Click Here to Download this Blog Post –  Long COVID 2025 Part 5

Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 5 of a 5 Part Series about Redefinition of Long COVID

“Long Covid” – the most important point – treatment.   Patients at times are completely disabled.  We feel that attempting to test the autonomic nervous system abnormalities and treating them pharmacologically offers the best chance of symptom improvement and functional improvement.  This is a slow fix and may take six months to one year to start seeing improvements.  We have used vasoactive agents, volume-expanding agents, and rate-lowering agents, such as beta-blockers or Corlanor,  and other agents depending on the abnormal physical findings, vital sign findings, especially with provocations, such as tilt and stand and HRV data along with sudomotor dating.  Lifestyle changes, volume expansion orally or intravenously, and antioxidant mitochondrial cocktails are also helpful in our empiric assessments.

There are several long Covid centers that sprung up.  The majority of these have closed, and when individuals look on the internet and call for appointments, they find out that a lot of them are now closed and not operating.  The ones that are operating will often see patients with Telemed and will not bring them in, nor will they test their autonomic nervous system function.  We feel that to get a proper evaluation, you need your autonomic nervous system evaluated and a treatment algorithm has to be put out aggressively as patients, many of them who are young, do indeed feel as though they are having their life taken from them by these post-viral syndromes and the sooner one could feel better symptomatically and have a better understanding of the disorder and can function better the sooner their quality of life can improve, and they can get on track.   There is no guarantee of successful treatment, but we have seen that along with other post-viral chronic fatigue states and autonomic dysfunction states, these treatment protocols are extremely effective in improving quality of life and function in many of our patients with these disorders, including the long Covid syndrome.

Click Here to Download this Blog Post –  Long COVID 2025 Part 4

Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 4 of a 5 Part Series about Redefinition of Long COVID

Not everyone is at risk of long Covid, although anyone can get it.  People at higher risk, according to the committee, were female sex, repeated infections, and more severe infections.

Alarmingly, it is estimated that from death certificates through 2023, The Centers for Disease Control and Prevention estimated that approximately 5000 patients in the United States have died from long Covid or from a condition in which long Covid was a contributing cause.  This number is probably much higher, in our opinion.

A very general definition of long Covid, states that it occurs three months as a continuous relapsing and remitting or progressive disease that affects one or more organ symptoms after a SARS-CoV-2 infection.  It can manifest in many ways, including singular or multiple symptoms that were described above.  To repeat, shortness of breath, cough, persistent fatigue, post-exertional malaise, difficulty concentration, memory change, recurring headache, lightheadedness, a fast heart rate, sleep disturbance, problems with taste or smell, bloating, constipation, and diarrhea.  Singular or multiple diagnosed conditions may result consisting of interstitial lung disease with low oxygen or hypoxemia, cardiac arrhythmia, such as atrial fibrillation, cognitive impairment that does not improve, mood disorders, anxiety, migraine, stroke, blood clots, chronic kidney disease, postural orthostatic tachycardia syndrome (POTS) and other forms of dysautonomia, chronic fatigue syndrome, mast cell syndromes, fibromyalgia, connective tissue disorders, hyperlipidemia, diabetes, and autonomic immune disease, such as lupus, rheumatoid arthritis, and Sjögren syndrome.

There have also been articles reporting increased incidences of ANA in people with long Covid syndrome, especially females.  We have not seen this in our testing of our patients.  We have not identified any autoimmune marker that is unique or specific for patients with long Covid syndromes.  However, we do agree with the symptom complex that the committee has set forth in the three-month cutoff that they have made.  We are not sure that long Covid is much different than any long viral or long post-bacterial infection sequelae syndrome in that they all involve autonomic nervous system dysregulation.

Click Here to Download this Blog Post –  Long COVID 2025 Part 3

Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 3 of a 5 Part Series about Redefinition of Long COVID

The committee stresses that asymptomatic infections or mild infections can also produce this Long Covid syndrome and is not necessarily related to the severity of the initial Covid, or even a recurrent Covid infection.  It may have a delayed onset for weeks or months and can affect children and adults.

The committee also emphasized that there are no biomarkers available to conclusively diagnose this condition.  Therefore, it is purely a clinical diagnosis, and the definition is based on clinical observations and findings.  There is no blood test available.  They emphasize that it can cause disability and affect a person’s ability to work, attend school, care for their family, and care for themselves.  This is extremely important as it causes loss of work days, work productivity, and quality of life to the individuals affected.   Many patients have described long Covid as having “taken their lives away from them”.

As we look at the features of long Covid syndromes, we note that many of them are found and even without Covid infections in individuals who have connective tissue disorders, such as Ehlers-Danlos syndrome with postural orthostatic tachycardia, mast cell abnormalities with hives, flushing, and GI-disabling symptoms, and other dysautonomia states.  Chronic fatigue, we feel, is a manifestation of an autonomic dysfunction state where one does not get adequate blood supply to the brain and gets brain fog and cognitive dysfunction associated with it.  We have previously commented on measuring the autonomic nervous system, both the sympathetic and parasympathetic branches and observing a sympathetic withdrawal state, which causes venous pooling as being a major contributor to chronic fatigue both in long Covid syndrome and in dysautonomia states in general, many of which are precipitated or triggered by viral infections.  **Therefore, although there are no biomarkers or blood tests that can diagnose long Covid syndrome, we feel that the clinical symptoms and presentation in the proper setting, along with an objective testing of the autonomic nervous system, which looks at heart rate variability often coupled with respiration rate are important to monitor.

