Postmoid syndrome in adults and children

Even a child today knows what a coronavirus infection COVID-19 is. But not many people know the postcoid syndrome. Although, in fact, we are talking about a fairly common pathological condition after coronavirus disease, which does not have specific symptoms, but can continue for quite a long time, disrupting the ability to work and delaying the recovery of patients.

Postcoid syndrome - this diagnosis raises many questions. As a rule, people think: have had an infection, recovered, and there is no need to worry anymore. But the coronavirus is more insidious than doctors expected: it is able to remind of itself for a long time with various pathological signs in the form of a sounded syndrome.

Epidemiology

According to information from several scientific articles on postcoid syndrome, the following statistics can be derived: about 15% of patients who underwent COVID-19 indicate further unsatisfactory health and a feeling of inadequate recovery for more than 20 days after the illness. In about 2%, unpleasant symptoms persist for more than three months. Nevertheless, numerous surveys of those who have been ill themselves say that these indicators are actually much higher. After all, many patients are transferred to home treatment even before the symptoms disappear completely, and not all of them seek medical help with the development of postcoid syndrome. [1]

One study involved more than 380 people with coronavirus infection, whose average age was 69-70 years. It was noted that the complete recovery of most of them could be said only three months after the onset of the infectious lesion. More than 50% of these people complained of difficulty breathing, more than 30% of a cough, about 70% indicated severe fatigue, and 14% developed depression. At the end of the experiment, the patients underwent repeated X-rays: it was found that only 60% of them had a completely "healthy" picture. 

In addition, American doctors initiated a telephone survey, during which the following information was received: at least 35% of patients reported that within 2-3 weeks after the disease they still do not feel as good as before infection. Among young people aged 18 to 34 years, every fifth person had pathological symptoms for several more weeks. 

Causes of the postcoid syndrome

Postcoid syndrome is a consequence of a disease such as  COVID-19  , an acute coronavirus infection, in which the respiratory system and the digestive tract are mainly affected. By its origin, the coronavirus belongs to zoonotic infections. [2]

Most people who become infected with the coronavirus pathogen COVID-19 note the appearance of moderate or mild symptoms of the disease, and recovery occurs without specific treatment measures. Of particular danger is the severe course of the disease, which is more typical for elderly and debilitated patients with background pathologies - for example, diabetes mellitus, chronic lesions of the respiratory or cardiovascular system, and malignant processes. 

Nevertheless, postcoid syndrome can develop in absolutely any patients who have had COVID-19, regardless of how the infection proceeded: whether it was latent or a severe course of the disease.

Today, experts have several theories to explain the occurrence of the syndrome. According to one of them, painful manifestations after recovery are a consequence of the development of chronic thrombovasculitis.

Indeed, coronavirus infection affects not only the respiratory tract, but also blood vessels, including the brain. The vascular walls become inflamed, and this process can continue for some time after recovery.

Such a theory has a right to exist, but it does not explain all the signs of postcoid syndrome. Therefore, scientists still have a lot of work to do to find the causes of the complication.

Risk factors

Doctors still cannot answer the question of why some patients have a coronavirus infection without consequences, while others develop postcoid syndrome. However, it was noticed that most often COVID-19 leaves behind unpleasant symptoms in those who have been ill who belong to risk groups:

• elderly patients;
• suffering from hypertension, cardiovascular pathologies;
• suffering from chronic respiratory diseases, diabetes mellitus, obesity;
• people with initially weakened immunity, oncopathologies, cerebrovascular disorders.

Age patients are one of the first identified risk groups. Postcoid syndrome is especially dangerous for people over 60 years old. The main reason for this danger is a gradual weakening of the activity of the immune system, at the same time several existing background diseases. During COVID-19, there is a decrease in the number of individual immune cells - in particular, T-killers and natural killer cells. If a person already has impaired immunity, then the consequences of the pathology may turn out to be dire. [3], [4]

Persons suffering from cardiovascular diseases have a high risk of not only developing postcoid syndrome, but also other complications, including death. In people with diabetes, in most cases, there are functional changes in the lung tissue, a decrease in the volume of air circulation, general respiratory disorders, which contribute to the further development of adverse consequences.

