Covid-19 patients at risk of developing lung fibrosis

Doctors from the All India Institute of Medical Sciences (AIIMS) have recommended lung transplants for two patients who have recovered from Covid-19, because of extensive fibrosis — a condition where lung tissues harden, with lesions caused as the infection heals.

The country's first lung transplant in a Covid-19 patient was performed in Chennai in the end of August.

While most people recover fully from Covid-19, some experience persistent symptoms like breathlessness, fatigue, erratic heartbeat, gastrointestinal problems, and muscle and joint pains for several weeks. A few develop irreversible cardiovascular and respiratory damage.

"If you look at the available data, about 60 to 80% of the individuals who have recovered from Covid-19 may have some form of sequelae (a condition caused by another disease). It can be mild in the form of fatigue and body aches. But it can also be very serious in the form of individuals requiring to be on long-term oxygen therapy. We have had two individuals who have had extensive lung fibrosis and are being advised lung transplants. And we have people who have significant cardiac abnormalities and stroke," AIIMS director Dr Randeep Guleria said in the weekly 'National Grand Rounds' to present current evidence to doctors across the country.

Apart from lung and heart conditions, Dr Guleria also warned about psychiatric disorders as a result of not just the infection, but the lockdown and social isolation imposed to prevent the spread of the infection.

Referring to a study from Italy, Dr Anant Mohan, who heads the pulmonary medicine department in AIIMS said only 12.6% of all recovered Covid-19 trial participants were completely symptom-free after two months, 32% had one or two symptoms, and 55% had three or more symptoms — the most common of which are fatigue, shortness of breath, joint pain, chest pain, and cough.

Dr Saurav Mittal, from the same department, presented three cases of post-Covid-19 complications and how they can be managed.

The first case of a healthy 65-year-old man demonstrated that there could be persisting fibrosis in previously healthy patients that makes them oxygen dependent. The second case of a 43-year-old healthy man was to demonstrate how even after getting better. Covid-19 patients might develop blood clots in the lungs and secondary infections that can lead to deterioration. And, the third case of a 45-year-old man with mild disease who developed a fever 15 days later was to shows that other infections like dengue could be the reason for the second phase of symptoms.

When it come to fibrosis in the lungs, Dr Mohan said that although there was no estimate of the prevalence, he thought the doctors would see several patients in the clinics with such cases.

"There is no estimate of prevalence of post-Covid-19 fibrosis but given the volume of Covid-19 cases, even if it is a small percentage, the absolute numbers are likely to be huge," he said.

The doctor said based on knowledge of fibrosis without known causes, and fibrosis caused by other coronavirus diseases like Severe Acute Respiratory Syndrome (Sars) and Middle East Respiratory Syndrome (Mers) shows that people above the age of 65, those who had severe disease, had a long stay at the intensive care unit (ICU) and needed mechanical ventilation, and those who smoke and drink are at a higher risk of developing fibrosis.

"Lung transplant is an option for a very select group of people — those with extensive fibrosis and acute respiratory distress but who do not have other co-morbidities like renal dysfunction and muscle wasting after Covid-19," said Dr Mohan.

As for the heart, Dr Ambuj Roy, professor from the department of cardiology at AIIMS, said patients with severe pneumonia and other respiratory infections have a higher risk of heart attacks. "Once a patient recovers from Covid-19, we cannot lower our guards. As we have seen in the case of severe pneumonia, the risk of heart attack goes up by as much as six times. We need to closely follow the recovered Covid-19 patients who have multiple risk factors. Those who are on cardio-protective medicines should continue taking them diligently and those with higher risk should also be prescribed these medicines," he said.

The doctor also referred to a study from Germany which showed that among 100 recovered Covid-19 patients, 78 had some cardiac involvement and 60 had ongoing inflammation of the heart muscle.

Professor Pratima Murthy, head of psychiatry at the National Institute of Mental Health and Neuro-Sciences (NIMHANS), Bengaluru, who also joined the rounds via video conference said, "In the beginning, there was a lot of anxiety of getting Covid-19 and stress and depression due to the lockdown. When patients get admitted to hospitals, there are various social and economic factors at play that can lead to extreme depression, suicidal attempts and suicides. People may also develop post traumatic stress disorder about their hospitalisation experience. The inflammatory diseases are known to impact the central nervous system and may trigger mood disorders. It can also increase risk of schizophrenia and psychosis."