A Practice-Based Approach to Emergency Department Evaluation and Management of Patients With Postacute Sequelae after COVID-19 Infection: Long COVID

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Publication Date: January 2024 (Volume 26, Number 1)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 01/01/2027.

Authors

Peer Reviewers

Abstract

Afflicting millions of people across the world, “long COVID” is a new disease entity that can present with a diverse array of symptoms of variable severity, affecting nearly every organ system. The presumptive diagnosis of long COVID is largely clinical, and should be made only after other serious etiologies have been excluded. Workup is driven by the patient‘s presenting acute symptoms, comorbidities, and physical examination findings. This issue reviews the research and current evidence on the etiology of COVID-19 infection and long COVID and presents a practice-based approach to the management of patients presenting with its postacute sequelae.

Case Presentations

A 35-year-old woman presents to the ED complaining of palpitations and retrosternal chest pain that is mostly relieved by sitting forward…

• The patient, who works as a paralegal and has been healthy all her life (although she smokes a half-pack of cigarettes daily), reports that her symptoms occasionally prompt anxiety so severe that she has self-treated with recreational marijuana. The palpitations have recurred frequently over the past 3 months, but she dates their initial incidence to a PCR-confirmed diagnosis of COVID-19 about 2 weeks before that.
• Her temperature is 37.8°C; heart rate,122 beats/min; blood pressure, 124/84 mm Hg; and respiratory rate, 24 breaths/min, with shallow breathing. Her ECG shows pronounced sinus arrhythmia.
• The patient reports that her initial COVID infection was treated conservatively as an outpatient but caused 2 weeks’ absence from work. Since then, her more-constant symptoms have been dyspnea with even minimal activity such as climbing 1 flight of stairs. She also complains of cough that is sometimes productive of yellowish sputum, with both tussive chest pain and back pain. The palpitations are worse than usual today and make her feel like she is “having a heart attack, or an aneurysm, or something bad.” This is her first ED visit for these symptoms, but she has visited her primary care provider’s office several times and been encouraged to hydrate and take acetaminophen.
• You consider whether there is anything that can be done to pinpoint a treatable cause of her symptoms—always following a “consider the worst case first” (here, perhaps pulmonary embolism), while also assuaging her anxiety...

A 25-year-old male healthcare worker presents to the ED complaining of several days of subjective fever, generalized fatigue and myalgias, sore throat, headache, and anosmia…

• The patient’s vital signs are normal, as are his cardiovascular and pulmonary examinations. There is a localized 4-cm-wide scaly, pink, macular eruption on his back that is notably pruritic. With his eyes covered, he cannot differentiate the odors of coffee, iodine solution, and water.
• The patient reports that similar symptoms have waxed and waned over the preceding 6 to 8 weeks, but the anosmia had been consistent since he was diagnosed with COVID-19 about 3 months ago. Upon further questioning, he reports 3 episodes over the past several weeks of mucoid, nonbloody diarrhea, which resolved with over-the-counter medications; relatively persistent nausea and poor appetite (though he reported no weight loss); easy fatigability; and recurrent episodes of “hives” that he had never experienced before and with which he had identified no potential precipitant.
• Other than being obese (body mass index, 32.1 kg/m²) and having a history of childhood asthma, he considers himself to be healthy. He presents today because he feels believes that these symptoms are related to his prior COVID infection, and he is concerned he may still be “carrying” the virus and putting both coworkers and patients at risk.
• You consider what the etiology of his rash might be, how ill he is, and how to discuss contagion risk with him at this point in his clinical course...

A 45-year-old woman presents to the ED complaining of 2 days of persistent diaphoresis and lightheadedness, with bilateral upper extremity “pins-and-needles” shooting pain…

• The patient reports that she had a confirmed COVID-19 diagnosis 8 weeks ago. Her acute COVID symptoms were mild headache and dizziness as well as typical upper respiratory infection symptoms. She was treated with nirmatrelvir/ritonavir (Paxlovid™) but had rebound symptoms after the treatment course. Her symptoms eventually subsided 2 weeks after stopping the medication.
• On physical examination, the patient has a normal temperature of 36.6°C; heart rate, 104 beats/min; blood pressure, 112/62 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 92% on room air. She is diaphoretic, but has an otherwise unremarkable physical examination, and a normal neurological examination.
• On further history, she reports that her upper extremity neurological symptoms occur several times a day. They are associated with activity and exertion, and are usually relieved by rest. She has seen several neurologists and had been put on a trial of pregabalin, without relief. This visit to the ED was prompted by the associated diaphoresis and lightheadedness that had not occurred in the past.
• At this point, what other diagnostic testing should be done for this patient, or should she be reassured and discharged?

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