Cognitive disorders and fatigue
Cognitive deficits found both in the subacute stage and in the further course after COVID-19 comprise executive functioning, processing speed, category fluency, memory encoding and recall. This applies to patients with both initially mild and severe COVID-19 courses [
1,
4,
27]. Cognitive deficits are also reported to coexist with fatigue [
34], which commonly leads to severely limiting, disproportionate, subjective exhaustion on a somatic, cognitive and/or psychological level. Postexertional malaise and exertion intolerance, not sufficiently modulated through sleep or recovery are key features of fatigue.
If self-reported cognitive deficits occur, a cognitive screening assessment e.g. the Montreal Cognitive Assessment (MoCA) should be performed. If pathological results are detected and the symptoms are persistent for several months with restrictions regarding the activities of daily life (ADLs), further examination is indicated. Diagnostic includes the examination of serum and cerebrospinal fluid (CSF) including CNS autoantibodies against intracellular and surface antigens and neurodegenerative markers, cerebral imaging, and detailed neuropsychological assessment. A significant association between neurocognitive symptoms and anti-nuclear antibodies (ANA) may indicate autoimmunity as an etiological cofactor in post-COVID-19 syndrome [
33]. Antineural autoantibodies in CSF are associated with pathological performance in cognitive screening assessment (Franke et.al. manuscript currently under revision). Mannose-binding lectin and increased levels of interleukin 8 have been described as possible biomarkers but are not yet used routinely [
21].
Self-report questionnaires such as the Fatigue Scale (FS), the Fatigue Severity Scale (FSS) or the Fatigue Assessment Scale (FAS) should be used to assess the symptoms and severity of fatigue.
To date there are no established and effective medical treatment options for post-viral fatigue and cognitive impairment, as well as related conditions such as myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). If there are indications of autoimmunity, therapeutic approaches including corticosteroids, intravenous immunoglobulins or therapeutic apheresis can be administered depending on risk and expected benefit.
A causal therapy for fatigue is unknown. Non-drug therapeutic approaches such as relaxation techniques, moderate physical activity, acquisition of adequate coping behavior strategies in addition to psychotherapeutic or psychopharmacological treatment are recommended.
Headache
A meta-analysis of cohort studies indicates that headache persists in 44% after COVID-19 illness. If headache is already reported during the acute infection, there is an increased prevalence of persistent headache in the context of post-COVID-19 [
14].
Self-report instruments (e.g. Brief Pain Inventory) should be used to assess symptoms including the severity of chronic pain. Depending on the clinical presentation and examination, an extended laboratory examination can be carried out to rule out other (e.g. rheumatological) causes. MR imaging should be performed in individual cases to exclude structural causes.
Hyposmia/anosmia and hypgeusia/ageusia
A reduction or loss of smell and taste is frequently reported in the aftermath of COVID-19 and may last longer than 6 months after the acute infection [
2].
Hyposmia/hypgeusia or anosmia/ageusia should be objectified e.g. using the SS-16 item sniffin sticks test and taste test. Neurological and/or ENT presentation should include a thorough case history excluding competing or alternative causes. Further laboratory diagnostic and endoscopy may be considered. In addition, atrophy of the olfactory bulb has been reported [
20]
Constant and structured olfactory training is recommended [
12]. The aim is to stimulate the regeneration of olfactory receptor neurons of the olfactory mucosa. The odor of rose, lemon, eucalyptus and cloves are commonly used (Hüttenbrink KB, et al. Riech- und Schmeckstörungen. S2k-Leitlinie der DGHNOKHC. Stand: 31.10.2016. AWMF online). The application of intranasal corticosteroids has been reported in case reports but remains controversial [
18].
Myalgia, muscle weakness and neuropathy
Muscle pain, particularly of the proximal muscles, and muscle weakness are commonly reported and may persist for up to 6 months after the acute infection [
17,
30].
Therapeutic procedures depend on diagnostic findings and are applied according to existing guidelines (
https://dgn.org/leitlinien/ll-69-ll-myositissyndrome). If laboratory results obtain unremarkable, symptomatic treatment can be tried, e.g. administering gabapentine or pregabaline. Physiotherapy and moderate exercise should be implemented.
Pathophysiology of LCS and PCS
Pathophysiological mechanisms in PCS and LCS are scarcely understood. Different explanatory pathways are currently discussed e.g. neurotransmitter-mediated changes, an endothelial-microcirculatory dysregulation, persisting (non-specific) post-infectious inflammation and (virus-triggered) immune-mediated mechanisms including humoral and cell-mediated autoimmunity [
31]. In most published studies, SARS-CoV-2 RNA was neither detected in CSF, nor intrathecally produced SARS-CoV-2 directed IgG antibodies can be held responsible as the cause of PCS [
32]. Neurofilament, a neuronal degeneration marker is interestingly often increased in patients with neurological manifestation during the acute infection, however not in patients with PCS [
19]. 18FDG-PET ([18F]-fluorodeoxyglucose positron emission tomography) conducted in LCS patients with cognitive deficit (less than 26/30 points on the MoCA test; Montreal Cognitive Assessment) showed in 10/15 patients a hypometabolism in frontoparietal brain regions [
16]. A follow-up [
5] of eight patients six months after the acute infection showed an improvement in symptoms and considerable normalization of brain metabolism in PET.
Longitudinal MRI studies have demonstrated changes in the structure of the prefrontal cortex and parahippocampal regions [
13].
Already the SARS-1 pandemic has proven that individual patients may retain long-lasting clinical complaints, especially pain, fatigue, depression, and sleep disorders. The lack of disease-specific biomarkers impedes etiological assignment as well as the exclusion of other (premorbid) diseases.