Pathogenesis

Most patients infected with COVID-19 recover from the disease within a few weeks. But it happens that pathological signs disappear only partially, or after a mild form of coronavirus infection, other residual symptoms appear. In such situations, they talk about the development of postcoid syndrome, which consists in the appearance of various complaints for more than 3-4 weeks after recovery. [5]

The exact pathogenetic mechanisms of the development of postcoid syndrome are not yet clear. There are several options for an unintended consequence, for example:

• Coronavirus infection directly affects human organs, and the lungs, heart, blood vessels, kidneys, stomach and intestines, and the brain are hit.
• Coronavirus provokes the development of an inflammatory process in the inner lining of blood vessels. The patient develops vasculitis, endotheliitis, which, in turn, cause blood clotting disorders. The presence of microscopic blood clots in the bloodstream negatively affects the blood supply to a number of organs, in particular, the heart, kidneys, adrenal glands, thyroid gland, brain, gonads, etc.
• Coronavirus can infect nerve cells in the brain and large nerve trunks, resulting in a wide variety of symptoms, ranging from sleep disturbances and depression to arrhythmias and shortness of breath.
• Infection stimulates an overreaction on the part of the immune system, a number of autoimmune responses start, and a chronic inflammatory process develops, which is caused by the activation of mast cells, which release many mediators.

Postcoid syndrome is a multifactorial consequence that, like COVID-19, has not yet been adequately studied. 

Symptoms of the postcoid syndrome

The clinical picture of postcoid syndrome, which patients with COVID-19 speak about, is quite diverse. It may include the following symptoms:

• fever, pain in the chest, abdomen and / or joints, severe fatigue;
• breathing difficulties, cough;
• feeling of heaviness and chest pain, rapid heartbeat;
• neurocognitive impairment, "fog in the head", impaired concentration, memory impairment, pain in the head, insomnia or drowsiness, numbness of the limbs, tingling in the fingers and toes, dizziness;
• abdominal pain, recurrent nausea, diarrhea, appetite disorders (including possible anorexia);
• muscle and joint pain;
• anxiety disorders, depression;
• ear pains, a feeling of tinnitus, sore throat, loss of smell, change in taste, the appearance of additional tastes;
• skin rashes.

In addition, during the postcoid syndrome, disorders of the blood coagulation system and metabolic disorders were often noted. [6]

The most common early signs of PTSD are as follows:

• paroxysmal weakness, often very pronounced, not allowing you to do ordinary household chores or even get out of bed;
• a strong decrease in endurance, inability to perform even moderate physical activity;
• failure of circadian rhythms, when nocturnal insomnia replaces daytime sleepiness (sleep inversion);
• muscle pain caused by a decrease in the protein content of the muscles during the acute period of COVID-19.

Psychoemotional disorders are found everywhere in patients:

• depression, pessimistic mood, depression, anxiety, in severe cases - suicidal thoughts;
• emotional lability, sudden mood swings, loss of behavioral self-control;
• panic attacks, accompanied by attacks of changes in blood pressure, nausea, dizziness.

The so-called postcoid asthenovegetative syndrome is more typical for female patients prone to vegetative-vascular disorders. Typical signs of this disorder are:

• changes in blood pressure (often increased, but sometimes hypotension);
• feeling short of breath;
• paroxysmal dizziness, loss of balance;
• paroxysmal nausea (vomiting - rarely);
• the emergence of various fears (including the fear of death);
• paroxysmal sensation of cold or heat.

The respiratory organs can also malfunction, and even in those patients who did not have obvious respiratory problems during the acute course of COVID-19. With the development of postcoid syndrome, the following signs appear:

• feeling of lack of air;
• heaviness in the chest, feeling of incomplete inhalation;
• periodic spasms of the bronchi, which may be accompanied by severe shortness of breath, tachycardia, dizziness.

