Version October 2024
INTRODUCTION — The coronavirus disease 2019 (COVID-19) pandemic has resulted in a growing population of individuals recovering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. These patients may experience a wide range of symptoms after acute illness, which is referred to by several terms (eg, "long COVID").
In this topic we will discuss the clinical presentation and diagnosis of adults following the acute phase of COVID-19 illness.
The management of patients with persistent symptoms following the acute phase is described separately:
●(See "COVID-19: Management of adults with persistent symptoms following acute illness ("long COVID")".)
The management of adults with acute COVID-19 is reviewed elsewhere:
●(See "COVID-19: Management in hospitalized adults".)
●(See "COVID-19: Evaluation of adults with acute illness in the outpatient setting" and "COVID-19: Management of adults with acute illness in the outpatient setting".)
Rehabilitation issues for general patient populations, including patients with chronic pulmonary or cardiac conditions, are discussed separately:
●(See "Pulmonary rehabilitation".)
●(See "Cardiac rehabilitation programs".)
●(See "Overview of geriatric rehabilitation: Patient assessment and common indications for rehabilitation".)
●(See "Geriatric rehabilitation interventions".)
TERMINOLOGY AND STAGES OF RECOVERY — The recovery process from acute COVID-19 infection exists on a continuum and does not reflect active systemic infection. We agree with the following definitions for the phases of COVID-19 as proposed by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) [1-3]. However, we acknowledge that differences exist between the WHO and the CDC as to the preferred timeline for the definition of long COVID.
●Acute COVID-19 – Symptoms of COVID-19, up to four weeks following the onset of illness. During this phase, management is focused on detecting and treating acute COVID-19-related symptoms and complications. This phase is not discussed in this topic but is discussed in separate topic reviews. (See "COVID-19: Diagnosis" and "COVID-19: Management of adults with acute illness in the outpatient setting" and "COVID-19: Management in hospitalized adults".)
●Post-COVID condition – This refers to a broad range of persistent or new symptoms/symptom clusters (physical, cognitive and/or emotional) that develop during or after probable or confirmed COVID-19. The CDC considers post-COVID conditions to be present if recovery does not occur after the four-week acute phase even though many patients continue to recover between 4 and 12 weeks [2]. Consistent with the WHO [3], we prefer to diagnose patients with a post-COVID condition at least three months after illness onset. This three-month period allows clinicians to rule out the usual recovery period from an acute illness since the recovery period can be long, especially if acute illness was severe. All groups agree that the symptoms must have an impact on the patient's life or well-being and are not explained by an alternative diagnosis. This content is discussed in this topic.
While our preferred term in this topic is "long COVID," terminology varies and includes other terms, such as "post-acute sequelae of SARS-CoV-2 infection (PASC)," "post-acute COVID-19," "chronic COVID-19," "long hauler syndrome," and "post-COVID syndrome" [4-8].
PATHOGENESIS — The pathogenesis of prolonged symptoms after recovery from acute COVID-19 remains poorly understood, although there is accumulating evidence of physiologic changes in individuals with long COVID compared with COVID-19 survivors without residual symptoms. It is likely that multiple pathophysiologic mechanisms are involved, explaining the heterogeneity of ongoing symptoms.
Several observational studies have implicated the following mechanisms, but none have been robustly proven as causative [9-19]:
●Viral persistence
●Virus-induced inflammation
●Cellular injury
●Endotheliopathy
●Hypercoagulopathy
●Select gene expression profiles
●Reduction in serotonin levels
●Dysbiosis
●Autoimmunity
●Immune dysregulation
●Complement dysregulation
While one study implicated a deoxyribonucleic acid (DNA) sequence near a gene called FOXP4, in the pathogenesis of long COVID, these results were not peer reviewed and require repeat validation [20].
