Post-Acute COVID-19 Care: Case 7

eConsult Clinical Question

A 62-year-old male patient is experiencing long term fatigue, loss of smell and taste, mental fog after COVID infection. Do you have any additional therapeutic recommendations and recommendations about timing for vaccinations?

eConsult Response

Fatigue: Suspect patient is experiencing fatigue and post-exertional malaise. Consult physical therapy to help patient align breathing with ventilatory thresholds prior to the first ventilatory threshold (VT1) and anaerobic respiration. Would also recommend baseline CXR, spirometry, EKG, orthostatic vital signs with patient standing for at least 10 minutes before obtaining the final set of blood pressure and heart rate.

Changes in smell and taste: Generally speaking, most patients make meaningful recovery. However, there are patients with more chronic residual issues. Typically, younger patients and patients with earlier recovery of olfactory function have a better prognosis. As some patients recover, they also experience phantom smells or parosmia. Parosmia is an unusual perception of unpleasant smells like rotten eggs or fish when you are around normal food like chicken. Phantom smells are smells like smoke, natural gas, burning odors that aren’t really present. These both can occur during the healing process and may indicate a phase of recovery. Unfortunately, there are few therapeutic interventions that have proven successful. Some patient reported tactics may or may not work for some patients. Smell training with things like essential oils are popular, although the evidence for their benefit is limited. Smell training consists of creating a smell kit of 4 essential oils. Typically, this includes rose, lemon, eucalyptus, and clove, but could include alternative fragrances if desired. Patients should smell each odor for 20 seconds twice per day for three months. These two websites are good references and include detailed instructions: https://www.fifthsense.org.uk/ and https://abscent.org/.

Referral to Otolaryngology may be indicated if there is no improvement after 3 months of treatment. Antioxidants such as alpha-lipoic acid are popular, but again limitations exist in the data. Safety is also an important concern. Please ensure homes have working smoke detectors, monitoring food expiration dates. Low Ferritin: We see this quite often in Long COVID patients. Treatment with iron supplementation is reasonable, although there is not a lot of treatment outcome data yet. Caution with constipation and other side effects.

Vaccination: At present, there is limited evidence to guide recommendations. In general, all Long COVID treatment clinics are advising patients to get vaccinated. However, educate patients that they may feel stronger side effects than others. Also, important to advise patients that after the vaccination side effects resolve, most feel the same, a few feel long term improvement, and there are some that experience relapses. With that in mind, timing is important in the event there are any significant life events to consider.

Other considerations to consider:

1. Screening for brain fog, we have a great speech language therapy (SLT) program for these patients.
2. Further evaluation of sleep, consider referral to sleep, neuropsychology as indicated.
3. Social determinants of health factors and support structure.
4. Workplace accommodations.

These real-life examples have some limitations. Given the evolving recommendations and guidance on COVID-19 care, these cases should not be considered complete or definitive and may not reflect the most up-to-date guidance.