Docs question why some COVID-19 patients develop post-recovery complications

Surviving COVID-19 — and leaving the hospital — isn’t always the end of the journey.

Crain’s interviewed several leading clinical specialists and researchers in Michigan who focus their care on patients most likely to have post-hospitalization complications from coronavirus.

Dr. Meilan Han., a critical care physician and professor of pulmonary disease at Michigan Medicine in Ann Arbor, said discharged patients are leaving the hospital with multiple other problems. Patients sometimes have blood clots form in their lungs or legs either during hospitalization or after discharge, leading to the possibility of strokes.

“We are seeing patients having prolonged periods of not doing well” after recovering initially from COVID-19, Han said. “We don’t have tons of data yet and the information is anecdotal, but patients complain about persistent fatigue, malaise, lingering shortness of breath.”

Neurosurgeon Dr. Hazem Eltahawy, president of the Michigan Association of Neurological Surgeons, said some patients could face long-term neurological effects after a COVID-19 infection.

“There could be direct damage through thrombogenic effects (blood clots in the brain or lungs),” said Eltahawy, who also is chair of neurosurgery at St. Mary Mercy Hospital in Livonia. “It has been demonstrated that one of the significant reasons why this virus is so morbid is that it creates blood clots that are widespread and presents in multiple small vessels across the brain.”

Eltahawy said the clots could reduce blood flow and also create inflammatory reactions that could be severe enough to show up on imaging studies.

“The consequences could certainly leave a neurological mark on the central nervous system. The brain has limited ability to regenerate as opposed to other organs,” Eltahawy said. “Sometimes what is lost does not fully recover.”

Dr. Aditya Pandey, an associate professor of neurological surgery at Michigan Medicine, said some post-COVID-19 patients are coming back with stroke-like symptoms and other cerebrovascular complications.

Another possibility is people developing infections in the brain either caused by or associated with COVID-19.

“We don’t have any statistics yet or the downstream effects, but some people feel the hyperinflammation (with COVID-19) creates a propensity to form clots in the brain, or the legs and goes to the lungs that can lead to strokes,” he said.

Han said some people — after surviving COVID-19 in the intensive care unit on a ventilator — are developing what is similar to acute respiratory distress syndrome.

ARDS causes inflammation to the walls of the air sacs in the lungs that can make it difficult to breathe, limit the ability of red blood cells to deliver oxygen and possibly lead to pneumonia or asthma, Han said.

Patients can also develop sepsis, a general blood infection, because of inflammation in the body. Han said most pulmonologists believe COVID-19 patients who develop ARDS-like symptoms and lung damage should be treated as if they have acute respiratory distress syndrome. Treatment varies but usually includes oxygen, sedation, medication and fluids.

“Many of those patients are known to have significant lung function abnormalities that may persist for years. The data suggests five years, but not all have it,” Han said. “We’ll just have to see whether COVID tends to follow the same pattern.”

Heart, asthma issues in Detroit

Dr. Heather Abraham, an internist with University Physician Group in Detroit, said patients she has seen the past several months have a range of post-COVID-19 symptoms that include heart failure, asthma, shortness of breath and neurological issues.

“It is not just patients who were admitted. Some were positive and just stayed home. One patient lost 30 pounds and was sick for a month,” Abraham said. “There is something incredibly inflammatory about COVID. Some cardiologists have recommended full cardiac workups, echocardiograms and some patients may warrant cardiac catheterization” because of heart damage they have suffered.

A new report from the Centers for Disease Control and Prevention shows that people with heart disease and diabetes were hospitalized six times more often and died 12 times more often than otherwise healthy individuals infected with the coronavirus during the first four months of the pandemic. Abraham said Detroit has higher rates of chronic diseases, including asthma, hypertension, diabetes and heart disease, all problems that COVID-19 makes worse.

In Detroit, the prevalence of asthma is 29 percent higher among adults than those living in the rest of the state, according to a 2016 report from the Michigan Department of Health and Human Services.

Abraham said many patients also have social and psychiatric issues that complicate recovery.

Dr. Michael Brennan, an endocrinologist in St. Clair Shores who practices at Beaumont Health hospitals, said a COVID-19 infection can make diabetes and kidney problems worse.

“People are complaining about problems. They aren’t making things up. But what is the intervention we can do to fix these things?” Brennan said. “Hopefully these things will be transient, but some people will develop lifelong problems. There are cases where the virus makes this worse.”

Brennan said he has treated COVID-19 patients with recurring symptoms after they have been discharged.

“What we’ve seen with COVID-19 is that there’s a huge inflammatory response. This leaves people who you would call having pre-diabetes or borderline diabetes, who have insufficient insulin reserves, made worse by the inflammation process,” Brennan said.

Fortunately, Brennan said he believes many younger patients who haven’t developed full onset diabetes can recover after several weeks.

But it depends on age. “It’s a spectrum. If it’s a 25-year-old gentleman, or lady, most times they can get back to being normal with regard to pancreatic function, but if they’re a 78-year-old … (they aren’t) going to be able to function at the same level as before, in most cases,” he said.

Another problem that happens with COVID-19 patients is what is called a “cytokine storm” in which the body’s immune system goes into a potentially fatal overdrive and leads to multi-organ failure.

“Those individuals seem to have an inflammatory response that exacerbate the diabetes,” Brennan said. “When they go home, some of those individuals do need medication for diabetes. … Some may need insulin in addition to the glucocorticoid use. If they left the hospital on glucocorticoids, they may need some more help with diabetes management.”

“Docs question why some COVID-19 patients develop post-recovery complications” originally appeared in Crain’s Detroit Business.