Click Here to Download this Blog Post –  Long COVID 2025 Part 2

Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 2 of a 5 Part Series about Redefinition of Long COVID

In the New England Journal of Medicine, a pivotal article titled Long Covid Defined, authored by Ely, Brown, and Fineberg et al., was published on July 31, 2024. It describes how the COVID-19 pandemic, while recognized for its deadly acute phase that claimed over one million lives in the U.S. and seven million globally, also gave rise to a lingering public health emergency—Long COVID. The authors emphasized that millions of survivors now suffer from chronic, often disabling symptoms.

Estimating the Scale of Long COVID

Various estimations suggest that Long COVID may affect up to 10% of adults who contracted the virus and 2% who were vaccinated. According to the New England Journal article, survey data shows that around 7% of adults and over 1% of children report symptoms consistent with Long COVID. This equates to approximately 50–60 million people globally who may be suffering from the syndrome.

Defining Long COVID: A Committee-Based Approach

The article introduced a formal definition of Long COVID, developed by a specialized committee. They noted hallmark symptoms such as cognitive impairment, neuromuscular issues, depression, and severe fatigue. Due to the lack of standardized diagnostic criteria, the committee employed a multi-phase process involving systemic engagement, focus groups, and questionnaires to gather comprehensive insights.

Clinical Definition and Symptomatology

According to the committee, Long COVID is an infection-associated chronic condition following SARS-CoV-2 infection. It is defined by a disease course lasting at least three months and may be continuous, relapsing and remitting, or progressively worsening. Long COVID can affect multiple organs and presents with a wide variety of symptoms.

Common symptoms include:

• Shortness of breath and chronic cough

• Persistent fatigue and post-exertional malaise

• Cognitive dysfunction (“brain fog”) and memory issues

• Recurring headaches, lightheadedness, and rapid heart rate

• Sleep disturbances and altered taste or smell

• Gastrointestinal symptoms such as bloating, constipation, and diarrhea

These symptoms are frequently observed in conditions involving dysautonomia—disorders of the autonomic nervous system affecting both the parasympathetic and sympathetic branches.

Viral Triggers and Related Conditions

The symptoms of Long COVID are not unique to SARS-CoV-2. Similar post-viral syndromes have been linked to Epstein-Barr virus, enteroviruses, and others. The committee pointed out that Long COVID can manifest as singular or multiple overlapping conditions.

These include:

• Interstitial lung disease and low oxygen saturation (hypoxemia)

• Heart complications like arrhythmias and cardiovascular disease

• Strokes, blood clots, and kidney dysfunction

• Postural Orthostatic Tachycardia Syndrome (POTS)

• Fibromyalgia and other chronic fatigue-type conditions

• Connective tissue diseases and metabolic disorders such as diabetes and hyperlipidemia

• Autoimmune diseases like lupus, rheumatoid arthritis, and Sjögren’s syndrome

• Mast Cell Activation Syndrome (MCAS)

Click Here to Download this Blog Post –  Long COVID 2025 Part 1

Dr. Nicholas L. DePace, M.D., F.A.C.C.

This is Part 1 of a 5 Part Series about Redefinition of Long COVID

Long Covid: A Chronic Condition Emerging From the Pandemic

In the New England Journal of Medicine, an article was published Long Covid Defined, authored by Ely, Brown, and Fineberg et.al; July 31, 2024.  They describe how the COVID-19 pandemic was a dangerous acute outbreak of infection that killed more than one million people in the United States and seven million worldwide.

Millions Left With Lasting Symptoms

More importantly, the authors emphasize that millions were left with chronic, disabling symptoms post-infection, known as Long Covid. Estimates suggest up to 10% of adults infected and 2% of vaccinated individuals may develop it.

Prevalence Among Adults and Children

The article cites survey data indicating that 7% of adults and more than 1% of children may suffer from Long Covid—translating to 20 to 50 million cases in the U.S. and 60 million globally.

A New Definition for Long Covid

A committee defined Long Covid as an infection-associated chronic condition lasting at least three months after SARS-CoV-2 infection. It may follow a continuous, relapsing, remitting, or progressive course and affect one or more organs.

They used a multiphase process of systemic engagement and information gathering and included focus groups, questionnaires and so forth.

The committee stated that long Covid is an infection-associated chronic condition that occurs after the SARS-CoV-2 infection and is present for at least three months as a continuous, relapsing, and remitting or progressive disease state that affects one or more organs.

Common Symptoms and Clinical Manifestations

Key symptoms include cognitive impairment, neuromuscular issues, depression, and severe fatigue. Additional symptoms include shortness of breath, persistent cough, post-exertional malaise, brain fog, fast heart rate, sleep disturbances, and gastrointestinal issues like bloating and diarrhea.

Link to Dysautonomia and Other Viral Triggers

These are symptoms that we see very commonly in people with dysautonomia or autonomic dysregulation syndromes, that is, abnormalities of the autonomic nervous system involving either or both branches, the parasympathetic and sympathetic systems.

Other viruses are known to cause these symptoms, including Epstein-Barr, enteroviruses, and so forth.  The symptoms are not specific for Covid in a post-viral syndrome.

However, the committee went on to state that singular multiple conditions, such as interstitial lung disease, low oxygen levels or hypoxemia, heart disease and arrhythmias, strokes and blood clots, kidney disease and racing heart rate when standing (postural orthostatic tachycardia syndrome), and other forms of dysautonomia and chronic fatigue-type syndromes can be present.

They discussed fibromyalgia, connective tissue disease disorders, hyperlipidemia, diabetes, and autoimmune disorders, such as lupus, rheumatoid arthritis, and Sjögren’s disease.  They even discussed mast cell activation syndrome as being operative in a long Covid syndrome.