and duration of COVID-related skin issues. “It does point to the fact that COVID can trigger some sort of response in the body that can last for quite some time,” she explains. But she notes that this is “certainly not a reason for panic or alarm” – the vast majority of COVID patients with skin manifestations make a full recovery, even if it takes a little longer than expected.
If you are experiencing long-haul skin symptoms that might be related to COVID, talk to your doctor. Dr. Freeman is the principal investigator of the COVID-19 Dermatology Registry, a partnership between the American Academy of Dermatology and the International League of Dermatologic Societies. This registry collects anonymous information about COVID skin manifestations around the world. “I would encourage patients to tell their provider about entering them in the registry,” she suggests, so the data can be used to help scientists better understand these symptoms and what they mean. In addition, have your doctor check your inflammation levels. “Their provider may choose to look more at inflammatory markers or levels of autoimmunity,” she notes, “to see if there is anything else going on.”
If a patient experiences severe illness from COVID-19, they are likely to feel some lasting psychological effects from their ordeal. “Of course, there’s going to be the psychological issues associated with acute illness,” Dr. Comellas says, such as post-traumatic stress disorder, depression, and anxiety. A 2014 analysis in The Lancet Respiratory Medicine found that up to 25% of critical illness survivors experience poor mental health outcomes and functional disabilities for at least one year after their hospital discharge.
Similarly, Dr. Chotani explains, patients who have spent weeks in the ICU could experience lingering mental and physical health effects from that experience. “They may also suffer from post-intensive care syndrome (PICS),” he says, a condition characterized by “physical impairment due to malnutrition, cognitive impairment which can result in decreased memory, decreased attention, and decreased mental sharpness or ability to solve problems, and psychiatric impairment.”
A mental health professional trained in cognitive behavioral therapy (CBT) can be key to helping you identify and confront your symptoms of PTSD or depression before they take over your life. You may want to consider therapy for yourself or a loved one who has recently had a life-changing experience with COVID-19. And to manage physical disabilities in the months after your recovery, continue to work with your team of healthcare providers to monitor your symptoms and address any emerging challenges.
Dr. Chotani notes that in previous studies of SARS (a coronavirus that spread throughout the world in the early 2000s), survivors sometimes showed signs of fatigue and muscle weakness for years afterward. “What we know is that SARS survivors had poorer exercise capacity and health status and had chronic fatigue symptoms 3.5 years after being diagnosed,” he explains. “So, one possible long-term effect is chronic fatigue syndrome.” The specific cause of chronic fatigue syndrome is unknown, but one notable trigger is viral infections, which can cause significant stress to your internal organs.
Unfortunately, it won’t be clear for awhile which effects of COVID-19 are long-lasting or permanent. “I think we’re going to have to wait at least a year before we know whether some of the organs involved in infection could show some damage that we think has passed already,” Dr. Comellas explains. The hope is that some of these effects may lessen or disappear as the body recovers from illness.
The key will be identifying survivors at different intervals for doctors to assess. “We need survivors at one-month intervals, three-month intervals, one-year intervals, and ten-year intervals … in order to get a complete picture,” Dr. Galiatsatos says. “It will take time for us to say in confidence what survival of COVID-19 looks like.”
How to Stay Safe
Since doctors are still don't have a lot of answers or information, it’s crucial to stay attentive about protecting yourself from the virus. This is especially true if you fall into a high-risk category due to age or pre-existing conditions.
Follow CDC social distancing guidelines:
Stay six feet apart from others
Wear a mask
Wash your hands frequently
Avoid public places where this level of distance is not possible
In the meantime, do the best to keep yourself healthy. “If you do have pre-existing conditions, definitely make sure they are well-controlled,” Dr. Galiatsatos suggests. He notes that based on data from other viral infections, experts know that people with well-maintained diabetes or blood pressure have better outcomes from infection than those who don’t manage their conditions as well.
“Being able to work with your doctor and have these pre-existing conditions well taken care of goes a long way to potentially keeping yourself safe if you catch the virus and end up developing symptoms,” he says.
