COVID-19 after-effects evident 3 months after hospital discharge

Patients hospitalized for COVID-19 may experience after-effects of the condition 3 months post-discharge, according to a study from The Netherlands.

“[T]his study shows that [3 months after recovery from acute COVID-19] … a substantial number of patients reports severe problems in several health domains including fatigue, functional impairment, and quality of life (QoL),” said the authors. “[Furthermore,] we found only 9 percent of our cohort to be free of residual [pulmonary] disease after 3 months.”

This prospective observational study involved 124 patients (mean age 59 years, 60 percent male) who attended the COVID-19 aftercare facility of the Radboud University Medical Centre, Nijmegen, The Netherlands, following discharge from hospital for COVID-19 (n=97) and general practitioner-referred patients with mild COVID-19 disease who were not hospitalized but had symptoms that persisted for >6 weeks (n=27).

Of the overall cohort, 27, 51, 26, and 20 had mild, moderate, severe, and critical disease, respectively. Patients were hospitalized for a median 8 days and those with critical disease were in the ICU for a mean 15 days.

Assessments were carried out a mean 13 weeks after SARS-CoV-2 symptom onset (mean 10 weeks post-discharge). Assessments conducted included resting pulse-oximetry, spirometry, single-breath diffusion capacity, body plethysmography, low-dose chest CT imaging (discharged patients) or chest X-ray imaging (non-hospitalized patients), and 6-minute walking test (6MWT). Patients were also assessed for frailty, cognition, anxiety, depression, and post-traumatic stress syndrome. The Short Form Health survey and the Nijmegen Clinical Screening Instrument were used to measure health status.

Only 2 percent of patients were current smokers, while 60 percent were former smokers. Forty percent had no relevant comorbidities. Median C-reactive protein, D-dimer, and ferritin levels, and mean leukocyte count were normal in all groups at follow-up.

Forty-two percent of patients had lung diffusion capacity below the lower limit of normal (LLN) following hospital discharge, while 91 percent had residual pulmonary parenchymal abnormalities. [Clin Infect Dis 2020;doi:10.1093/cid/ciaa1750]

“Residual pulmonary parenchymal abnormalities … correlated with the lower lung diffusion capacity after 3 months,” said the authors. However, they noted that the extent of the residual pulmonary parenchymal abnormalities was significantly lower than that at hospital admission.

In contrast, 93 percent of patients with mild disease had normal X-ray chest images, with two patients exhibiting mild signs of bronchial disease.

Reduced ground-glass opacification (GGO) on CT imaging was observed in 99 percent of patients following discharge from hospital.

Twenty-six percent of all patients demonstrated radiological signs of fibrosis, while 60 percent had bronchiolectasis. None of the patients had active pneumonia.

Older age, lower total lung capacity, and more frequent desaturation in the 6MWT were significantly associated with signs of residual fibrosis.

Despite normal mean 6MWT and fat-free mass index (FFMI), exercise capacity was reduced in 22 percent of patients (6MWT <80 percent predicted) and FFMI was below LLN in 19 percent, while 36 percent exhibited mental and/or cognitive dysfunction.

About two-thirds of patients (64 percent) experienced functional impairment in daily life, while 69 and 72 percent experienced fatigue and poor QoL, respectively. Abnormal scores for anxiety and depression were noted in 10 and 12 percent of patients, respectively, with no difference according to disease severity. However, patients with mild disease appeared to have significantly worse health status compared with patients with moderate-to-critical disease, the reasons for which are undetermined, the authors said.

Sixty-four percent of patients had normal scores on all mental and cognitive status questionnaires. The authors suggested that physicians look out for the potential development of post-traumatic stress over time.

The authors acknowledged the possibility for selection bias, particularly among those with mild disease, noting that the results of this group of patients may not be generalizable to all patients with mild COVID-19 disease. These findings were also from a single centre, comprised a small population, and were deduced after a relatively short follow-up period. As such, larger, longer-term studies are necessary “to elucidate natural trajectories of COVID-19 recovery, to find predictors of complicated long-term trajectories, and to develop strategies to decrease long-term COVID-19 morbidity,” they said.