What Happens After a COVID-19 Infection?

Brian Kriete, MD, an ENT (or ear, nose and throat) physician and medical director of Surgical Services with Phelps Health, talks about what happens after people are infected with COVID-19 and the long-term effects of the disease.

Paige Heitman: Today, we are speaking with Dr. Brian Kriete on our program today. Welcome back, Dr. Kriete.

Dr. Brian Kriete: Thanks for having me.

PH: So, we have been talking a lot about COVID-19 vaccinations, and we are going to continue to talk about that today. As we learn more about the trajectory of COVID-19, what do we know about how individuals’ needs are following the acute period of illness?

BK: This a very interesting and developing topic. There is a lot of anecdotal results out there with people saying, ‘Hey, I'm having these weird symptoms after COVID-19. What is going on?’ Well, it turns out there is actually something that goes on afterward that has actually been fairly common. What we are finding is about 10% of folks that recover from the initial acute [COVID-19] infection develop some form of long-term issue. There is no real definition for this yet, but an article came out earlier this month in The British Journal of Medicine that tried to define it a little bit better.

BK: The [article] talks about a post-acute COVID-19 syndrome, which is defined as symptoms that persist beyond three weeks of the initial onset of symptoms. Then, [the article] also defines a more chronic type of infection, in which a person is having symptoms 12 weeks after the initial infection. Given the prevalence of the infection and the fact that 10% of people are having problems after they have recovered, this is going to be a fairly large problem and something worth talking about for sure.

PH: What is the difference between the post-acute COVID-19 syndrome and the people who have a long-term, 12-week recovery period? What is the difference between that? Is it their age? Is that how severe their infection was?

BK: So that is the interesting part; post-acute COVID-19 syndrome does not seem to depend on the severity of your infection. Some of the folks that were essentially non-symptomatic developed some of these symptoms down the road as well, so that is interesting. Post-acute COVID-19 syndrome remains a mystery for some folks, but there are some fairly common symptoms that you can run into with this to say, ‘Hey, maybe there's something going on here. Maybe I did have this.’

PH: Something else that I have found to be really interesting, and this has happened with some of my family members and the community, is people have had prolonged recovery. So, after that two-week period of being infectious with COVID-19, are they still contagious? Can they still test positive if they are still having symptoms of COVID-19?

BK: So, that is an excellent question, and there is a lot of confusion surrounding this. Folks with mild to moderate disease—and those would be the folks that could stay at home and manage their symptoms without having to go to the hospital—there is pretty good evidence to show that as long as you are no longer [running a fever] and you are 10 days out from your initial onset of symptoms, your chances of spreading the disease are relatively low, somewhere around 1% to 5%. So, your chance of being contagious at that point, as long as you're no longer [running a fever] are very, very low. You may have shortness of breath and fatigue still, but at that point, your chances of spreading COVID-19 are fairly low. Now, you can still detect the virus in your nose, so if you went and were [tested for COVID-19], you can test positive for up to 12 weeks afterwards. However, what the researchers have found is that even though the virus is present, it does not replicate very well, and you are no longer contagious at that point.

PH: Okay, so even if you still test positive, are you still able to go back to work or school at that point in time?

BK: So, the current CDC recommendations do say that as long as you are 10 days out from initial symptom onset and you have been symptom-free for over 24 hours, you are clear to go back to work or school, and your chances of being contagious are fairly low.

PH: That is really good to know.

BK: But, that is barring any symptoms; the fatigue and the shortness of breath may still be an issue for you. Also, you have to be medically cleared, not just clear from the infection.

PH: Okay, so if people have recovered after that 10-day period, and I am thinking about myself, here, because I immediately went back to the gym because I was super gung ho. I had been quarantined for 10 days, and I needed to get out and do something active.

BK: As we all do.

PH: Yeah. The first thing I did is I went back to the gym, and it kicked my butt.

BK: So, you noticed some issues with that.