A similar picture can last from one week to six months or even more.

Often, with post-coid syndrome, the nervous system is also affected, which is manifested by the following pathological symptoms:

• headaches, persistent or paroxysmal, disturbing periods;
• thermoregulatory failures (prolonged increase in temperature, or vice versa, decrease);
• frequent chills, muscle tremors (even against the background of normal body temperature);
• sensitivity disorders in the form of paresthesias, tingling, burning, itching sensations on the skin;
• change in gustatory and olfactory sensations (up to six months or more). [7]

How long can the temperature last with post-coccygeal syndrome? In most cases, temperature readings do not exceed subfebrile numbers, staying at around 37.3 ° C (especially in the evenings) for no more than one week, if there are no other background diseases. In some patients, febrile temperature persists for 1-2 weeks, renewing for several days after a short "light" interval. But a low temperature (usually 36.5 ° C) can be kept for a little longer - up to several weeks. [8]

The specific lesion of the cardiovascular system in COVID-19 makes itself felt during the postcoid syndrome. In about 20% of cases, people who have been ill have a heart rhythm disorder, the development of acute or chronic heart failure. Most often, the following signs are observed:

• drops in blood pressure (increase or decrease), in severe cases, orthostatic collapse develops, which is characterized by a sharp drop in pressure up to fainting;
• vasculitis, angiitis, which are accompanied by the appearance of a skin rash, hemorrhages and hematomas on the skin;
• arrhythmias, tachycardia, bradycardia.

Postmoid syndrome often manifests itself as digestive disorders associated with both an infectious lesion of the gastrointestinal tract and with antibiotic therapy and other medications. Patients often voice complaints:

• deterioration of intestinal peristalsis, periodic occurrence of constipation or diarrhea;
• a change in appetite (more often - a loss of craving for food).

If you do not take any measures, then intestinal dysbiosis can cause a weakening of the immune defense, the development of anemia, and allergic processes. [9]

Inflammatory urogenital diseases, in women - dysmenorrhea, endocrine diseases, can become other possible signs of post-coccygeal syndrome. Most often, the first "bells" are noted in organs previously affected by any chronic pathologies. Sometimes disorders that the patient did not know about "make themselves felt". In order to prevent the appearance of serious health problems, it is recommended to listen carefully to your feelings and, if suspicious symptoms appear, immediately consult a doctor. [10]

Postcoid syndrome in children

Postcoid syndrome also occurs in childhood, even if the child has suffered a mild form of the disease. Just like in adults, children have the possibility of damage to internal organs, respiratory and cardiovascular systems.

What are the signs of this? Most often, patients complain of shortness of breath, palpitations, anxiety attacks, digestive disorders, sleep disturbances, lethargy. On the part of the immune system, failures are also noted. Children can be disturbed by attacks of fear, up to panic attacks. 

It is known that children tolerate COVID-19 more easily than adults. They are less likely to develop pneumonia and other complications. However, postcoid syndrome is also typical for small patients. For example, infants under 1 year of age have a significant decrease in appetite, which is why they lose weight. Sleep quality deteriorates: babies do not fall asleep well, sleep anxiously, although in the daytime they are lethargic and drowsy.

Pediatricians note a number of cases of the development of multisystem inflammation in children, or Kawasaki-like syndrome. In this case, we are talking about a severe complication with an unfavorable prognosis, up to a lethal outcome. Patients who have undergone such a syndrome are at a high risk of developing coronary pathologies in the future.

To prevent adverse events from developing, parents should closely monitor their children even after recovering from COVID-19. After any pathology, a recovery stage must go through, which involves a decrease in mental and physical activity, providing the baby with plenty of drink and quality nutrition. If suspicious signs appear, you should consult a doctor as soon as possible and, if necessary, undergo a series of additional examinations.

