Postcoccygeal syndrome in adults and children

Today, even a child knows what the COVID-19 coronavirus infection is. But not many people know about post-COVID syndrome. Although, in fact, we are talking about a fairly common pathological condition after coronavirus disease, which has no specific symptoms, but can last for quite a long time, impairing the ability to work and delaying the recovery of patients.

Post-Covid syndrome - this diagnosis raises many questions. As a rule, people think: I got over the infection, recovered, and there is no need to worry anymore. But coronavirus is more insidious than doctors assumed: it can remind of itself for a long time with various pathological signs in the form of the voiced syndrome.

Epidemiology

According to several scientific articles on the topic of post-Covid syndrome, the following statistics can be drawn: about 15% of patients who have had COVID-19 report continued poor health and a feeling of incomplete recovery for more than 20 days after the disease. About 2% experience unpleasant symptoms for more than three months. However, numerous surveys of those who have recovered from the disease themselves indicate that these figures are actually much higher. After all, many patients are transferred to home treatment before the symptoms have completely disappeared, and not all of them seek medical help when post-Covid syndrome develops. [ 1 ]

One study involved more than 380 people with coronavirus infection, with an average age of 69-70 years. It was noted that most of them could not talk about a full recovery until three months after the onset of the infectious lesion. More than 50% of these people complained of difficulty breathing, more than 30% of coughing, about 70% indicated severe fatigue, and 14% developed depression. At the end of the experiment, the patients underwent repeated X-rays: it was found that only 60% of them had a completely “healthy” picture.

In addition, American doctors initiated a telephone survey, during which the following information was obtained: at least 35% of patients reported that within 2-3 weeks after the disease they still did not feel as well as before the infection. Among young people aged 18 to 34, every fifth person had pathological symptoms for several weeks.

Causes post-coital syndrome

Post-Covid syndrome is a consequence of a disease such as COVID-19 – an acute coronavirus infection that primarily affects the respiratory system and digestive tract. By its origin, the coronavirus is a zoonotic infection. [ 2 ]

Most people infected with the coronavirus pathogen COVID-19 report moderate or mild symptoms of the disease, and recovery occurs without specific treatment measures. Of particular danger is the severe course of the disease, which is more typical for elderly and weakened patients with background pathologies - for example, diabetes mellitus, chronic respiratory or cardiovascular diseases, malignant processes.

However, post-COVID syndrome can develop in absolutely any patient who has recovered from COVID-19, regardless of how the infection progressed: whether it was latent or severe.

Today, specialists have several theories explaining the occurrence of the syndrome. According to one of them, painful manifestations after recovery are a consequence of the development of chronic thrombovasculitis.

Indeed, coronavirus infection affects not only the respiratory tract, but also blood vessels, including the brain. The vascular walls become inflamed, and this process can continue for some time after recovery.

This theory has a right to exist, but it does not explain all the signs of post-Covid syndrome. Therefore, scientists still have a lot of work to do to find the causes of the complication.

Risk factors

Doctors cannot yet answer the question of why some patients experience coronavirus infection without consequences, while others develop post-COVID syndrome. However, it has been noted that COVID-19 most often leaves behind unpleasant symptoms in those who have recovered from the disease and belong to risk groups:

• elderly patients;
• suffering from hypertension, cardiovascular pathologies;
• suffering from chronic respiratory diseases, diabetes, obesity;
• people with initially weakened immunity, oncopathologies, cerebrovascular disorders.

Elderly patients are one of the first risk groups to be identified. Post-Covid syndrome is especially dangerous for people over 60 years of age. The main reason for this danger is the gradual weakening of the immune system, several existing background diseases at the same time. During COVID-19, the number of individual immune cells decreases - in particular, T-killers and natural killers. If a person's immunity is already impaired, the consequences of the pathology can be completely disastrous. [ 3 ], [ 4 ]

People with cardiovascular diseases have a high risk of not only developing post-COVID syndrome, but also other complications, including death. People with diabetes in most cases have functional changes in the lung tissue, reduced air circulation, general respiratory disorders, which contribute to the further development of adverse effects.