PH: Yeah, and I was out for four days after I did that. So after being quarantined for a length of time, should people go back to their normal lives, or should they work back up to that?

BK: The answer is: it depends. Some of the more common symptoms that you are going to see with some of these long-term symptoms include things like fatigue, continued shortness of breath, cough (believe it or not), joint pain, chest pain, and some people describe a burning in their chest for months afterward. The brain fog is a big one. I have had a lot of people say, ‘Hey, I just could not function for a week or two afterward. I could not think straight, I could not keep my mind straight.’ Depression, muscle aches, headaches and intermittent low grade fevers can continue to pop up.

BK: Palpitations are another common one. I have been hearing about how, especially with folks in the hospital, that have had palpitations. The biggest thing with that is that it depends on your situation. If you just cannot even get up out of bed and walk across the room to go to the bathroom, you probably should not be going to the gym. You need to take it slow, and I would recommend if you were having those symptoms, to at least give your doctor a phone call and say, ‘Hey, something doesn't seem right.’ Perhaps they can give you a more measured workout program to where you can work yourself back into it slowly, but that would be my recommendation.

PH: Yeah, that is a great recommendation. I remember I started doing cardio and I was on the stair climber and I was about five minutes in and my first thought was, ‘Man, I can't breathe. Maybe I should stop.’ I do want to backtrack for a second. Whenever you say palpitations, what do you mean? Just for our listeners.

BK: I have never had this, so I cannot describe it myself, but a lot of people describe it as kind of a fluttering in the chest. You just feel like your heart is just pounding out of your chest and beating really, really fast. That is a sign that you are having a change to your heart rhythm. Now, I do not want to just write that off to say, ‘Hey, that is normal, probably nothing to worry about.’ If you have these, you probably should contact your doctor because there can be some more serious side effects with this.

PH: Whenever you say serious side effects, do you mean heart concerns, or heart conditions?

BK: Right, so this is where it becomes a little bit more concerning in folks that have underlying medical conditions. They are at higher risk for developing things like inflammation of the heart muscle, or pericarditis. You can have lung function abnormalities to where you just cannot breathe right for prolonged periods of time, and it can cause kidney injury. We talked about some of the neurological things, but one of the big things we have seen with this is loss of smell and taste, depression and anxiety. All of those things can be a little bit more serious, and you need to seek medical attention for those.

PH: One thing you just mentioned that I think is really interesting, specifically because you are an ENT, is loss of taste and smell, and this was something that I had whenever I contracted COVID-19. Loss of taste and smell is so interesting. Why do we have that with COVID-19, and how can a virus cause loss of taste and smell?

BK: So this is not unique; there are other viruses that cause of loss of smell, and typically taste is affected as well, because they are intimately intertwined. With COVID-19, it has been a lot more common. We have seen upwards of 80% to 90% of people that test positive for COVID-19, having some sort of smell disturbance. There has been studies done that have demonstrated as much as 95% of people have some sort of damage to their sense of smell. Fortunately, for the vast majority of people it is short-lived, and it typically recovers within a week or two.

BK: What we found is with COVID-19 in particular, it affects some of the supporting cells that supply nutrients to the nerves in your nose that help you develop your sense of smell. There is some temporary damage to the sensory nerves in your nose, so you lose your sense of smell. Usually with viral induced [illness], we call it anosmia; loss of smell, the taste disturbance, is typically related to the smell disturbance. But, in this case, the sense of taste has been affected as well, separate to the sense of smell. Fortunately, this is not a long-term problem for most, but upward of 5% of folks have some prolonged loss of smell, and some people even have permanent damage to it.

PH: How do we cope with loss of taste and smell, because we eat every day? We cook every day.