Stages

The British National Institute for Health and Care Excellence in conjunction with the Scottish Intercollegiate Organization and the Royal College of General Practitioners in 2020 recommended distinguishing the following stages of the disease:

1. Acute stage - complaints and pathological signs are present up to 3-4 weeks.
2. Prolonged symptomatic stage - complaints and pathological signs are present for four to twelve weeks.
3. Directly the stage of postcoid syndrome - complaints and pathological signs continue for more than 12 weeks, without being the result of any other disease. 

Forms

The diagnosis of "postcoid syndrome" has not yet been introduced into official medical use and is not considered a generally accepted term, but it is already often used to characterize the phenomenon of a long course of the recovery period after COVID-19.

In the absence of an officially recognized term, experts proposed to divide pathology into the following types:

• long-term COVID-19 - if symptoms persist for more than 3 weeks after an infectious manifestation;
• chronic form of COVID-19 - if symptoms persist for more than 12 weeks after the first signs of infection are detected.

Experts also believe that laboratory confirmation criteria for coronavirus infection are not a prerequisite for identifying a long-term or chronic type of disease. [11]

Complications and consequences

Postmoid syndrome is itself a complication of the COVID-19 coronavirus infection. However, it can also lead to the development of adverse consequences - in particular, many patients had disorders of the blood coagulation system and metabolic disorders. For example, diabetic patients often have difficulties in establishing control over the disease.

In addition, there is documentary evidence of such pathological consequences as inflammation of the heart muscle and cardiovascular insufficiency, cardiac arrhythmias and thrombotic complications. Some patients developed post-infectious encephalitis. 

Similar problems can arise from the respiratory, musculoskeletal and nervous systems. The reasons for this development of events are unknown, however, many experts associate the emergence of complications immediately with a number of pathophysiological mechanisms, including vascular lesions - vasculitis.

Other possible negative consequences of postcoid syndrome include visual impairment and arthritis. [12], 

In order to prevent the occurrence of complications, doctors recommend a multilateral approach to all patients with COVID-19, paying attention not only to their physical condition, but also to their psychology.

Diagnostics of the postcoid syndrome

To diagnose postcoid syndrome, doctors use the following tactics, involving a follow-up visit to a patient who has had COVID-19:

• determination of existing symptoms and the chronology of their appearance;
• assessment of the presence of complications associated with postcoid syndrome;
• assessment of the severity of symptoms;
• determination of concomitant pathologies and the degree of likelihood of the influence of coronavirus infection on their course.

After collecting the necessary information, the doctor proceeds to a physical examination, measures the temperature, blood pressure, counts the pulse, and checks the degree of blood oxygen saturation. [13]

Then he prescribes laboratory tests:

• general blood test (extended);
• the level of electrolytes, liver enzymes, indicators of renal function;
• troponin, creatine kinase, ferritin, C-reactive protein, D-dimers, BNP natriuretic peptide, thyroid-stimulating hormone, thyroid hormones;
• the level of vitamin D (a deficiency or low level of this vitamin determines the complexity and duration of the course of postcoid syndrome);
• general urine analysis, analysis of total protein, urea, potassium, sodium.

Instrumental diagnostics for postcoid syndrome without fail includes X-ray and electrocardiography. Additionally, it is possible to prescribe spirography, ultrasound of the heart, daily monitoring of the heart rate and blood pressure, ultrasound of the abdominal cavity and retroperitoneal space. 

If in the acute period of the disease the patient needed oxygen therapy, then an additional examination is prescribed for him approximately 5 weeks after the completion of inpatient  treatment . X-rays are performed after 3 months, and the likelihood of thrombosis is also assessed.

