Commonly Missed Diagnoses: Covid-19 (Covid? RU Serious?)

Leslie, a teacher in her mid-30s, made her appointment with WholeHealth Chicago at the suggestion of her primary care physician, who knows we see a lot of patients with chronic fatigue syndrome and fibromyalgia. He’d ordered myriad tests, including, of course, one for Covid antibodies. Leslie had begun feeling poorly in the middle of 2020, and you might as well start with the most obvious culprit.

But her Covid swab and antibodies test results were both negative. In fact, they’d been negative on three separate occasions. Because Leslie’s symptoms had started after a mild flu-like illness (again Covid-negative), she most likely was experiencing the weeks-long malaise that can follow any viral infection. This is quite common after a bad case of infectious mononucleosis (mono), but also can occur when recovering from other viruses. Fortunately, most malaise of this type resolves on its own.

Leslie’s symptoms

Leslie’s, however, was not resolving. She was tired, achy, and she told me her brain felt like mush. She’d asked her doctor about alternative therapies and he referred her to us.

When I first saw her and reviewed her stack of negative Covid-19 test results (called false-negatives), my guess was that despite them her symptoms were indeed a result of infection with SARS-CoV-2, the virus that causes Covid-19.  

Leslie’s were long-haul symptoms.

It’s estimated that 20% of patients who had flu-like symptoms in 2020 and 2021 were in this situation. Likely Covid-19, but we can’t prove it.

For reasons that are unclear, the swab somehow missed the virus particles in her nose or her immune system didn’t generate enough antibodies to show up as a positive blood test. And because with any case of Covid-19 neither the swab nor the blood test stays positive for all that long, there’s a relatively short window of opportunity to catch a positive test, if you’re lucky to catch it at all.

Positive test results or not, fortunately most people recover from Covid-19 infections. There are probably people with cases so mild–a 48-hour scratchy throat, for example—that they don’t remember any particular illness at all and thus never bother getting tested.

Covid-19 long-haul symptoms

But here’s the issue: even with a mild case of Covid-19 (positive test result, negative test result, or no test at all), you’re still susceptible to long-haul problems, now correctly named “post-acute COVID-19 syndrome.”

Let me draw your attention to a review article of the same name, published just last week in Nature Medicine, a highly respected scientific journal that contains articles by physicians and scientists from all specialties. This review article includes a total of 34 contributing authors, a huge number for a medical article, and what caught my eye immediately was that experts from virtually every medical specialty had contributed findings.

Before you start reading the list below of potential long-haul symptoms, the important take-away is this: virtually any new symptom you developed in 2020 or 2021 that was not readily diagnosed by your doctor could have been (or, as in Leslie’s case, still could be) a manifestation of post-viral Covid, though it pays to make a distinction here.

Heartburn from late night pasta and red wine? Not Covid. Headaches from hours of Zoom meetings? Annoying, but also not Covid.

Sudden onset of stabbing pains in your arms and legs? Possible post-Covid. Feeling faint when standing? Possible post-Covid.

Here we go:
–Lungs: Shortness of breath, reduced exercise capacity, low oxygen.
–Blood: Blood clotting issues; elevated inflammatory markers; a sense of feeling inflamed (achiness, feverishness);
stroke.
–Heart: Chest pain, palpitations, shortness of breath, tachycardia (rapid heart rate), autonomic dysfunction (POTS, blood pressure drop when standing); EKG changes, arrhythmias (heart rhythm problems).
–Neurologic: Loss or alteration of smell and taste, ringing in ears, numbness and tingling of extremities, dizziness, seizures.
–Psychiatric: Fatigue, malaise, muscle aches, headaches, brain fog, clinical depression, sleep disturbances, PTSD, generalized anxiety, psychotic behavior.
–Kidney: Reduced kidney function.
–Endocrine: New diabetes or worsening of pre-existing diabetes, thyroid function, osteopenia; suppression of hypothalamic-pituitary-adrenal axis (adrenal fatigue).
–Gastrointestinal: Alteration of gut microbiome; shedding of Covid in feces.
–Skin: Hair loss (occurs in 20% of those with Covid-19).
–Multisystem inflammatory syndrome in children (under age 21), in which a variety of body parts become inflamed (heart, lungs, kidney, brain, skin, eyes, intestines).

If you have the ill luck to develop one or more of these long-haul symptoms after your Covid-19 infection, at least you’ll know what’s wrong. You may feel pretty miserable, but based on what I’m reading and my own patients, the odds are definitely in your favor for a full recovery.

But what if you never knew you had Covid-19?

You’re in a different situation if you start developing these symptoms, you don’t remember having Covid, and your test results are consistently negative. Then what? Your biggest challenge is finding the right doctor

If your first symptom is, for example, rapid heart rate and lightheadedness, you’ll be referred to a cardiologist, who can’t find anything wrong. Then you mention numbness and tingling, and the cardiologist refers you to a neurologist. Hair loss? “Better see a dermatologist?” Get the drift?

There’s no one around to connect the dots. Each specialist sees you in terms of her specialty and if you mention another symptom will send you to another specialist.

Normally, I’d say you’re stuck in an unfortunate spot and you’ll need to rely on your body’s innate ability to heal itself. As I mentioned, most people do eventually recover from post-Covid syndrome whether they know they have it or not.

Some good news

We’ve all traveled through the last long stressful year, and yet there’s some light at the end of this tunnel. Getting immunized against Covid-19 may actually trigger a reversal of post-Covid syndrome symptom

Click here for an excellent story from the Washington Post.

Yes, that’s right. Based on a small study, getting immunized can relieve post-Covid symptoms or at least keep them from worsening. Sometimes literally in a few hours (!) people who have been feeling crummy for weeks start feeling better.

Here’s a theory as to why this occurs, written by an immunologist.

This makes sense if post-Covid syndrome is the result of a smoldering viral population that a person’s immune system can’t clear. You get vaccinated and your immune system starts grinding out viral-killing antibodies, and lo! You start feeling better.

This is what happened with Leslie. Scheduled to return to work (although she was physically incapable of doing so), she received her two shots and within a few days knew she was feeling better.

So save yourself a lot of potential misery. Stay safe, of course (more than half a million people in the US have died from Covid-19 and people are still dying), but do get vaccinated at your earliest opportunity, symptoms or no symptoms.

Be well,
David Edelberg, MD