Long
COVID
By Associate Professor Chris Barnes
Published March 2023
"Long COVID": Laboratory investigations to support patient management
By Associate Professor Chris Barnes
Published March 2023
Most people infected with COVID-19 will fully recover within a few weeks of infection. In a study of almost 3,000 patients with COVID-19 infection from NSW, 80% of patients had fully recovered by 30 days. However, up to 5% of patients will continue to have symptoms beyond 12 weeks following infection.1
There is no agreed definition of “Long COVID” syndrome. The WHO (World Health Organization) has provided a clinical case definition for “post COVID-19 condition”. This definition includes patients with a range of potentially overlapping and intermittent symptoms including fatigue, shortness of breath, and cognitive dysfunction, that impact everyday functioning. The symptoms extend beyond 12 weeks from COVID-19 infection and are present for at least 2 months.2 There is limited understanding of the pathogenesis and risk factors for patients developing Long COVID.
There is an absence of well-established evidence-based guidelines for the investigation and management of patients presenting with potential Long COVID. Clinicians may be faced with the diagnostic and management dilemma of how best to approach patients suspected of having Long COVID syndrome. Tertiary referral centres are being inundated with patients suspected of having Long COVID syndrome, with some patients being forced to wait up to one year before being seen.3
Clinical assessment of patients presenting with symptoms suggestive of Long COVID syndrome can be difficult. Symptoms can be varied and overlapping, often without objective clinical signs. The NICE (The National Institute for Health and Care Excellence) guideline on Long COVID includes commonly reported symptoms, which can be classified as follows.4
Commonly reported “Long COVID” symptoms
| Respiratory / ENT and Cardiovascular symptoms | |
|---|---|
| - Breathlessness - Cough - Cardiovascular symptoms - Chest tightness - Chest pain - Palpitations | - Tinnitus - Earache - Sore throat - Dizziness - Loss of taste and/or smell - Nasal congestion |
| Generalised and Neurological symptoms | |
|---|---|
| - Fatigue - Fever - Pain - Cognitive impairment (‘brain fog’, loss of concentration or memory issues) - Headache - Sleep disturbance | - Symptoms of anxiety - Peripheral neuropathy symptoms (pins and needles and numbness) - Delirium (in older populations) - Mobility impairment - Visual disturbance - Symptoms of depression - Symptoms of post-traumatic stress disorder |
| Gastrointestinal symptoms | |
|---|---|
| - Abdominal pain - Nausea | - Diarrhoea - Weight loss and reduced appetite |
| Musculoskeletal / skin symptoms | |
|---|---|
| - Joint pain - Muscle pain | - Skin rashes - Hair loss |
In the setting of high clinical demands, self-report questionnaires have been proposed as a potential guide to support clinical decision-making. The Symptom Burden Questionnaire™ for Long COVID (SBQ™-LC) is a comprehensive patient-reported outcome tool measuring the frequency and severity of symptoms in patients with Long COVID.5 This questionnaire highlights the varied range of symptoms of patients presenting with Long COVID and includes 17 independent scales with a summed raw score, which can be transformed to a linear (0-100) score with higher scores associated with higher disease burden.
Recommended laboratory investigations
[Download Long COVID Brochure]
Targeted laboratory investigations are essential in supporting the assessment of patients presenting with symptoms suggestive of Long COVID. It is important to acknowledge that the variety of potential symptoms of patients presenting with Long COVID may make excluding underlying medical conditions difficult. Additionally, comorbidities that require targeted therapy may compound symptoms of Long COVID. The approach below is suggested to support the investigation of patients presenting with potential Long COVID with an initial baseline series of investigations followed by a more targeted methodology directed towards the patients’ symptoms.