If a person has any serious signs of postcoid syndrome, it is necessary to send him for urgent diagnosis in order to exclude the development of potentially dangerous complications (severe hypoxemia, multisystem inflammatory syndrome, etc.). If regular shortness of breath is detected, the patient is referred for the diagnosis of latent hypoxia. [14]

For some people who have recovered, it is advisable to recommend self-monitoring of blood oxygen saturation using a pulse oximeter for several days. In addition, you can conduct a test by measuring the pulse and recording breathing patterns at rest and after exercising for a minute.

When orthostatic tachycardia is detected, blood pressure indicators are measured in different body positions (standing, lying).

Additional consultations of specialized specialists are prescribed based on the detected violations.

Differential diagnosis

Differential diagnosis of postcoid syndrome should be carried out with other diseases and pathological complications, with respiratory and cardiovascular disorders, pathologies of the digestive and nervous systems.

Treatment of the postcoid syndrome

The tactics of treatment for postcoid syndrome depends on the detected pathological changes and symptoms. Provided that severe complications of coronavirus infection are excluded, the treatment regimen is based on the use of symptomatic and supportive drugs that make the patient feel better. In severe cases, respiratory rehabilitation may be required.

General therapeutic principles include adherence to bed rest, adequate high-calorie nutrition and adequate drinking regime, control of water-electrolyte balance and hemostasis, correction of respiratory and other disorders. [15]

Clinical guidelines based on specific symptoms:

Long-lasting cough	With proven attachment of a bacterial infection, antibiotics are prescribed, and in other cases, breathing exercises are recommended.
Dyspnea	It is recommended to perform breathing exercises aimed at increasing the efficiency of the respiratory muscles.
Constant feeling of tiredness	They use expectant tactics, recommend rest, rest with a gradual return to physical activity. No special drugs are prescribed for treatment. It is possible to take vitamin preparations under the supervision of a physician.
Elevated temperature	Antipyretic drugs are prescribed, mainly Paracetamol.
Neurological symptoms	For pain in the head, Paracetamol is used, for other disorders, symptomatic drugs.

Recommendations in terms of physical activity for those who have been ill:

Absence of signs of postcoid syndrome	Compliance with adequate physical activity.
Mild symptoms of postcoid syndrome	Observance of moderate physical activity, with limitation of sedentary periods. Elimination of prolonged and exhausting loads with increased training intensity.
Postponed mild to moderate coronavirus infection	A gradual build-up of loads, starting with stretching exercises (I week) and low-intensity training. As the symptoms worsen, the period without exercise is prolonged.
Course of COVID-19, accompanied by pain in the bones and muscles, in the throat and chest, with cough and fever	Exclusion of intense training for 3 weeks after the elimination of symptoms.
Lymphopenia and the need for oxygenation	Conducting laboratory diagnostics and consulting a specialist before resuming physical activity.
Cardiovascular complications	Conducting laboratory diagnostics and consulting a specialist before resuming physical activity.

It is very important to establish an adequate daily regimen for a person suffering from postcoid syndrome. The doctor should give appropriate advice:

• to refuse the use of psychostimulants (coffee, nicotine, alcohol);
• to normalize nutrition, the need for a gradual increase in physical activity, insolation;
• on stress management practices (rest, adequate sleep, relaxation).

Many patients are shown counseling with a psychologist based on cognitive behavioral therapy.

Medicines

With postcoid syndrome, symptomatic drugs are prescribed according to individual indications. If there is an elevated temperature that causes discomfort to a person, then Paracetamol or Ibuprofen is prescribed (1 tablet 2-3 times a day). Regular use of antipyretic drugs is undesirable (it can negatively affect the health of the digestive tract), repeated use is carried out only after the next increase in temperature indicators. Both Paracetamol and Ibuprofen can be taken as tablets or rectal suppositories. Doctors advise giving preference to any one of these drugs, rather than alternating them. Acetylsalicylic acid, Metamizole and Nimesulide should not be used to lower the temperature. [16]

Mucolytic, expectorant drugs are prescribed in the presence of difficult-to-discharge viscous sputum. Shown Ambroxol, Carbocisteine, Acetylcysteine.