Whether the constellation of symptoms and persistent issues experienced by patients represents a new syndrome unique to COVID-19 or whether there is overlap with the recovery from other infectious and critical illnesses is unclear. One population-based cohort study of over 26,000 patients who survived hospitalization for COVID-19 found no difference in the burden of post-illness disease including selected ischemic and nonischemic cerebrovascular and cardiovascular disorders, neurologic disorders, rheumatoid arthritis, or mental health conditions compared with influenza or sepsis cohorts [21]. Also, in support of a common pathogenesis for post-acute sequalae among infectious pathogens, features of long COVID overlap with other post-viral conditions, such as postural orthostatic tachycardia syndrome, myalgic encephalomyelitis/chronic fatigue syndrome, and others. (See "Post-intensive care syndrome (PICS) in adults: Clinical features and diagnostic evaluation" and "Postural tachycardia syndrome" and "Clinical features and diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome".)
PREVALENCE — The true prevalence of long COVID is unknown due to varying definitions and methods of analysis.
●In the largest study to date, a meta-analysis of 54 studies and two medical record databases from 22 countries estimated that between March 2020 and January 2022, at three months, 6.2 percent of individuals who had symptomatic COVID-19 infection experienced at least one of a predetermined set of three long COVID symptom clusters (persistent fatigue with bodily pain or mood swings [3.2 percent], cognitive problems [2.2 percent], or ongoing respiratory problems [3.7 percent]) [22]. These data did not include patients who were infected with the Omicron variant.
●Another report from an electronic health record of nearly 1 million ambulatory patients with COVID-19 reported that 15 percent had at least one long COVID symptom at 12 to 20 weeks following infection compared with 2.9 percent of patents without COVID-19 [23].
Prevalence rates vary depending upon several factors, which are mostly discussed in the linked sections listed below:
●Prevalence of individual symptoms (table 1). (See 'Symptom types/cluster' below.)
●Impact of the COVID-19 variant, vaccination, reinfection, and disease severity. (See 'Impact of COVID-19 variant' below and 'Impact of reinfection' below and 'Impact of COVID-19 severity' below.)
●Prevalence in children. (See "COVID-19: Clinical manifestations and diagnosis in children", section on 'Post-COVID-19 condition ("long COVID")'.)
RISK FACTORS — Risk factors for the development of long COVID are poorly defined but may include the following:
●Older age, higher body mass index, and comorbidities [24].
●Females ≥20 years [22,25].
●Pre-existing conditions (eg, depression, anxiety, allergies, obstructive lung disease) [24-26].
●Severe acute COVID-19 illness (See 'Impact of COVID-19 severity' below.)
CLINICAL SYMPTOMS — It is important to note that many studies evaluating the prevalence and severity of persistent post-COVID-19 symptoms have significant methodologic limitations, such as lack of a control population, selection and reporting bias, and lack of standardized assessment protocols. Thus, data are highly variable and often depend upon the population studied.
Described in this section are the types of symptoms experienced by patients. Duration of symptoms and time to resolution vary widely and, in some patients, symptoms may last up to three years. These data are discussed separately. (See "COVID-19: Management of adults with persistent symptoms following acute illness ("long COVID")", section on 'Prognosis and expected recovery time course'.)
Symptom types/cluster — Collectively, symptom clusters can be categorized as physical, psychological, and cognitive, with many patients experiencing symptoms in one or more categories. These symptoms are similar to the syndrome experienced by patients recovering from critical illnesses known as post-intensive care syndrome (PICS). PICS is discussed in detail separately. (See "Post-intensive care syndrome (PICS) in adults: Clinical features and diagnostic evaluation".)
Persistent physical symptoms following acute COVID-19 are common, even after mild illness, and typically include fatigue, dyspnea, chest pain, and cough.
Patients recovering from COVID-19 may also have additional psychological symptoms (eg, anxiety, depression, posttraumatic stress disorder [PTSD]) and cognitive dysfunction (eg, poor memory and concentration) (table 1).
Many of these symptoms lead to financial and physical disability.
