Introduction
The SARS-CoV-2 virus, more commonly known as COVID-19, and its subsequent post-viral sequelae (long COVID) is associated with a range of clinical symptoms, specifically postinfectious functional gastrointestinal disorders and disorders of gut-brain interaction. GI symptoms are thought to be associated with intestinal flora changes from activation of immune pathways and pro-inflammatory cytokines, resulting in dysbiosis of the gut microbiome.
In a meta-analysis of 31 studies involving 4682 patients, those patients with high-severity COVID resulting in hospital admission had a higher probability of abdominal pain and hepatic inflammatory markers. Preliminary studies suggest that the most common GI symptoms patients experienced include post-COVID diarrhea, nausea, vomiting, abdominal pain, anorexia, acid reflux, gastrointestinal hemorrhage, lack of appetite and constipationā·.
Case description
History
A male patient in his 50s had a past medical history of asthma. In May 2021, he received the Johnson & Johnson booster. In January 2022, he tested positive for COVID-19. He saw his primary care provider just after testing positive for COVID with shortness of breath, low-grade fever, body aches, fatigue, chest tightness and vomiting. He was subsequently sent to the emergency department for escalation of care.
His ED workup revealed a normal chest X-ray, EKG, BMP and CBC. He was treated with IV fluids, Tylenol and Zofran and discharged to home. He took 50 mg prednisone daily for five days and was given an albuterol inhaler. He continued to see his PCP for lingering symptoms, which included diarrhea, cough and fatigue. His PCP treated him with a Z-pak, Zofran and Imodium.
Presentation and Treatment
I saw this patient in April 2022. His initial labs were significant for erythrocyte sedimentation rate (ESR) of 36 and a vitamin D level of 9.0. He had a negative anti-nuclear antibody (ANA) test and normal thyroid stimulating hormone (TSH).
He complained of fatigue, tachycardia, muscle and joint pain, diarrhea, insomnia and brain fog. He was diagnosed with sleep apnea and autonomic dysfunction.
In November 2022, the patient completed a colonoscopy and esophagogastroduodenoscopy (EGD) which showed sigmoid diverticulosis and erosive esophagitis with a nonobstructive Schatzki ring, gastritis, respectively. He began taking 40mg pantoprazole daily for the erosive esophagitis.
He continued to have debilitating diarrhea and abdominal symptoms. A gastric emptying study revealed accelerated gastric emptying, and he was started on 550 mg Rifaximin three times a day for two weeks and simethicone daily; he had no relief of his symptoms.
He was then started on 0.125 mg hyoscyamine every six hours for relief of his symptoms and three sessions of IV fluids for dehydration. He reported some symptom relief, but still had diarrhea up to five to six times a day and associated cramping pain. He sought a second opinion. He had also cut out dairy and processed and fatty food and began taking probiotics and turmeric, but he experienced no relief.
The diagnosis of dumping syndrome was deemed less likely due to the absence of post-prandial hypotension. His folate and vitamin B12 levels were low and were supplemented. A 24-hour stool test showed 1066 g of stool and lipids/hr = 5.6, which was negative for malabsorption. He was started on a histamine blockade: 40 mg Pepcid twice daily, 30 minutes before breakfast and 30 minutes before bedtime, along with 10 mg Zyrtec twice daily.
Unfortunately, in 2023, the patient relocated out of state and was lost to follow-up.
Discussion
This case highlights the debilitating symptoms of long COVID and the difficulties of managing these patients. For the general gastroenterologist, standard workup and treatment is often met with inadequate outcomes.
A 2022 study examining 320 COVID patients prospectively followed up at one, three, and six months found a significant increase in new onset, postinfectious functional gastrointestinal disorders/disorders of gut-brain interaction (PI-FGID/DGBI) over time. 11.3% of the patients studied had developed these symptoms at one month, and 6.6% had persistent symptoms at six months.
The persistence of GI symptoms was also seen in a 2021 study following patients six months after a COVID infection. 29% of patients reported persistent GI symptoms. In addition, hospitalized patients were more likely to report GI symptoms related to COVID than their nonhospitalized counterparts.
Although the literature on treatment regimens for the persistent GI symptoms of long COVID patients is limited, preliminary studies suggest a role for probiotics to mitigate dysbiosis with the goal of curated probiotics to produce antiviral metabolites that support adaptive immunity.
In a 2021 study of 11 COVID patients with persistent GI symptoms one month after hospital discharge, fecal microbiota transplantation helped to promote the recovery of normal intestinal flora and improve symptoms. As for rehabilitation for patients with long COVID, one study focused on the impact of gut dysbiosis on neurological symptoms and fatigue, and suggests exercise and breathing-focused treatment to improve long COVID symptoms, namely lung function, quality of life and anxiety, and exercise capacity.
As further interdisciplinary research suggests a link between psychiatric illness and the gut microbiome, a 2023 study points to the role of psychiatric intervention and an interdisciplinary approach to post-COVID rehabilitation to reduce the impact of psychological stress on activation of dyspepsia and inflammation of the GI tract.
Conclusion
Physical medicine and rehabilitation physicians are uniquely trained to treat patients with symptoms involving multiple body systems. Physiatrists have experience in managing multiple disorders at once and have the ability to look at the patient as a whole.
Awareness of all possible gastroenterological symptoms in the long COVID population is key to decreasing the length of time of patientsā suffering. While long COVID symptoms and management remain challenging for most medical providers, awareness of etiologies of each symptom will aid in patient recovery and improve quality of life.