| Baseline investigations | ||
|---|---|---|
| - Full blood count - Kidney and liver function tests - C-reactive protein - Iron studies | - Vitamin B12 - EBV and CMV serology - Beta HCG if appropriate - ESR | - Thyroid function - HbA1c - Immunoglobulins |
PATIENTS PRESENTING WITH:
| Respiratory / ENT and Cardiovascular symptoms | Generalised and Neurological symptoms | Gastrointestinal symptoms | Musculoskeletal / skin symptoms |
|---|---|---|---|
| - Troponin - ECG / 24 Holter monitor - B-type natriuretic peptide (BNP) - Chest X-ray | - Blood culture (if fever present) - Hormonal profile (e.g. early morning testosterone) - Serum protein electrophoresis - Calcium, magnesium and phosphate - Cortisol and ACTH levels | - Faecal calprotectin - Coeliac screen - Hydrogen breath test - Faecal MCS - Lipase and amylase - Urine MCS | - ANA / ENA / DsDNA - Creatine kinase |
Summary of Long COVID investigative recommendations
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Covid-19 and Urinary Symptoms
The COVID-19 pandemic has raised concerns about its potential impact on various body systems,
including the urinary tract.
Recent studies suggest that elderly patients with COVID-19 may experience urinary symptoms,
such as urinary incontinence, urgency, frequency, and hematuria. This could be due to
the direct or indirect effects of COVID-19 on the urinary tract or as a result of the systemic
inflammatory response triggered by the virus.
It is important to note that urinary symptoms
alone are not specific to COVID-19 and could be caused by other medical conditions, such as urinary
tract infections, prostate enlargement, or bladder dysfunction. However, given the potential overlap
of symptoms and the severity of the COVID-19 pandemic, it may be helpful to test for COVID-19 when
elderly patients present with urinary symptoms.
Timely diagnosis of COVID-19 in these
patients may facilitate appropriate management and prevent the spread of the virus to other vulnerable
individuals. Healthcare providers should remain vigilant and consider COVID-19 testing in elderly
patients with urinary symptoms, particularly if they have been exposed to the virus or have other risk
factors for COVID-19. It is also essential to provide comprehensive care and support to older adults
with COVID-19 and urinary symptoms to prevent further complications and improve their overall health
outcomes.
References
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7995211/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9233460/
- https://www.nature.com/articles/s41585-022-00586-1
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References
- Liu B, Jayasundara D, Pye V, Dobbins T, Dore GJ, Matthews G, et al. Whole of population-based cohort study of recovery time from COVID-19 in New South Wales Australia. (2666-6065 (Electronic)).
- WHO. A clinical case definition of post COVID-19 condition by a Delphi consensus, 6 October 2021 2021 [Available from: https://www.who.int/publications/i/item/WHO-2019-nCoVPost_COVID-19_condition-Clinical_case_definition-2021.1.]
- Mannix L. Long COVID clinics ‘inundated’ with patients, and doctors can’t cope. Sydney Morning Herald. 2022.
- Shah W, Hillman T, Playford ED, Hishmeh L. Managing the long term effects of covid-19: summary of NICE, SIGN, and RCGP rapid guideline. BMJ. 2021;372:n136.
- Hughes SE, Haroon S, Subramanian A, McMullan C, Aiyegbusi OL, Turner GM, et al. Development and validation of the symptom burden questionnaire for long covid (SBQLC): Rasch analysis. BMJ. 2022;377:e070230.
About the Author
Associate Professor Chris Barnes
MBBS FRACP FRCPAAssociate Professor Chris Barnes
MBBS FRACP FRCPA- non–malignant haematological conditions including…
- paediatric haematology
Associate Professor Chris Barnes joined Clinical Labs in 2016 and is the National Director of Clinical Pathology. Prior to this, he worked as a consultant haematopathologist with Healthscope Pathology from 2009. Chris is a dual-trained clinical and laboratory haematologist, having trained at the Royal Children’s Hospital and the Royal Melbourne Hospital. He also undertook training at The Hospital for Sick Children in Toronto, Canada. He holds a part-time public hospital appointment at the Royal Children’s Hospital, where he serves as the Director of the Henry Ekert Haemophilia Treatment Centre. Chris has extensive clinical research interests and is the principal investigator on eight separate clinical trials based at the Murdoch Children’s Research Institute. He has held numerous leadership positions, including Chair of the Medical Staff Association at the Royal Children’s Hospital and Chair of the Australian Haemophilia Directors Association. He is currently the Chair of the Australian Bleeding Disorders Registry with the National Blood Authority and a Director of Melbourne Haematology and Melbourne Paediatric Specialists. Chris’ focus within Clinical Labs is the national supervision and management of clinical pathology disciplines, including haematology, biochemistry, microbiology and immunopathology.
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