Long Haul Covid. Is this really a Fibromyalgia related problem?
Updated: Aug 11
The following is a discussion on long-haul COVID from the national internal medicine meeting a month ago. It is helpful as one considers the connection between fibromyalgia and related problems.
They looked at long-haul covid, also referred to in the study as post-acute sequelae of SARS-CoV-2 infection (PASC).
This study and other related studies were discussed.
They tracked 189 self-referred patients with a history of COVID-19, 104 of them with a persistent or new symptom since infection, and a control group of 120 patients with no antibodies to SARS-CoV-2.
What were the significant findings? They discovered no increased inflammatory markers or other signs of ongoing inflammation.
Researchers performed lab tests, including C-reactive protein, D-dimer, and autoantibodies, and no difference was found between those with long-haul COVID and those without. Exploratory studies found no evidence of persistent viral infection, autoimmunity, or abnormal immune activation in participants with PASC.
The most frequent symptoms with PASC were fatigue, dyspnea, parosmia, concentration impairment, headache, memory impairment, insomnia, chest discomfort, and anxiety. Anxiety was six times more common in those with PASC. Other symptoms of fibro fog that were observed included memory and concentration impairment. The SF-36, a short-form survey score, measures general health and well-being and has components of physical and mental health. A higher score from 0-36 signifies better health. The physical score was 7 points and the mental health was 4 points lower in the long-haul COVID patients. They did find that 64% were women. These findings are consistent with the differences between women and men in fibromyalgia and chronic fatigue syndrome. The older criteria that involved tender points missed many men and estimated that only 10% were women. Many medical doctors, including myself, feel fibromyalgia and chronic fatigue syndrome represent the "other half of the same walnut", describing the same disorder but emphasizing pain in one and fatigue in the other.
They noted the limitation of how much actionable information could be drawn from the findings. "In summary, PASC is a significant clinical entity that has yet to be precisely defined," Dr. Lane concluded in his summary.
The solution for both individual patients and society is more research, noted panelist Carlos del Rio, MD, FACP, a distinguished professor in the division of infectious diseases at Emory University School of Medicine in Atlanta.
He pointed internists to chronic fatigue syndrome because the immunologic fatigue syndromes that happen after viral illnesses have been around for longer than most of us—since the beginning of the last century," he said. "The postviral fatigue, the cognitive impairment, the changes in sleep … It looks very similar to the chronic fatigue syndrome literature."
Dr. del Rio noted that differentiating these patients is one of the main challenges of treating PASC. "Please listen to the patient and strive to understand the symptoms. Nevertheless, let us make sure they do not have another illness." As with fibromyalgia and related problems, they, by their nature, mimic other conditions.
Dr. Lief and the other experts discussed clinical vignettes related to PASC during the forum, including one about a patient who was still unable to work eight months after an ICU stay for COVID-19.
In the Q and A discussion, the question of whom to refer to for these patients with long-haul COVID was answered.
"The issue is we have 80 million, 90 million, 100 million Americans that have been infected? If 10% of them get PASC … there's no referral place that can take all the patients," answered Dr. del Rio. "We have all set up clinics, and our clinics are full very quickly."
Thus, the care will fall to general internists, he continued. "In the early years of HIV, some of the people that are now called experts … became experts because they saw the patients. I think something similar is happening here. None of us are experts; we are all learning as we go," Dr. del Rio said. "You have to be a thorough internist. I think you have to be open to inquiry, read the literature, understand science, and stay up to date."
Finally, the experts also delved briefly into potential therapeutics, noting that vaccines, antivirals, steroids, and more unlikely therapies have all been discussed but not yet proven to alleviate PASC.
"There is such appetite for intervention that sometimes we must be careful with interventions that are not particularly scientific," said Dr. Hope, who recommended using medications when appropriate but more often "trying to help the patient understand where less might be better than more."
My interpretation of the data is that long-haul COVID is on the fibromyalgia continuum, with some meeting the criteria but others having some, likely representing less severe cases. As a physician who enjoys educating, inspiring, and treating those with fibromyalgia and seeing them improve, I recognize that I can not treat more than a fraction. Nevertheless, I hope that the insights I have gleaned can be spread to as many people as possible, doctors and patients. This study reinforces my observation with similar patients where COVID unmasked or triggered someone's predisposition to fibromyalgia. With comprehensive treatment, they can get better.