BK: Unfortunately, like most damage to nerves, it just takes time to recover if it is going to recover at all. There has been some research to show that, believe it or not, a form of sniffing or smell rehab, where you go through a regimented program of smelling certain smells at certain times throughout the day, can re-train the brain to learn how to smell. I will not say it is a hard science, but it is something we have been using, and there is not much more we can do outside of that. There are other causes of this. Do not get me wrong; COVID-19 is not the only thing that can cause a loss of smell, because there are some more serious things you should be concerned about. Folks that have severe allergies or nasal polyps will oftentimes have decreased airflow through the nose, so that can certainly affect your sense of smell. There are certain forms of cancer that can cause this as well, so if you have had COVID-19, and you lost your sense of smell, that is probably what [the loss of smell stemmed from], but if you are not sure that you have had COVID-19, and [loss of smell] develops, and it doesn't come back, it definitely needs to be checked out.

PH: Whenever you talk about this sniffing regiment, or this type of therapy, what are some of the smells utilized?

BK: We use different essential oils, and so forth, and there are different programs out there, so it all depends on the physician. Like I said, there is no hard science to back this up yet, but it is the best thing that we have right now.

PH: I remember when I could not taste. I accidentally always used too much cayenne pepper, which I traditionally use anyway, and my food is always too spicy. Whenever we have COVID- 19 and we have that loss of taste, can it change our taste buds at all whenever we get that back?

BK: Absolutely. Most people will recover, like I said, but some people have permanent change and some people will be doing fine for a while. They will lose their sense of taste, their sense of smell will go, and then it recovers. A couple of months down the road, they notice things change; things that used to smell good to them, they really cannot stand anymore, and this is a little bit more dangerous than people would think. If you cannot smell, you have to realize that, ‘Hey, there's a fire in the building. I may not be able to realize that.’ Smell is one of our senses that we need to help protect us, and it can be potentially dangerous.

PH: Yeah, that is really concerning, and [people] should definitely schedule an appointment with you to figure that out if that's something that's of concern to them. Something else that I think we often do not think about with COVID-19 is ear infections. Is this a common occurrence with people who have tested positive for COVID-19?

BK: I haven't seen that in the literature, and I'll be honest, I haven't seen it a lot in my office yet, but I know you and your husband have had issues with this yourself.

PH: Yes.

BK: Any time there is a viral infection and inflammation in the upper airway, you can develop an ear infection, but it is not something I've seen a big part of this so far.

PH: What about other types of auditory damage with COVID-19?

BK: So that is kind of interesting. I feel like I am seeing that a lot more [auditory damage] now with COVID-19. Certainly, the big thing people think about is the loss of smell, but in fact just this morning, I saw a patient that feels as though she's lost some hearing as a result. Once again, it is a result of the virus getting into the nerves that supply your hearing and into your cochlea, and oftentimes causing some permanent damage there. A viral-induced hearing loss in our realm is considered an emergency, and many times can be improved with steroids, but if it's not addressed within the first week or two, your chances of recovery go down quite a bit, so it's an important thing to keep an eye on. Some symptoms that would suggest having some hearing loss, because oftentimes it is hard to tell, would be ringing. If you start having this ringing in your ears, you can't figure out where it's coming from, and it doesn't go away after a day or two, that needs to be looked into and pursued.

PH: So whenever you talk about this ringing, is that something that is consistent? Does it come and go? What does that look like or feel like?

BK: [Ringing in the ears] varies from person to person, but what we typically find is it is high-pitched, [but] not always; it can be a low pitch. Some people describe it as a machine-like roar; some people describe it as it sounds like locusts outside in the summer time, or crickets. Typically, it is a high pitch; it is typically worse in quiet environments when there is no background noise to drown that out, and usually it is constant. This is a sign that you have had some nerve damage, and a sign that you probably should get this checked out sooner [rather] than later.

PH: Good to know. Now that we have talked about some ear issues and some loss of taste and smell, what are some other issues that can happen with COVID-19 that people just might not be aware of, but are things that they should be thinking about?