Pathogenesis

Most patients infected with COVID-19 recover from the disease within a few weeks. But it happens that the pathological signs disappear only partially, or other residual symptoms appear after a mild form of coronavirus infection. In such situations, they talk about the development of post-COVID syndrome, which consists of the appearance of various complaints for more than 3-4 weeks after recovery. [ 5 ]

The exact pathogenetic mechanisms for the development of post-Covid syndrome are not yet clear. There are several options for the occurrence of an unforeseen consequence, for example:

• Coronavirus infection directly affects human organs, and the lungs, heart, blood vessels, kidneys, stomach and intestines, and brain are “under attack”.
• Coronavirus provokes the development of an inflammatory process in the inner lining of blood vessels. The patient develops vasculitis, endotheliitis, which in turn causes blood clotting disorders. The presence of microscopic blood clots in the bloodstream negatively affects the blood supply to a number of organs, in particular, the heart, kidneys, adrenal glands, thyroid gland, brain, sex glands, etc.
• The coronavirus can affect nerve cells in the brain and large nerve trunks, which leads to a wide variety of symptoms, ranging from sleep disturbances and depression to arrhythmia and shortness of breath.
• The infection stimulates a hyperreaction of the immune system, a series of autoimmune responses are initiated, and a chronic inflammatory process develops, which is caused by the activation of mast cells that release many mediators.

Post-COVID syndrome is a multifactorial consequence that, like COVID-19, has not yet been sufficiently studied.

Symptoms post-coital syndrome

The clinical picture of post-Covid syndrome, which is reported by those who have recovered from COVID-19, is quite diverse. It may include the following symptoms:

• fever, pain in the chest, abdomen and/or joints, severe fatigue;
• difficulty breathing, cough;
• a feeling of heaviness and pain in the chest, rapid heartbeat;
• neurocognitive impairment, brain fog, decreased concentration, memory impairment, headache, insomnia or drowsiness, numbness in the extremities, tingling in the fingers and toes, dizziness;
• abdominal pain, periodic nausea, diarrhea, appetite disorders (including possible anorexia);
• muscle and joint pain;
• anxiety disorders, depression;
• ear pain, sensation of noise in the ears, sore throat, loss of smell, change in taste perception, appearance of additional tastes;
• skin rashes.

In addition, during the post-COVID syndrome, disorders of the blood coagulation system and metabolic disorders were often noted. [ 6 ]

The most common early signs of developing post-COVID syndrome are:

• paroxysmal weakness, often severe, preventing one from doing ordinary household chores or even getting out of bed;
• a strong decrease in endurance, the inability to perform even moderate physical activity;
• disruption of circadian rhythms, when nighttime insomnia is replaced by daytime sleepiness (sleep inversion);
• muscle pain caused by a decrease in the protein component of the muscles during the acute period of COVID-19.

Psychoemotional disorders are found in patients everywhere:

• depression, pessimistic mood, depression, anxiety, in severe cases – suicidal thoughts;
• emotional lability, sudden mood swings, loss of behavioral self-control;
• panic attacks accompanied by attacks of changes in blood pressure, nausea, and dizziness.

The so-called post-Covid asthenovegetative syndrome is more typical for female patients prone to vegetative-vascular disorders. Typical signs of such a disorder are:

• changes in blood pressure (usually increased, but sometimes hypotension);
• feeling of difficulty breathing;
• paroxysmal dizziness, loss of balance;
• paroxysmal nausea (vomiting – rare);
• the emergence of various fears (including the fear of death);
• a sudden sensation of cold or heat.

The respiratory system can also fail, even in those patients who did not have obvious respiratory problems during the acute stage of COVID-19. With the development of post-COVID syndrome, the following symptoms appear:

• feeling of lack of air;
• heaviness in the chest, feeling of incomplete inhalation;
• periodic spasms of the bronchi, which may be accompanied by severe shortness of breath, tachycardia, and dizziness.

