We talk non-stop about it, studies (some without peer review) happen day after day, we read about outbreaks, vaccines in progress, ways in which the virus infects the organism, about supercontagators, R number … However, the reality is that, faced with the coronavirus, we are practically in diapers and it is that very little is known about this fierce enemy that has managed to put all humanity in check (and continues to do so).
What is known about COVID-19 is that, in the case of many people, not only will it be enough, as if it were a small thing, to overcome it, but it will generate complications that may turn into (irreversible) sequelae. As Judith Sánchez-Raya, head of the Physical Medicine and Rehabilitation Service of the Vall d’Hebron University Hospital, tells us: “The sequelae are considered from six months after leaving the ICU. What we see now are complications. The sequels are definitive ”. Therefore, we could get even more surprises. “We thought that this only affected the respiratory system and no, there is neurological involvement, we have seen cases of heart inflammation, kidney damage … It affects other organs,” Sánchez-Raya tells us.
And exactly what are these coronavirus complications? Let’s go by parts because there is a good collection.
Pulmonary complications
“Above all, we are seeing inflammatory disorders or scar disorders that can evolve towards a certain degree of pulmonary fibrosis, ” says Xavier Muñoz, pulmonologist at the Pneumology Service of the Vall d’Hebron University Hospital.
Inflammatory lesions are a consequence of the overreaction that can occur in the body to a stimulus that comes from outside, in this case, the threat of the virus. They can be cured, either with treatment or even spontaneously. “They are lesions of the type of pneumonitis, organized pneumonia, bronchiolitis … They are inflammatory lesions that, if we do not correct them, can also evolve into pulmonary fibrosis.”
Pulmonary fibrosis is another story. As we can read on the Mayo Clinic website , “pulmonary fibrosis is a lung disease that occurs when lung tissue is damaged and scarring occurs. This thickened and stiff tissue makes it harder for your lungs to work properly. As pulmonary fibrosis worsens, you have more and more difficulty breathing ”.
As for the appearance of scars (they do not disappear), “in some cases they are compatible with pulmonary fibrosis or sometimes they are another type of more banal scars, the result of the pneumonia process, which has been left as if you had a cut”, we explains the pulmonologist.
Contracting the coronavirus can lead to loss of lung capacity . We asked the pulmonologist if after the illness, he could recover. “ If it is not in the context of these inflammatory lesions, scars or pulmonary fibrosis, yes it can be recovered. Sometimes with rehabilitation and sometimes spontaneously. The most normal thing is that he ends up recovering. The recovery of lung capacity can last two to three months after you have pneumonia. There are people who also recover in a month. If there is no more serious injury, than those mentioned above, the resolution is usually complete, ”says Muñoz.
As if this were not enough, if you have been unlucky enough to have needed mechanical ventilation, there is a risk of contracting a type of pneumonia, known as ventilator-associated pneumonia . It is a common infection caused by the abnormal way in which air is entering the lung. “Evolution can be the same as that of the virus. The normal thing is that it evolves to healing and almost without sequelae , but in some cases inflammatory phenomena can also persist, in others scars form and in others, the least, evolve towards forms of pulmonary fibrosis ”, the pulmonologist tells us.
We asked the doctor about the most vulnerable people and those who already have respiratory diseases such as asthma or COPD. “With COPD, there are doubts. The rest of respiratory diseases do not seem to be a risk factor neither for having more COVID nor for it to be more serious. With the data we have today, it doesn’t seem like it. Both those who have asthma and those who do not, can catch it. The severity can be the same, mild or severe whether you have asthma or not. In COPD, it does seem that you may be more susceptible to catching the disease and that it may also be more serious ”.
Regarding the age of the patient, Muñoz is blunt: “There is no doubt here. In older people, the severity is much higher ”. “We don’t really know the mechanisms, but it seems that the key is in the front door. There is a receptor in cells, which is the entry gate of the virus and this receptor, with age, expresses itself much more. If you are a young person and you do not have this receptor, you will get much less virus and if you are older, you will get much more. Obviously if you get a lot more virus, the risk is much higher ”. According to the doctor, the people with the highest risk of contracting coronavirus and that it is more serious are the elderly, patients with heart disease, very obese people, diabetics and kidney disease.
Motor complications
Who has not read or heard cases in which people affected by coronavirus, upon waking up in the ICU, could not even walk? These patients have spent a long time in the intensive care unit, sedated and intubated, connected to mechanical ventilation due to the seriousness of their situation. “ The patients are sedated, without moving, while the lung recovers, which determines that the non-use of these muscles gives us an atrophy for not using them. It is very powerful because the body is subjected to such stress that it is in the situation of catabolism, of consuming all the resources to face the aggression that is, in this case, Covid disease “, explains Dr. Ángeles Ballesteros , Coordinator of the Neurointensive and Trauma Working Group of the SEMICYUC (Spanish Society of Critical Intensive Medicine and Coronary Units).
Here, in addition, it is added that the patient loses the desire to eat, so the body tries to obtain the nutrients it needs from wherever it is . If it is not from the diet, it will lay hold of the muscle and further muscle loss will occur. “It is important to maintain fairly decent nutritional parameters so that so much muscle mass is not lost,” says Dr. Luisa Bordejé, coordinator of the SEMICYUC Metabolism and Nutrition Working Group. And for this, they have opted for hyperprotein diets and, in some hospitals, vitamin D and omega 3 have also been used. Regarding the adequacy of giving vitamin D, Bordejé tells us: “There is no clear evidence of its efficacy, but Yes, there are hospitals that have been giving it empirically and we will have to see the results ”. Regarding omega 3, the doctor tells us that parenteral feeding (by vein) seems to be effective but that it has been given at the discretion of each one (not counting the stock break that occurred at the beginning of the crisis) .