Physical symptoms — Several observational series describe a broad range in persistent physical symptoms in patients following acute COVID-19 [25,27-39]. A meta-analysis of 194 studies found that 45 percent of COVID-19 patients experienced at least one long COVID symptom and described the prevalence of each. Prevalence of common symptoms in nonhospitalized individuals are listed below [40]:
●Fatigue – 34 percent
●Dyspnea – 20 percent
●Muscle pain/myalgias (including chest pain) – 17 percent
●Insomnia – 15 percent
●Anosmia – 13 percent
Studies that include a control group have generally demonstrated lower frequency of persistent symptoms attributable to COVID-19 [38,41]. For example, one large prospective study that included a control group found the following:
●Fatigue – 3 percent
●Dyspnea – 3 percent
●Muscle pain/myalgias – 5 percent
●Anosmia – 7 percent
Less common persistent physical symptoms include joint pain, headache, sicca syndrome, rhinitis, dysgeusia, poor appetite, dizziness (from orthostasis, postural tachycardia, or vertigo), hoarseness, alopecia, sweating, reduced libido, diarrhea, and other gastrointestinal symptoms [42].
Preliminary data suggest a higher risk for autoimmune inflammatory rheumatic diseases (AIRDs) in those with a history of COVID-19 compared with patients who did not have COVID-19 or patients who had influenza. AIRDs include rheumatoid arthritis, psoriatic arthritis, spondyloarthritis, and connective tissue diseases (CTDs; eg, systemic lupus erythematosus, Sjögren's disease, systemic sclerosis, polymyalgia rheumatica, mixed CTD, dermatomyositis, polymyositis, polyarteritis nodosa, and vasculitis) [43-46]. This was illustrated in a large Korean and Japanese cohort study that analyzed national health system data from 2020 and 2021 (ie, before the Omicron variant) [46]. The analysis demonstrated an increased risk of AIRD in patients who had COVID-19 compared with uninfected patients (adjusted hazard ratio [HR] 1.25, 95% CI 1.18-1.31 [Korea] and 1.79, 95% CI 1.77-1.82 [Japan]) and patients who had influenza (adjusted HR 1.3, 95% CI, 1.02-1.59 [Korea] and 1.14, 95% 1.10-1.17 [Japan]). The risk appeared to diminish over time and dissipate after 12 months, and vaccination possibly reduced the risk.
Persistent cardiovascular events and imaging abnormalities are discussed in more detail separately. (See "COVID-19: Cardiac manifestations in adults", section on 'Long-term cardiovascular effects' and "COVID-19: Management of adults with persistent symptoms following acute illness ("long COVID")", section on 'Chest imaging'.)
Psychological or cognitive symptoms — Psychological and cognitive complaints are also common following acute COVID-19 infection (eg, up to 25 percent) [25,31,34,35,37,47-53]. These include anxiety, depression, PTSD, and impaired cognition (eg, memory and concentration deficits).
Psychological complaints may also be more common following COVID-19 than in those recovering from other viral illnesses. As an example, a retrospective examination of electronic health records in the United States reported that the risk of developing a new psychiatric illness following COVID-19 was higher compared with patients recovering from other medical illnesses, such as influenza [50]. Another UK study demonstrated cognitive deficits in patients with mild to moderate COVID-9 lasting a year or longer [53].
Post-intensive care syndrome — PICS is a syndrome that occurs in survivors of critical illness where patients experience symptoms in one or more of three categories (physical, psychological, or cognitive domains). Among intensive care unit (ICU) survivors, at least three-quarters of individuals with COVID-19 report at least one component of PICS [37,54-57].
In a study of 301 patients who survived critical illness due to COVID-19, 74 percent of patients had at least one component of PICS at one year; the most common symptoms were physical weakness (39 percent), joint stiffness/pain (26 percent), mental/cognitive dysfunction (26 percent), and myalgias (21 percent) [37]. Rates of PICS symptoms appear to be similar to that experienced by non-COVID-19 ICU survivors [57,58]. However, in one retrospective analysis, survivors of COVID-19-related acute respiratory distress syndrome (ARDS) were less likely to suffer from anxiety and depression compared with non-COVID-19-related ARDS [59]. PICS symptoms in the family members (known as PICS-family) of patients who developed COVID-19-related ARDS has also been described but waned by 12 months [60,61].