Ambroxol	The dose for adults is ½ tablet 2-3 times a day, after meals. The drug should not be taken without consulting a doctor. Possible side effects: diarrhea, nausea, dry mouth, heartburn.
Carbocisteine	It is taken orally 750 mg three times a day. The drug is contraindicated in patients with stomach and duodenal ulcers or chronic glomerulonephritis. Possible side effects: abdominal pain, diarrhea, nausea, allergic reactions.
Acetylcysteine	It is taken in a dose of 400-600 mg per day (children from 2 years old - 200-300 mg per day), after meals. Possible side effects include nausea, diarrhea, headache, tachycardia, allergic reactions, bronchospasm. In postcoid syndrome, the drug is taken under strict medical supervision.

If bronchial obstruction is noted, bronchodilator drugs (eg, Salbutamol) can be used. It is preferable to practice metered inhalations, but nebulizers should not be used unless absolutely necessary.

Most of those who have recovered, including those with postcoid syndrome, need to restore the microflora in the body. For this purpose, probiotics are prescribed - these are drugs that include different strains of lacto and bifidobacteria. Such beneficial bacteria are found in any fresh fermented milk products, however, you can take additional probiotic agents - for example, Linex, Bifikol, Bactisubtil, Floristin. Vitamin D is also needed - it is taken in a course of 3-5 thousand IU per day. [17]

For neurological disorders, psycho-emotional disorders, sedatives, drugs containing essential amino acids are indicated. In particular, the drug L-tryptophan is prescribed, which contains an amino acid necessary for the production of niacin, which in turn activates the production of serotonin. Despite the relative safety of this drug, only a doctor can prescribe it. It is undesirable to take Tryptophan to persons who are being treated with monoamine oxidase inhibitors, since the combination of such medications increases the risk of CNS excitation. Caution is also observed for pathologies from the kidneys and liver. [18]

Prevention

Experts recommend not to ignore the visit to your doctor after discharge from the hospital, or after you feel better, if you were treated on an outpatient basis. You should also not try to rehabilitate yourself. The amount of help needed may depend on the severity of the course of COVID-19, and on the implementation of the recommendations of the attending doctor, and on the individual characteristics of the body.

Even after the supposed recovery, one should not avoid performing control clinical tests, biochemical blood tests. It is imperative to make a coagulogram and determine the D-dimer index. It must be remembered that the most common complications of coronavirus infection are thrombotic disorders. That is why it is very important to know and monitor hemostasis indicators - especially if the patient continues treatment with anticoagulants.

The required laboratory minimum after recovery also includes an assessment of urea and creatinine levels, electrolyte balance, albumin, protein (total), liver transaminases, ferritin, blood sugar, C-reactive protein. Of course, a biochemical blood test will not be able to specifically characterize an infectious disease. However, the identification of any violations will allow the doctor to timely detect a malfunction in the work of certain organs, to assess the likelihood of complications.

If possible, doctors recommend donating blood for an assessment of the level of vitamin D. Many experts talk about the relationship of a lack of this vitamin with a high risk of developing adverse effects, including postcoid syndrome. [19],  [20], [21]

Forecast

To assess the prognosis of postcoid syndrome, the results of laboratory tests and instrumental diagnostics are important. If a patient is found to have parallel current other diseases (respiratory, digestive, neurological, cerebrovascular, cardiovascular), then the quality of the prognosis greatly deteriorates: such a patient is closely monitored for deterioration of the condition. Individuals with one or more risk factors are also necessarily monitored. The decision about where the observation will be carried out - in a hospital, in a municipal institution or at home, is decided by the attending physician on an individual basis for each specific case. Such a decision may also depend on clinical symptoms, the need for supportive treatment, risk factors and the quality of outpatient conditions, etc. Children and pregnant women, young mothers in the postpartum period also require special monitoring. [22]

If the postcoid syndrome proceeds with positive dynamics, without obvious complications, then we can talk about a favorable outcome of the pathology.