BK: I think the biggest thing that people are not really ready for would be some of the neurologic problems with this, like brain fog, and we don't know exactly what causes this. It might be the systemic inflammation and release of all these chemicals that cause inflammation; it might be the virus actually getting into the central nervous system. So, that's certainly something to be concerned about. Fatigue is by far the most common complaint, but depression [can become] a big part of this as well. I do not know if that is from the viral infection, from the inflammation, [or] from all the isolation we've been experiencing.

BK: There are a whole host of different things you can see with [COVID-19], but if you start having symptoms of facial weakness, like Bell's palsy, that could be a feature of the virus. Or, it could be a sign that you are having a stroke, because with [COVID-19] you can have vascular disease and blood clots, which lead to stroke. If you develop anything like unilateral weakness, your face goes numb, your face just is not working well, then that is something that needs to be checked out immediately.

PH: What about migraines or headaches, things like that? If people normally have those, or even if they do not have those, and they start having them more frequently, should they go and get those checked out as well?

BK: Yes, absolutely, because as I said, one of the big consequences of this virus are blood clots that you typically would not experience, so [headaches] can be major concerns. Chances are, it is probably related to the inflammation and the infection, and it makes your migraines progress a little bit, but it is something that should be investigated.

PH: Now, will that inflammation that you are talking about, people who have had [COVID-19], as they go throughout the year, will that inflammation go down, or is that something that stays stagnant?

BK: More to come on that; we do not know. We do not really know. We do not know what is going to happen with these folks that are having symptoms 12 weeks out still. Are they going to recover? Will they slide into something like a chronic fatigue syndrome that we have seen with some of the other viral illnesses? We are just not sure yet.

PH: What about people with comorbidities such as diabetes, hypertension, kidney disease, etc.? What type of post-COVID-19 care should they seek? Should they even be seeking care right now, or should they just wait and see what happens?

BK: What I would say is, if you are feeling well, not having any problems, my guess is you are probably doing fine. It is just like if COVID-19 was not around. If you are having chest pain, go get checked out, [because] there is a good chance you are having a heart attack. You would certainly be at high risk for that with this. If you have COPD or underlying lung problems and you feel like your breathing has gotten worse, you need to go get that checked out; that needs to be evaluated. [COVID-19] does not change the fact that you still need to be seen. The workup is exactly the same, but it may increase your chance of things like that.

PH: You know, that also made me think of things that we're still doing in light of COVID-19. We still have restrictions in place, right?

BK: That's correct.

PH: But that does not mean our hospital is not safe. Our hospital is probably safer now than it has ever been before. Correct?

BK: Oh, absolutely, absolutely. We have some pretty strong safeguards in place, and I would feel completely comfortable with my family coming in. I wouldn't have any problems with that.

PH: At what point should somebody seek medical care for continued symptoms? How long do we let these symptoms go on? Does it depend on [our] symptoms?

BK: So some things to keep in mind is if you have worsening breathlessness, if you just feel like you can't catch a breath and you just can't manage at home, it is time to get checked out. A lot of people have these pulse oximeters or oxygen monitors at their house. If you notice your levels are getting below 92%-90%, you probably should go get checked out unless you've already been seen and you [know you have] COVID-19.

BK: Unexplained chest pain [also] needs to be evaluated. You could be having a heart attack, or it could be related to your cough; it is hard to say. Any new onset of confusion should be concerning. As I said, strokes have been a little bit more common with this. Facial numbness, facial weakness, things like that, and any type of focal weakness [should be checked out], and if you develop a facial weakness, or if you notice, ‘Hey, my right hand just doesn't seem to be working well,’ you need to go get checked out.

PH: How can people prioritize daily tasks when they are recovering from COVID-19? Some people may live alone or might have to return to work more quickly than others to support families. They might even be a Paige and might want to go to the gym the day after they are out of quarantine.