Details regarding the identification and management of PICS are discussed separately. (See "Post-intensive care syndrome (PICS) in adults: Clinical features and diagnostic evaluation" and "Post-intensive care syndrome (PICS): Treatment and prognosis".)
Functional and financial disability — Persistent symptoms following COVID-19 can affect functional ability. Studies suggest that over 50 percent of patients have some functional disability in activities of daily living persisting four months or longer after acute COVID-19 [30,31,48,62-66].
Among those who were critically ill due to COVID-19, the rate of disability at six months does not appear to be different to that in patients with non-COVID-19-related critical illness, despite a longer duration of mechanical ventilation [58].
Long COVID may also be associated with financial disability. In one retrospective study of 825 COVID-19 hospital survivors, 23 to 50 percent had financial problems [66]. How this rate compares with non-COVID-19 hospital survivors was not reported.
Impact of preventative measures — It is likely that any measure that decreases the incidence or severity of acute COVID-19 infection will, in turn, decrease the incidence and severity of long COVID.
Vaccination — The most effective means to prevent post-COVID-19 conditions is to prevent COVID-19 (eg, vaccination, masking, social distancing, hand hygiene).
Several studies report lower rates of post-COVID-19 symptoms in patients who are vaccinated [24,67-76]. A meta-analysis of 16 observational studies totaling 614,392 patients reported a significant reduction in the incidence of long COVID with vaccination prior to infection; odds ratios ranged from 0.22 to 1.03 (after one dose), 0.25 to 1 (two doses), and 0.48 to 1.01 (any dose) [75]. A significant reduction in the incidence of long COVID was also reported in patients who received the vaccine after infection (odds ratio ranging from 0.38 to 0.91).
Treatments — Treatments for acute COVID-19 also appear to be associated with reduced prevalence of long COVID, although data are conflicting [77-80].
Limited data have reported reduced likelihood of developing long COVID with agents including interleukin-6 receptor antagonists [77], nirmatrelvir plus ritonavir (ie, "Paxlovid") [78], and the investigational agent metformin [79].
In contrast, in a retrospective analysis of a United States Veterans Health Administration database of over 150,000 nonhospitalized patients with COVID-19, those treated with nirmatrelivir-ritonavir had a similar incidence of post-COVID-19 conditions compared with matched controls, except for a lower risk of thromboembolic events (subhazard ratio 0.65, 95% CI, 0.44-0.97) [80].
Impact of COVID-19 severity — Although those with mild initial COVID-19 can develop long COVID, studies suggest that patients who have more severe initial illnesses or are hospitalized, particularly those who are admitted to the ICU, are more at risk of developing long COVID [81]. It remains unclear if individuals with asymptomatic infections are at risk of long COVID [25,31,82-93].
Impact of reinfection — One study reported that reinfection with SARS-CoV-2 may increase the risk of persistent symptoms (HR 2.1, 95% CI 2.04-2.16), as well as death and rehospitalization [94].
Impact of COVID-19 variant — The prevalence of persistent symptoms may also vary depending on the COVID-19 variant, although the impact of vaccination may have influenced these findings. As examples:
●Among over 97,000 vaccinated individuals in the United Kingdom, infection with the Omicron variant was associated with a lower risk of developing persistent symptoms compared with the Delta variant (4.5 versus 10.8 percent) [95]. However, methodologic issues, including self-reporting through an electronic application and a shorter duration of follow-up for Omicron- versus Delta-infected patients, limit the interpretation of these findings.
●Similarly, another observational study of nonhospitalized health care workers with COVID-19 reported that the prevalence of persistent symptoms waned with each successive COVID-19 wave (48 percent in wave 1 [wild-type variant], 36 percent in wave 2 [Alpha variant], and 17 percent in wave 3 [Delta and Omicron]) [24].