A similar picture can last from one week to six months or even more.

Often, with post-COVID syndrome, the nervous system is also affected, which manifests itself in the following pathological symptoms:

• headaches, constant or paroxysmal, disturbing in periods;
• thermoregulatory failures (prolonged increase in temperature, or, conversely, decrease);
• frequent chills, muscle tremors (even with normal body temperature);
• sensory disturbances in the form of paresthesia, tingling, burning, itching sensations on the skin;
• changes in taste and smell (up to six months or more). [ 7 ]

How long can the temperature last with post-Covid syndrome? In most cases, the temperature readings do not exceed subfebrile numbers, staying at around 37.3°C (especially in the evenings) for no more than one week, if there are no other background diseases. Some patients have a febrile temperature for 1-2 weeks, resuming for several days after a short “light” interval. But a low temperature (usually 36.5°C) can last a little longer - up to several weeks. [ 8 ]

Specific damage to the cardiovascular system during COVID-19 also makes itself known during post-COVID syndrome. In about 20% of cases, people who have recovered experience heart rhythm disturbances, development of acute or chronic heart failure. The most common symptoms are:

• fluctuations in blood pressure (increase or decrease), in severe cases orthostatic collapse develops, which is characterized by a sharp decrease in pressure up to a fainting state;
• vasculitis, angiitis, which are accompanied by the appearance of skin rashes, hemorrhages and hematomas on the skin;
• arrhythmias, tachycardia, bradycardia.

Post-Covid syndrome often manifests itself as digestive disorders associated with both infectious lesions of the gastrointestinal tract and antibiotic therapy and the use of other medications. Patients often voice complaints:

• on deterioration of intestinal peristalsis, periodic occurrence of constipation or diarrhea;
• change in appetite (most often – loss of craving for food).

If no measures are taken, intestinal dysbacteriosis can cause a weakening of the immune system, the development of anemia, and allergic processes. [ 9 ]

Other possible signs of post-covid syndrome may include inflammatory urogenital diseases, in women - dysmenorrhea, endocrine diseases. Most often, the first "bells" are noted in organs previously affected by some chronic pathologies. Sometimes disorders that the patient did not know about "make themselves known". In order to prevent the emergence of serious health problems, it is recommended to listen carefully to your feelings and immediately consult a doctor if suspicious symptoms appear.

Post-Covid syndrome in children

Post-Covid syndrome also occurs in childhood, even if the child has suffered a mild form of the disease. Just like in adults, children are at risk of damage to internal organs, the respiratory and cardiovascular systems.

What are the symptoms? Most often, patients complain of shortness of breath, strong heartbeat, anxiety attacks, digestive disorders, sleep disorders, and lethargy. There are also failures in the immune system. Children may be bothered by attacks of fear, even panic attacks.

It is known that children tolerate COVID-19 easier than adults. They are less likely to develop pneumonia and other complications. However, post-COVID syndrome is also typical for small patients. For example, infants under 1 year of age have a significantly reduced appetite, which causes them to lose weight. The quality of sleep deteriorates: babies have trouble falling asleep, sleep restlessly, although they are lethargic and sleepy during the day.

Pediatricians note a number of cases of development of multisystem inflammation, or Kawasaki-like syndrome, in children. In this case, we are talking about a severe complication with an unfavorable prognosis, up to and including death. Patients who have experienced such a syndrome have a high risk of developing coronary pathologies in the future.

To prevent unfavorable developments, parents should closely monitor their children even after recovery from COVID-19. After any pathology, there should be a recovery stage, which involves reducing mental and physical stress, providing the baby with plenty of fluids and quality nutrition. If suspicious signs appear, you should consult a doctor as soon as possible and, if necessary, undergo a number of additional examinations.