One last point regarding the loss of muscle mass, the medication received while in the ICU, especially corticosteroids , also contribute to it.
When we talk about motor complications, we can not only stay in the affectation of the extremities. “This not only affects limb motility but also one of the main muscles, which is the diaphragm, to be able to breathe again,” says Dr. Ballesteros. After being intubated, patients will need to undergo motor rehabilitation and some also respiratory. Regarding the latter, Dr. Sánchez Raya tells us that it serves to ” teach the patient to breathe more effectively, so that he gains strength in his respiratory muscles and is able to remove respiratory secretions by himself and learn to breathe.” “They are exercises of blowing, of taking a deeper breath, of sighing… That is when there is an active mobilization. If there is not, an assisted cough device is used, which helps the patient to cough and expel mucus ”.
Regarding whether being young or middle-aged you are not going to have a problem, Ballesteros points out that “it is true that age takes its toll and there is less functional reserve as we get older, but cases have been seen in middle age, without no precedent, physically perfect, in people who do sports . Rest, sedation and the aggression that an infection of these characteristics supposes, with this severity, make it difficult to walk again in all cases. Age determines, of course, but not only that. Fundamentally it is the severity of the infection, which increases the days in which they have been with sedation and muscle relaxation ”.
Neurological complications
Dr. Ángeles Ballesteros tells us that two moments have been observed in which the coronavirus can have a neurological affectation: when the ICU is admitted and when mechanical ventilation is withdrawn. “Speaking with caution and in the absence of analyzing all the records, it is estimated that 15% of patients when admitted to the ICU may have a neurological manifestation.” “What has been seen is that patients can enter with a headache and / or a ‘confusional’ picture, as if a certain concern “.
In the second moment, in which the pneumonic process has been overcome, the sedation is withdrawn and with it the tube that has allowed air to reach the lungs of the patient. “What we are seeing is that when the sedation is withdrawn, there are very striking pictures of agitation, the patients do not finish connecting with the environment, this means that when we ask them for answers to simple orders, they do not respond . Many times they have mobility in all the extremities, there is no affectation in the motility, but yes as in the level of consciousness ”. “It occurs as a kind of delirium that is resolved with the passing of days. Sometimes it is not possible to progress in removing the tube because there is a lot of agitation, we have to maintain light sedation and, above all, look for causes, ”says Ballesteros.
This abnormal awakening has been baptized with the name of neurocovid and may be due to four reasons. The first would be a slight affectation of neurons that have not received all the oxygen they required , a consequence of pneumonia (it causes less oxygen in the blood). Another reason could be the possible damage to the central nervous system (brain and spinal cord) caused by the coronavirus. The third of the reasons would point to the drugs used to sedate the sick. The last and fourth reason that doctors consider would be that COVID-19 itself generates a procoagulant state that reverts into a deficit in the blood supply of the brain . This hypothesis, in addition to supporting the existence of this delirium and agitated state upon waking (lack of irrigation at the disc level, in small vessels such as capillaries), would answer why there are cases of people affected by coronavirus who also suffer stroke (lack of irrigation in large glasses). “What we are seeing so far is that this neurological affectation as such does not leave sequelae, except in cases where there is a stroke or a cerebral hemorrhage, there they are,” says Dr. Ballesteros.
Dr. Sánchez Raya also speaks of stroke as one of the complications that have been seen at the Vall d’Hebron Hospital. “In addition to the postuci syndrome, we have encountered neurological complications that we did not expect. It is not known exactly if it is due to the direct action of the virus or due to the alteration in the inflammatory system that it causes, lesions such as diffuse cerebral edema are occurring. There are patients who wake up in the ICU as if they had had a stroke, they do not fully move one limb, two limbs, half the body ”. “We asked them for an urgent resonance of the head and we see that there is a cerebral edema because they have caused microinfarctions in small vessels, secondary to all these complications of thrombosis and everything that the virus causes at an organic level.”
Cases of aphasia have also been observed, in which the patient has difficulty speaking due to an impairment in the language areas located in the cerebral cortex.
All these complications that we have mentioned correspond to the central nervous system, that is, to the one formed by the brain and the spinal cord. However, Sánchez Raya tells us that problems have also been seen in the peripheral nervous system, in charge of connecting the central one with the different limbs and organs. “There have been several cases of Guillain-Barré syndrome and patients with plexopathies, that is, with lesions of the arms, legs, loose nerves, arms or legs . This means that, for example, an arm cannot be moved ”.
Asked about the age of those who have suffered neurological problems, Sánchez Raya affirms that “complications have been seen in people in their 30s, 40s and 50s. We thought it would only happen to older people and people who have had sequelae are between 40 and 50 years old ” .
Other complications of the coronavirus
The sources consulted have also cited cases of heart inflammation, kidney damage, dysphagia (difficulty or inability to swallow), psychological problems and the possibility that the patient may suffer from chronic fatigue syndrome six months after leaving intensive care .