●Another prospective cohort study of 274 unvaccinated adults without an immunologic history of SARS-CoV-2 who were at high risk of infection reported that long COVID symptoms were less likely with the Omicron compared with the Delta variant [96].
Risk of rehospitalization — Although not specific to long COVID, approximately 10 to 30 percent of COVID-19 patients who are discharged from the hospital are rehospitalized within 30 to 60 days [63,64,97-99]. However, these data reflect earlier COVID-19 variants. Risk factors for readmission vary, but cited examples include age ≥65 years, discharge to skilled nursing facility or with home health services, and the presence of one or more comorbidities (including cognitive impairment and functional disability) [63,97,100]. Risk increased for male patients, White patients, patients with frequent emergency department visits within the previous six months, and patients experiencing daily pain [63].
DIAGNOSTIC EVALUATION — Our diagnostic approach is based upon accumulating data on patients with persistent symptoms following acute COVID-19, data extrapolated from patients recovering from similar illnesses (eg, influenza, sepsis, post-intensive care syndrome), and our clinical experience. Our approach is generally consistent with expert advice from international societies and guideline groups [5,101-117].
Timing of follow-up evaluation — The optimal timing of follow-up for the evaluation of long COVID after the acute illness is unknown and depends upon several factors, including the severity of acute illness, current symptomatology, and resource availability.
In general, for patients with persistent symptoms, particularly those with multisystem complaints or symptoms lasting beyond 4 to 12 weeks, we evaluate for the possibility of long COVID. Once diagnosed, referral for an evaluation in a specialized outpatient COVID-19 recovery clinic or a subspecialty clinic relevant to the patient's specific symptoms (eg, pulmonologist, neurologist) may be needed (if available).
The timing and location of follow-up for outpatients during the acute phase of the illness (eg, up to four weeks following illness onset) is reviewed in detail elsewhere. (See "COVID-19: Evaluation of adults with acute illness in the outpatient setting" and "COVID-19: Evaluation of adults with acute illness in the outpatient setting", section on 'Reevaluation for worsening clinical acuity'.)
Initial general assessment — Our approach to initial assessment is the following:
●Acute COVID-19 illness – We obtain a comprehensive history of the patient's acute COVID-19 illness, including the following:
•Illness timeline
•Duration and severity of symptoms including the need for hospitalization and intensive care unit admission (review of hospital records may be necessary)
•Type and severity of complications that occurred during the acute phase (eg, venous thromboembolism, presence and degree of kidney injury, supplemental oxygen requirements [including the need for noninvasive or invasive ventilation], cardiac complications, delirium)
•COVID-19 testing results
•Administered COVID-19-specific treatments
●Pre-COVID-19 illnesses and medications – We review the patient's premorbid medical history as well as ongoing comorbidities and medication list, including over-the-counter medications and supplements. A comparison of pre- versus post-COVID-19 conditions helps evaluate if current symptoms are new or possibly related to the presence or worsening of pre-existing medical illnesses.
●Current symptoms – We obtain a brief history of current residual or new physical symptoms (eg, fatigue, dyspnea, chest pain, cough, anosmia), physical limitations, functional disability, impact of symptoms on activities of daily living, and symptoms of anxiety/depression, posttraumatic stress disorder, and cognitive impairments. Collateral history from caregiver(s)/family members may be needed to obtain an accurate assessment. (See "Comorbid anxiety and depression in adults: Epidemiology, clinical manifestations, and diagnosis" and "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis" and "Evaluation of cognitive impairment and dementia".)
●Apply rating tools as indicated – For most patients, we also typically use standardized rating tools to complement symptom-directed clinical assessment when possible. As examples, we use the screening tests recommended by the Society of Critical Care Medicine's International Consensus Conference to predict and identify long-term physical and mental impairments after critical illness (table 2) [118]. The use of these standardized measures can help identify important information on medical and psychological issues, which may prompt additional assessments, treatments, and referrals to specialist providers, if appropriate. They can also be helpful to track patient progress over time.
