Before Molly Williams got sick, she could squat with a 150-pound barbell. Four months into the coronavirus pandemic, the disease continues to surprise doctors. And one of the unpleasant surprises is the duration of symptoms in some patients. Dr. John Wright of the Bradford Institute for Medical Research (BRI) has met two such patients: young women who continue to complain of fatigue and shortness of breath several weeks after the onset of the disease. Here is his report.
A doctor from the neighboring hospital, 27-year-old Amira Valli, cannot catch her breath after climbing a flight of stairs. Molly Williams, a 34-year-old physical therapist at our hospital, has always been an excellent athlete, but now she says shortness of breath has become a constant companion. In addition, she has experienced frequent bouts of severe anxiety and memory problems. They both came down with the coronavirus three months ago.
In March, we knew too little about the coronavirus. We thought it was strictly a respiratory disease, but it turned out that it affects almost every organ. We assumed that we would have to rely on invasive lung ventilation (ILV) in the intensive care unit, but it turned out that early non-invasive ventilation (NIV) in the hospital was much more effective. We also thought that after congratulating the patients on their recovery from this acute infectious disease and seeing them leave the hospital, we would not see them again. But four months later, the new enemy became our old enemy, and from time to time it seems like the only enemy. We have also become aware of the long-term consequences of this disease for patients – not only those who have ended up in the hospital, but also those who have been treated at home and seem to have overcome the acute form of the disease, only to suffer from recurrent or persistent symptoms. As a result, patients who had the disease a few months ago are still unable to return to normal life.
Dr. Amira Valli and Dr. Paul Whitaker
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From past medical experience, we knew that nearly half of those who contracted severe acute respiratory syndrome (SARS), similar to the coronavirus epidemic that erupted in 2003, developed chronic fatigue or other long-term symptoms. So it should come as no surprise that the malignant descendant of that virus, SARS-CoV2, inherited many of the unpleasant characteristics of its predecessor. We are receiving more and more requests for help from patients and their physicians. Some continue to experience early symptoms such as chest pain and shortness of breath. Others have developed new symptoms – headaches, memory loss and vision problems. Many have developed depression and anxiety. Most complain of constant fatigue, and all want to return to their normal lives. They rushed to celebrate their recovery from Covid-19, but now doubt is gnawing at them and a sense of despair is growing.
During the first week of her illness, Amira Valli had only mild symptoms: headaches, a scratchy throat, and a slight fever. By the end of the week, she thought the worst was over, but the new week brought shortness of breath, and now the shortness of breath isn’t going away. “Stairs are particularly difficult for me. After climbing a flight of stairs, my pulse goes up to 140. Last week was especially hard, I couldn’t fall asleep because I was short of breath, and I feel extremely exhausted,” Amira complains. According to her, this was compounded by an increasing sense of fear. The chest x-ray shows no abnormalities, and the auscultation is normal. But something is still wrong and we will try to get to the root of the problem.
Molly (second from left) and her fellow physiotherapists on their way to the ward with Covid-19 patients. The photo was taken just before Molly herself became ill.
Physical therapist Molly Williams volunteered to work with coronavirus-infected patients and most likely became infected herself in the hospital. She was a competitive gymnast in her youth, then took up Crossfit (a complex training system that incorporates elements of both light and heavy athletics) and even became a top twenty athlete in the UK. But now she is also experiencing shortness of breath. “My resting heart rate used to be 50 beats per minute, and now it’s around 90,” says Molly. “I get out of breath even when I talk, my leg muscles get incredibly tired, and when I walk my heart rate goes up to 133 beats.” According to Molly, she has uncontrollable urges to cry and becomes incredibly anxious about everything. She has also begun to have memory problems. “I forget everything all the time – I repeat the same thing many times, but my mind is unable to retain information. I try and I can’t remember the right word. Now I have to write everything down in order not to forget,” she says. “I have never had any health problems in the past and it is very difficult for me to deal with such a blow.
As a child, Molly Williams was involved in gymnastics. However, we still do not understand why these patients had such long-term problems. It is possible that the virus is hiding somewhere in their bodies and causing these persistent symptoms, as seen in Ebola survivors. Some of our patients continue to test positive for the virus several weeks after infection. This may be because the reagent detects residual fragments of viral RNA. If this is the case, it is possible that these RNA fragments trigger a prolonged immune system response, explaining these persistent symptoms. However, it is more likely that patients with prolonged symptoms have a stronger immune system response to the initial infection, which is exacerbated by the damage caused by the infection to the lungs and other organs. Our job as doctors and researchers is to find out what is causing all these long-term effects and then develop a treatment plan that will help these and other patients who have developed severe post-infection fatigue. This is an understudied area of research because it is very difficult to find answers. However, Covid-19 has become an incredible scientific catalyst, and the attention focused on patients with long-term symptoms can help advance the understanding of these processes.
Epidemiologist Professor John Wright is the director of the Bradford Institute for Medical Research. He is a veteran of the fight against cholera, Ebola and AIDS in tropical African countries.
My colleague, Dr. Paul Whittaker, at the request of patients, has established the first clinic for those who have recovered from COVID-19. The original plan was to follow patients who had recovered from coronavirus for 12 weeks after discharge from the hospital. However, it soon became clear that some of those who required hospitalization had completely returned to normal life, while some of those who were not hospitalized, such as Amira and Molly, continued to feel unwell. As a result, we now admit people to our clinic both on their own initiative and on the basis of referrals from their treating physicians. When people come to our clinic, we take a chest x-ray, check lung function and the musculoskeletal system, and ask them to fill out some questionnaires. Those with severe symptoms may be offered an echocardiogram (ultrasound of the heart), a computed tomography scan, and a full lung scan. “When we talk about people who have had Covid-19 but have not yet returned to normal life, I think we are only seeing the tip of the iceberg. Every week I get three or four calls from therapists who explain that they are seeing patients who have recovered from the coronavirus a few months ago but are still showing symptoms of the disease,” says Paul Whitaker. In our clinic, we will soon have a nutritionist and a physical therapist, and we will also need significant support from psychologists, because patients not only have cardiorespiratory complications, but also develop post-traumatic stress disorder, depression, neurological problems, and chronic fatigue syndrome. So it is very important to support them, to offer them psychological support and rehabilitation programs. We also need to know exactly what works and what does not. According to psychologist and consultant Rob Whitaker, those who recover from coronavirus often experience waves of unexplained crying, which may indicate the onset of cognitive disorders such as memory problems like Molly’s. “But at the moment it is very difficult to say what is related to emotions and fatigue and what is physiological. It is too early to say.