Stages

In 2020, the UK's National Institute for Health and Care Excellence, together with the Scottish Intercollegiate Organisation and the Royal College of General Practitioners, recommended distinguishing the following stages of the disease:

1. Acute stage – complaints and pathological signs are present for up to 3-4 weeks.
2. Prolonged symptomatic stage – complaints and pathological signs are present for four to twelve weeks.
3. The immediate stage of post-Covid syndrome - complaints and pathological signs continue for more than 12 weeks, without being a consequence of any other disease.

Forms

The diagnosis of “post-COVID syndrome” has not yet been introduced into official medical usage and is not considered a generally accepted term, but it is already often used to characterize the phenomenon of a long recovery period after COVID-19.

Due to the lack of an officially recognized term, experts have proposed dividing the pathology into the following types:

• long-term COVID-19 - if symptoms persist for more than 3 weeks after the infectious manifestation;
• chronic form of COVID-19 – if symptoms persist for more than 12 weeks after the first signs of infection were detected.

Experts also believe that laboratory confirmation criteria for coronavirus infection are not a prerequisite for identifying a long-term or chronic type of disease. [ 10 ]

Complications and consequences

Post-COVID syndrome itself is a complication of the coronavirus infection COVID-19. However, it can also lead to the development of adverse effects - in particular, many patients experienced disorders of the blood coagulation system and metabolic disorders. For example, patients with diabetes often have difficulty establishing control over the disease.

In addition, there is documented evidence of such pathological consequences as inflammation of the heart muscle and cardiovascular failure, cardiac arrhythmia and thrombotic complications. Some patients developed post-infectious encephalitis.

Similar problems can also arise from the respiratory system, musculoskeletal system and nervous system. The reasons for such developments are unknown, but many specialists associate the occurrence of complications with a number of pathophysiological mechanisms, including vascular damage - vasculitis.

Other possible negative consequences of post-COVID syndrome include deterioration of vision and arthritis. [ 11 ]

To prevent complications, doctors recommend taking a multifaceted approach to all COVID-19 patients, paying attention not only to their physical condition but also to their psychological

Diagnostics post-coital syndrome

To diagnose post-COVID syndrome, doctors use the following tactics, which involve a follow-up visit to a patient who has recovered from COVID-19:

• determination of existing symptoms and the chronology of their appearance;
• assessment of the presence of complications associated with post-COVID syndrome;
• assessment of symptom severity;
• determination of concomitant pathologies and the degree of probability of the influence of coronavirus infection on their course.

After collecting the necessary information, the doctor begins a physical examination, measures temperature, blood pressure, counts the pulse, and checks the degree of blood oxygen saturation. [ 12 ]

Next, he prescribes laboratory tests:

• general blood test (extended);
• electrolyte levels, liver enzymes, renal function indicators;
• troponin, creatine kinase, ferritin, C-reactive protein, D-dimers, B-type natriuretic peptide BNP, thyroid stimulating hormone, thyroid hormones;
• vitamin D level (deficiency or low levels of this vitamin determine the complexity and duration of post-COVID syndrome);
• general urine test, analysis of total protein, urea, potassium, sodium.

Instrumental diagnostics for post-COVID syndrome necessarily includes radiography and electrocardiography. Additionally, spirography, heart ultrasound, daily monitoring of heart rhythm and blood pressure, ultrasound of the abdominal organs and retroperitoneal space may be prescribed.

If the patient required oxygen therapy during the acute period of the disease, then additional examination is prescribed approximately 5 weeks after completion of inpatient treatment. X-rays are performed after 3 months, and the probability of thrombosis is also assessed.

If a person has any serious signs of post-COVID syndrome, it is necessary to refer him for urgent diagnostics - to exclude the development of potentially dangerous complications (severe hypoxemia, multisystem inflammatory syndrome, etc.). If regular shortness of breath is detected, the patient is referred for diagnostics of latent hypoxia. [ 13 ]

For some people who have recovered, it is advisable to recommend self-monitoring of blood oxygen saturation using a pulse oximeter for several days. In addition, you can conduct a test by measuring your pulse and recording your breathing patterns at rest and after doing physical exercise for a minute.