BK: I think what you can do is develop a progressive schedule, start slow. Take it a week at a time. I am going to do 25% of what I was doing before this hit, and do that for a week or two. If you are doing fine, [then] bump it up to 50% the next two to three weeks after that and so on and so forth. Probably the best advice would be to speak with your physician. They can give you a program that they feel would be safe for you.

PH: Great, and you just mentioned this, but I will give you a chance to restate it again. Are there any recommendations for conserving energy? According to the CDC, and you've even mentioned this, fatigue can be a long-term side effect of COVID-19, and it appears to be a pretty popular one among people who have had COVID-19.

BK: Right, this is not going to be news to anybody, but getting enough sleep is important, staying hydrated, eating a well-balanced diet, and staying up on your vitamins and minerals are probably the best way to go about this. As you mentioned, fatigue is a problem, so exercise can be a problem at first, but work into it slowly and just go at your own pace and then see how it goes.

PH: Something I think that is really important to talk about [is] just the experience of having COVID-19 in and of itself can be really frightening and really distorting to people. What are ways that we can help navigate those feelings of being overwhelmed?

BK: This is an interesting time. We have been inundated with messages from social media, and we have been told that, ‘Hey, this news channel doesn't know what they're talking about.’ The reliability of where we get our information has been a real problem lately. What I would suggest is trust your physicians, and trust the hospital that you [go to]. They give very good advice, and they have researched [COVID-19] extensively and know where to go. That would be number one. Find a trusted source, and in this case, I would say, probably the person you could talk to most easily would be your family provider.

BK: Stay connected to family and friends. Things are improving now that the vaccine is out. I've been through both rounds of my vaccination, so I'm good-to-go as far as that goes. [Hopefully,] we can start reconnecting and start visiting with these folks again. Do activities that you enjoy; go out and take a walk. Relax, and find something that you like to do. Do not be too hard on yourself if you find that you are fatigued. It is not unusual. Focus on things you can control like your diet and getting enough sleep.

PH: So you just mentioned that you have been through your second dose of the COVID-19 vaccine.

BK: Yes

PH: Why do you feel like [getting vaccinated is] really important?

BK: Way back when [COVID-19] started, there was this talk about, ‘Well, let's just let this thing pass through. The population will get herd immunity, and this thing will go away.’ Unfortunately, the cost of that [strategy] is really high, and we are seeing that now. I think we are well over 400,000 deaths in the United States, and we have got somewhere around 10%-15% of folks infected. What the vaccination allows us to do is develop herd immunity without the cost of hospitalizations and death and so forth.

BK: I think [vaccination] is important, and this is how [we will get COVID-19 to] end. This is how we get rid of all these masks; this is how we get to start to meet again, go to concerts, go to church without worrying about this.

PH: Yeah, I love what you just said. ‘This is how this ends.’ This is the beginning of the end, I think.

BK: That is right.

PH: Something else that I think [we should] mention is people who have had COVID-19, they should get the vaccine, right?

BK: Absolutely, because we are not sure how long immunity lasts. Right now, the CDC recommends that your chances of catching it again 90 days after infection are relatively low, but we do not know much more after that. I would recommend if you have had COVID -19 to get the vaccine.

PH: We have time for one more question. What are some types of self-management that people can practice when they are recovering from COVID-19?

BK: Keep an eye on your breathing. Like I said, if you notice increasing breathlessness, that is the time to go get checked out. If you have the ability to check your oxygen levels with a pulse oximeter at home, that is a good thing to do, but do not dwell on that. Do not keep it on your finger 24/7. Your symptoms will let you know when you are having problems. Rest, relax, get some sleep, and do your best to recover, self-pace, gradually increasing exercise, like we talked about. Pay attention to eating a well-balanced diet. I think eating well and resting are the key, and then working yourself back into normal activity slowly.

PH: Today we have been speaking with Dr. Brian Kriete, an ENT (or ear nose and throat physician) with Phelps Health. Dr. Kriete is currently accepting new patients.