Living Evidence - post acute sequelae of COVID-19
Living evidence tables provide high level summaries of key studies and evidence on a particular topic, and links to sources. They are reviewed daily and updated as new evidence and information is published.
Post-acute sequelae of COVID-19 (PASC) generally refers to a syndrome characterised by persistent and prolonged effects after acute SARS-CoV-2 infection. PASC is now recognised as a multi-organ disease with a broad spectrum of manifestations. The National Institute for Health and Care Excellence (NICE) rapid guideline noted COVID-19 disease spans:
- acute COVID-19: signs and symptoms of COVID-19 for up to four weeks
- ongoing symptomatic COVID-19: signs and symptoms of COVID-19 from four to 12 weeks
- post-COVID-19 syndrome: signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis.
This table includes information on ongoing symptomatic COVID-19 and PASC as defined by NICE. It focuses on symptoms, assessment and management.
Checks for new content are conducted each fortnight, and any updates that occur during that time are highlighted.
Approximately 40% of people experienced persistent cough at two to three weeks following initial symptoms. Often resolves by three months.
2.5% cumulative incidence of thrombosis at 30 days following discharge.
Assessment scheduled approximately one week following discharge from hospital for a patient with more severe COVID-19 requiring hospitalisation and three weeks following onset of illness for a patient who is older or with comorbidities and did not require hospitalisation.
Comprehensive history of the patient's acute COVID-19 illness.
Clinical assessment for respiratory, psychiatric and thromboembolic sequelae, as well as rehabilitation needs.
Need for laboratory testing is determined by the severity and abnormal test results during patient’s acute illness, and current symptoms. For most people who have recovered from mild disease, laboratory testing is not necessary. Blood tests including a full blood count, kidney and liver function tests, C‑reactive protein test, ferritin, B‑type natriuretic peptide (BNP) and thyroid function tests may be offered.
Clinical evaluation of cardiopulmonary symptoms.
Evaluation of exercise capacity and oxygenation.
Urgent referral of people with ongoing symptoms or suspected PASC to relevant acute services if they have symptoms that may be caused by an acute or life threatening complication including severe hypoxaemia, severe lung disease, cardiac chest pain or multisystem inflammatory syndrome in children.
Advice on self-management should be provided to people with ongoing symptomatic COVID-19.
Cough is managed in a similar fashion to cough in patients with post-viral cough syndrome and typically comprises over-the-counter cough suppressants.
For people with olfactory and gustatory symptoms, symptoms usually resolve slowly over several weeks and do not require intervention.
People with a need for rehabilitation services are typically referred within 30 days of recovery from initial infection. Rehabilitation programs generally last 6-8 weeks, and may include inpatient, outpatient, in-person, web-based or home rehabilitation.
Patients diagnosed with documented thromboses are managed in a similar way to thrombosis in non-COVID-19 patients. Direct oral anticoagulants and low-molecular-weight heparin are preferred anticoagulation agents over vitamin K antagonists.
Extended thromboprophylaxis considered for high-risk survivors.
Social, financial and cultural support.
Dyspnea may persist over two to three months, sometimes longer, and is reported in up to 65% of people.
Common non-specific neurological symptoms include headaches, dizziness, and cognitive blunting (“brain fog”).
Neurocognitive symptoms are reported in over 15% of people including concentration and memory problems which persist for six weeks or more after discharge.
Psychological symptoms (such as anxiety, depression, PTSD) are common after acute COVID-19 infection. Over 20% of people reported psychological symptoms or distress. This was higher (over 45%) in people who were in ICU.
Sleep disorders or insomnia, thromboembolism, chronic kidney disease and hair loss also reported.
Case reports of diabetic ketoacidosis reported 2-3 months after COVID-19 diagnosis.
Symptom assessment may include 6 minute walk test, pulmonary functions tests, chest X-ray, pulmonary embolism work up, echocardiogram and high-resolution computed tomography of the chest at 4-6 weeks and 12 weeks post discharge.
Screening for functional impairment.
Pulmonary function testing at 6-12 weeks following hospital discharge.
Complete neurological history and examination for neurologic and neurocognitive sequalae.
Evaluation for signs of hypercoagulability and thromboses.
People may also be assessed for other symptoms including renal, hepatic, endocrine, gastrointestinal, dermatologic, sleep, psychological and quality of life.
People with impaired renal function may benefit with early follow up with nephrologist after discharge of people with COVID-19 and acute kidney injury.
Serologic testing for type 1 diabetes-associated autoantibodies obtained in patients with newly diagnosed diabetes mellitus in the absence of traditional risk factors for type 2 diabetes.
Management for fatigue includes encouragement of rest, good sleep hygiene, and specific fatigue management strategies.
Management for dyspnea is similar to that in non-COVID-19 patients and may include pharmacotherapy, breathing exercises and consideration of pulmonary rehabilitation.
Chest discomfort does not generally require treatment. For severe discomfort NSAIDS may be administered.
Neurologic complications following COVID-19 should be managed in the same way as with other patients. People with severe psychiatric symptoms or are at risk of self‑harm or suicide should be referred urgently for psychiatric assessment.
Abnormal lung functions and structural changes were reported up to six months after hospitalisation in mild-to-critical COVID-19 patients.
Whilst fatigue and dyspnea typically last three months, symptoms can persist longer including seven months post infection. Other persistent symptoms can include loss of sense of smell or taste, brain fog, worsened health related quality of life, sleep difficulties, anxiety or depression.
3% of patients noted a skin rash at six months follow-up.
In a cohort study, at six months after discharge for COVID-19 persistent fever, thoracic pin, persistent anosmia or dysgeusia, dermatological symptoms, arrythmias, superinfection and pneumonia were associated with return to emergency services. Persistent fever, neurological symptoms, superinfection and pneumonia were associated with hospital readmission. Mean age, frequency of dependence and frequency of comorbidities were associated with post-discharge death.
High-resolution computed tomography of the chest.
Referral to an evaluation in a specialised outpatient COVID-19 recovery clinic, or relevant subspecialty clinic, for patients with persistent symptoms lasting beyond 12 weeks.
Approximately 50% of people reported persistence of at least one symptom at 12 month follow up, most commonly fatigue, followed by smell or taste impairment.^
Case report of ongoing symptoms including breathlessness, brain fog, fatigue, headache, poor temperature control, eye site deterioration, tingling in face, swollen glands and nausea reported over 12 months post COVID-19.
High-resolution computed tomography of the chest.
More than 50 long-term effects of COVID-19 have been reported in the literature. Only commonly reported and emerging symptoms have been included in the living table.
* Preliminary data, not fully established, in some cases small numbers or short follow up; interpret with caution
^ Commentary grey literature, pre peer review or news
Living evidence tables include some links to low quality sources and an assessment of the original source has not been undertaken. Sources are monitored daily but due to rapidly emerging information, tables may not always reflect the most current evidence. The tables are not peer reviewed, and inclusion does not imply official recommendation nor endorsement of NSW Health.
Last updated on 10 Jun 2021