When orthostatic tachycardia is detected, blood pressure readings are measured in different body positions (standing, lying down).

Additional consultations with specialized specialists are prescribed based on the violations discovered.

Differential diagnosis

Differential diagnostics of post-COVID syndrome should be carried out with other diseases and pathological complications, with respiratory and cardiovascular disorders, pathologies of the digestive and nervous systems.

Treatment post-coital syndrome

The treatment tactics for post-COVID syndrome depend on the detected pathological changes and symptoms. Provided that severe complications of coronavirus infection are excluded, the treatment regimen is based on the use of symptomatic and supportive drugs that improve the patient's well-being. In severe cases, respiratory rehabilitation may be required.

General therapeutic principles include bed rest, sufficient caloric nutrition and adequate drinking regimen, control of water-electrolyte balance and hemostasis, correction of respiratory and other disorders. [ 14 ]

Clinical recommendations based on specific symptoms:

Long-lasting cough	If a bacterial infection has been proven, antibiotics are prescribed, and in other cases, breathing exercises are recommended.
Dyspnea	It is recommended to perform breathing exercises aimed at increasing the efficiency of the respiratory muscles.
Constant feeling of fatigue	They use a wait-and-see approach, recommending rest, relaxation with a gradual return to physical activity. No special medications are prescribed for treatment. It is possible to take vitamin preparations under the supervision of a doctor.
Elevated temperature	Antipyretic drugs are prescribed, mainly Paracetamol.
Neurological symptoms	For headaches, Paracetamol is used; for other disorders, symptomatic drugs are used.

Recommendations regarding physical activity for those who have recovered from the disease:

No signs of post-covid syndrome	Maintaining adequate physical activity.
Mild symptoms of post-covid syndrome	Maintaining moderate physical activity, limiting sedentary periods. Avoiding prolonged and exhausting loads with increased intensity of training.
Previous coronavirus infection with mild to moderate course	Gradually increase the load, starting with stretching exercises (week 1) and low-intensity training. If symptoms worsen, the period without exercise is extended.
The course of COVID-19, accompanied by pain in the bones and muscles, in the throat and chest, with a cough and fever	Avoid intense training for 3 weeks after symptoms have resolved.
Lymphopenia and the need for oxygenation	Conducting laboratory diagnostics and specialist consultation before resuming physical activity.
Cardiovascular complications	Conducting laboratory diagnostics and specialist consultation before resuming physical activity.

It is very important to establish an adequate daily routine for a person suffering from post-Covid syndrome. The doctor should provide appropriate advice:

• to stop using psychostimulants (coffee, nicotine, alcohol);
• on normalizing nutrition, the need for a gradual increase in physical activity, and ensuring insolation;
• on stress management practices (rest, adequate sleep, relaxation).

Many patients are recommended to receive psychological consultations based on cognitive behavioral therapy.

Medicines

In case of post-covid syndrome, symptomatic drugs are prescribed according to individual indications. If there is an elevated temperature that causes discomfort to a person, then Paracetamol or Ibuprofen is prescribed (1 tablet 2-3 times a day). Regular use of antipyretic drugs is undesirable (it can negatively affect the health of the digestive tract), repeated administration is carried out only after the next increase in temperature. Both Paracetamol and Ibuprofen can be taken in the form of tablets or rectal suppositories. Doctors advise giving preference to one of these drugs, and not alternating them. Acetylsalicylic acid, Metamizole and Nimesulide should not be used to lower the temperature. [ 15 ]

Mucolytic and expectorant agents are prescribed in the presence of hard-to-expel viscous sputum. Ambroxol, Carbocysteine, Acetylcysteine are indicated.