An international Delphi consensus method has published a set of core outcome measures for the assessment of long COVID that may be a useful template for initial evaluation [119].
For patients who have specific symptoms, we evaluate further with more in-depth assessment. Further details on this specific evaluation are provided separately. (See "COVID-19: Management of adults with persistent symptoms following acute illness ("long COVID")".)
General laboratory testing — The need for laboratory testing in patients with suspected long COVID is determined by symptom type and the severity or complications of acute COVID-19. Most patients who have abnormal laboratory testing at the time of diagnosis improve during recovery [120].
Our general approach to the acquisition of laboratory tests is as follows:
●Mild illness with improving symptoms – For most patients who are recovering from mild acute COVID-19 and improving, laboratory testing is not necessary.
●Moderate and severe illness – For patients with persistent symptoms who are recovering from more severe illness, it is reasonable to obtain the following:
•Complete blood count (eg, persistent lymphopenia is associated with long COVID [121,122])
•Blood chemistries, including electrolytes, blood urea nitrogen, and serum creatinine
•Liver function studies, including serum albumin
Additional laboratory tests are appropriate for select patients with specific symptoms. This evaluation is discussed separately. (See "COVID-19: Management of adults with persistent symptoms following acute illness ("long COVID")".)
We do not routinely retest patients for active infection with SARS-CoV-2 (or for SARS-CoV-2 serology [antibodies]) unless active reinfection is a consideration.
DIFFERENTIAL DIAGNOSIS AND DIAGNOSIS
●Differential – Since the definition of long COVID includes symptoms that are not explained by an alternative diagnosis, competing diagnoses need to be reasonably excluded, clinically and/or with additional testing.
For patients who have symptoms following COVID-19 illness, we determine whether they are persistent, resolving, new, or worsening. We pursue symptoms that are new or worsening with appropriate investigation to distinguish long COVID from complications of acute illness or an alternate diagnosis. For example, a patient with persistent, new or worsening dyspnea may need to be assessed for thromboembolic and cardiovascular disease rather than be assumed to have long COVID. In contrast, those with resolving symptoms may not need any additional investigations. Comparison with pre-COVID-19 status also helps to distinguish specific long COVID symptoms from pre-COVID-19 conditions and provides a baseline to target during therapy. Details of this evaluation are provided separately. (See "COVID-19: Management of adults with persistent symptoms following acute illness ("long COVID")".)
●Diagnosis – Diagnostic criteria for long COVID vary, which provides a challenge to the clinician evaluating these patients. Long COVID is mainly a clinical diagnosis made in patients who have persistent or new symptoms/symptom clusters that develop during or after probable or confirmed COVID-19. Symptoms have generally persisted for three months, have an impact on the patient's life, and are not explained by an alternative diagnosis.
An International Classification of Diseases, Tenth Revision (ICD-10) code for long COVID exists (U09.9).
While a framework for identifying long COVID has been described using a post-acute sequelae of SARS-CoV-2 infection (PASC) score, further refinement and validation are needed before it can be clinically useful in diagnosis [123].
COVID-19 RECOVERY CLINICS — Several organizations have developed guidelines to address the evaluation and management of patients recovering from COVID-19, and many institutions have established dedicated, interdisciplinary outpatient COVID-19 recovery clinics to address the long-term needs of patients after recovery from acute illness [124-126]. Clinic protocols generally include a comprehensive physical, cognitive, and psychological assessment. However, high quality data on the outcomes of these evaluation and management strategies are lacking.
Care should not be delayed if patients experience a long wait time for evaluation in a dedicated COVID-19 recovery clinic. Thus, if referral to a COVID-19 recovery clinic is delayed or unavailable, referral to pulmonary, neurology, and/or physical medicine and rehabilitation specialists is appropriate, when indicated.
USEFUL WEBSITES — The World Health Organization has created a global COVID-19 clinical platform case report form for clinicians and patients to collect and report information, to allow for better understanding of the spectrum of post-COVID-19 conditions and recovery [127].