With the recent upswing in cases across the country, Dr. Chotani emphasizes the urgency of being careful. “With the cases now re-spiking, we need to be extremely vigilant,” he says. “Follow the advice of public health, infectious disease and epidemiology experts, and not what others are saying or portraying. Also, make sure that you are taking your medications for your under-lying conditions (comorbidities) on time and staying healthy.” The best we can do right now is look out for ourselves and each other.
COVID-19 and Lung Fibrosis: The Lancet. (2020.) “Pulmonary fibrosis and COVID-19: the potential role for antifibrotic therapy.” thelancet.com/journals/lanres/article/PIIS2213-2600(20)30225-3/fulltext
Lung Transplant Case: Northwestern Medicine. (2020.) “Lung Transplant Performed on a COVID-19 Patient at Northwestern Medicine.” nm.org/about-us/northwestern-medicine-newsroom/press-releases/2020/lung-transplant-performed-on-covid-19-patient-at-northwestern-medicine
Asymptomatic Lung Damage: Nature Medicine. (2020.) “Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections.” nature.com/articles/s41591-020-0965-6.pdf
Pulmonary Embolism and COVID-19: Radiology. (2020.) “Acute Pulmonary Embolism and COVID-19.” pubs.rsna.org/doi/10.1148/radiol.2020201955
Cardiovascular Damage and COVID-19: JAMA Cardiology. (2020.) “Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China.” jamanetwork.com/journals/jamacardiology/fullarticle/2763524
Blood Clotting Risk: American Heart Association. (n.d.) “Understand Your Risk for Excessive Blood Clotting.” heart.org/en/health-topics/venous-thromboembolism/understand-your-risk-for-excessive-blood-clotting
Brain Damage and COVID-19: Neurology. (2020.) “Neurochemical evidence of astrocytic and neuronal injury commonly found in COVID-19.” n.neurology.org/content/early/2020/06/16/WNL.0000000000010111.abstract
Strokes and COVID-19: New England Journal of Medicine. (2020.) “Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young.” nejm.org/doi/full/10.1056/NEJMc2009787
Hypoxia in COVID-19: Mayo Clinic Proceedings. (2020.) “Hypoxia in COVID-19: Sign of Severity or Cause for Poor Outcomes.” ncbi.nlm.nih.gov/pmc/articles/PMC7177114/
Mental Health of Illness Survivors: The Lancet Respiratory Medicine. (2014.) “Depression, Posttraumatic Stress Disorder, and Functional Disability in Survivors of Critical Illness: results from the BRAIN ICU (Bringing to light the Risk Factors And Incidence of Neuropsychological dysfunction in ICU survivors) Investigation: A Longitudinal Cohort Study.” ncbi.nlm.nih.gov/pmc/articles/PMC4107313/
Post-Intensive Care Syndrome: Journal of Translational Internal Medicine. (2017.) “Post-intensive Care Syndrome: An Overview.” ncbi.nlm.nih.gov/pmc/articles/PMC5506407/
Treatments for PTSD: Anxiety and Depression Association of America. (n.d.) “PTSD Facts & Treatment.” adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd/treatment
SARS and Chronic Fatigue: BMC Neurology. (2011.) “Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study.” ncbi.nlm.nih.gov/pmc/articles/PMC3071317/
Causes of Chronic Fatigue: Centers for Disease Control and Prevention. (n.d.) “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Possible Causes.” cdc.gov/me-cfs/about/possible-causes.html
CDC Social Distancing Guidelines: Center for Disease Control and Prevention. (2020.) “Coronavirus Disease 2019: Social Distancing.” cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html
COVID-19 and Diabetes Management: American Diabetes Association. (2020.) “How COVID-19 Impacts People with Diabetes.” diabetes.org/coronavirus-covid-19/how-coronavirus-impacts-people-with-diabetes
COVID Skin Symptoms: American Academy of Dermatology. (2020.) “How The Coronavirus Can Affect Your Skin.” aad.org/public/diseases/coronavirus/covid-toes
Long-Hauler Skin Manifestations: European Academy of Dermatology and Venereology. (2020.) “COVID-19 "long-haulers" in Dermatology? Duration of dermatologic symptoms in an international registry from 39 countries.”