Ambroxol	The adult dose is ½ tablet 2-3 times a day, after meals. The drug should not be taken without consulting a doctor. Possible side effects: diarrhea, nausea, dry mouth, heartburn.
Carbocisteine	Take 750 mg orally three times a day. The drug is contraindicated for patients with gastric ulcer and duodenal ulcer or chronic glomerulonephritis. Possible side effects: abdominal pain, diarrhea, nausea, allergic reactions.
Acetylcysteine	Taken in a dose of 400-600 mg per day (children from 2 years old - 200-300 mg per day), after meals. Possible side effects include nausea, diarrhea, headache, tachycardia, allergic reactions, bronchospasm. In case of post-covid syndrome, the drug is taken under strict medical supervision.

If bronchial obstruction is observed, bronchodilators (eg, Salbutamol) can be used. It is preferable to practice dosed inhalations, but nebulizers should not be used unless absolutely necessary.

Most people who have recovered, including those with post-COVID syndrome, need to restore the microflora in the body. For this purpose, probiotics are prescribed - these are drugs that contain different strains of lacto and bifidobacteria. Such beneficial bacteria are found in any fresh fermented milk products, but you can take additional probiotics - for example, Linex, Bificol, Bactisubtil, Floristin. Vitamin D is also necessary - it is taken in a course of 3-5 thousand IU per day. [ 16 ]

In case of neurological disorders, psycho-emotional disorders, sedatives, preparations containing essential amino acids are indicated. In particular, the drug L-tryptophan is prescribed, which contains an amino acid necessary for the production of niacin, which in turn activates the production of serotonin. Despite the relative safety of this drug, only a doctor can prescribe it. It is undesirable to take Tryptophan for people who are undergoing treatment with monoamine oxidase inhibitors, since the combination of such medications increases the risk of CNS excitation. Caution is also observed in case of kidney and liver pathologies. [ 17 ]

Prevention

Experts recommend not to ignore a visit to your doctor after being discharged from the hospital, or after you feel better if you were treated on an outpatient basis. You should also not try to rehabilitate yourself. The amount of help needed may depend on the severity of COVID-19, on following the recommendations of the attending physician, and on the individual characteristics of the body.

Even after the expected recovery, you should not avoid performing control clinical tests, biochemical blood tests. It is imperative to do a coagulogram and determine the D-dimer indicator. It is important to remember that the most common complications of coronavirus infection are thrombotic disorders. That is why it is very important to know and monitor hemostasis indicators - especially if the patient continues treatment with anticoagulants.

The required laboratory minimum after recovery also includes an assessment of urea and creatinine levels, electrolyte balance, albumin, protein (total), liver transaminases, ferritin, blood sugar, C-reactive protein. Of course, a biochemical blood test will not be able to specifically characterize an infectious disease. However, identifying any violations will allow the doctor to promptly detect a malfunction in certain organs and assess the likelihood of complications.

If possible, doctors recommend having your blood tested for vitamin D levels. Many experts talk about the relationship between a deficiency of this vitamin and a high risk of developing adverse effects, including post-COVID syndrome. [ 18 ], [ 19 ], [ 20 ]

Forecast

To assess the prognosis of post-covid syndrome, the results of laboratory tests and instrumental diagnostics are important. If the patient is diagnosed with other diseases (respiratory, digestive, neurological, cerebrovascular, cardiovascular), the quality of the prognosis is greatly impaired: such a patient is closely monitored for deterioration of the condition. Persons with one or more risk factors are also necessarily monitored. The decision on where the observation will be carried out - in a hospital, in a municipal institution or at home - is made by the attending physician on an individual basis for each specific case. Such a decision may also depend on the clinical symptoms, the need for supportive treatment, risk factors and the quality of outpatient conditions, etc. Children and pregnant women, young mothers in the postpartum period also require special monitoring. [ 21 ]

If post-COVID syndrome proceeds with positive dynamics, without obvious complications, then we can talk about a favorable outcome of the pathology.