The United States Department of Health and Human Services and the Department of Justice released a guidance statement on "long COVID" as a disability under the Americans with Disabilities Act, the Rehabilitation Act of 1973, and the Patient Protection and Affordable Care Act. These acts provide protections for individuals with disabilities to allow for full and equal access to civic and commercial life. This statement classifies "long COVID" as a disability if it substantially limits, either physically or mentally, one or more major life activities. An individualized assessment is needed to determine whether a person's symptoms fit these criteria [128].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Index of guideline topics".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Long COVID (The Basics)" and "Patient education: COVID-19 and pregnancy (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Terminology – Several terms have been used to describe persistent or new symptoms following acute COVID-19 illness, including "long COVID" (our preferred term in this topic), "post-acute sequelae of SARS-CoV-2 infection (PASC)," "post-acute COVID-19," "chronic COVID-19," "long hauler syndrome," and "post-COVID syndrome."(See 'Terminology and stages of recovery' above.)
●Prevalence, risk factors, and prevention – The true prevalence of long COVID is unknown, but data suggest that approximately 6 percent of patients may experience prolonged symptoms following acute infection. Risk factors are poorly defined but may include older age, higher body mass index, comorbidities, female sex, and severe illness. (See 'Prevalence' above and 'Risk factors' above.)
●Symptoms and course
•Persistent physical and psychological symptoms are common following COVID-19 (see 'Clinical symptoms' above):
-Persistent physical symptoms typically include fatigue, dyspnea, muscle aches/chest pain, cough, and anosmia. Less common persistent physical symptoms include joint pain, headache, sicca syndrome, rhinitis, dysgeusia, poor appetite, dizziness, hoarseness, insomnia, alopecia, sweating, and diarrhea and other gastrointestinal symptoms. (See 'Physical symptoms' above.)
-Patients may also experience psychological or cognitive complaints including anxiety, depression, and posttraumatic stress disorder (PTSD), as well as memory and concentration impairment. (See 'Psychological or cognitive symptoms' above.)
●Initial diagnostic evaluation – Our approach is the following (see 'Diagnostic evaluation' above and 'Initial general assessment' above):
•We obtain a comprehensive history of the patient's acute COVID-19 illness, including the illness timeline, duration and severity of symptoms, types and severity of complications, COVID-19 testing results, and any management strategies.
•We review the patient's premorbid medical history as well as ongoing comorbidities and medication list, including over-the-counter medications and supplements. A comparison of pre- and post-COVID-19 conditions helps identify whether current symptoms are related to the presence or worsening of other medical illnesses beyond long COVID.
•We obtain a brief history of current residual or new physical symptoms; physical limitations; and symptoms of anxiety/depression, PTSD, and poor cognition. We also enquire about the impact of symptoms on functional ability and activities of daily living and, when indicated, use standardized rating tools to further identify physical and mental impairments.
•Patients who had mild acute COVID-19 do not typically need laboratory testing. However, it is reasonable in those who had moderate to severe acute COVID-19 illness and those with persistent symptoms or complications of acute COVID-19 to obtain a complete blood count, blood chemistries, and liver function studies, including serum albumin. (See 'General laboratory testing' above.)
•The evaluation and management of individual symptoms are provided separately. (See "COVID-19: Management of adults with persistent symptoms following acute illness ("long COVID")".)
●Differential and diagnosis – A diagnosis of long COVID is a clinical one that can only be made in patients who have persistent or new symptoms/symptom clusters that develop during or after COVID-19. While criteria vary, we diagnose long COVID in those with symptoms that persist for three months after illness onset, have an impact on the patient's life, and are not explained by an alternative diagnosis. We exclude competing diagnoses, clinically and/or with additional testing (if needed). Further details of this evaluation are provided separately. (See "COVID-19: Management of adults with persistent symptoms following acute illness ("long COVID")" and 'Differential diagnosis and diagnosis' above.)
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