Medical Focus - GPH - Vol 3 No 2 250521

still predicted to around ±10% of those who were confirmed
to have had COVID-19.
All health care workers need to ensure that they continue to
take a full clinical history, perform an accurate physical examination
and order appropriate investigations as necessary
before settling on any specific diagnosis – there is significant
overlap of symptoms between COVID and other communicable
and non-communicable diseases.
Patients with chronic/newly diagnosed medical conditions
should be optimised in order to limit their contribution to
ongoing symptoms that may be considered under the diagnosis
of PASC.
• All health care workers and health care systems have a
responsibility to ensure that patients taking chronic medication
have access to their medications even during periods
of lockdown and quarantine.
• Distribution of chronic medications in a more decentralised
programme to ensure and improve access while
limiting travel to health care facilities during this time
needs to be investigated further.
• Post viral fatigue is a poorly understood but a viable alternative
to PASC in patients who become infected with
Influenza or other non-SARS-CoV-2 coronaviruses.
• Patients who present with symptoms in keeping with
COVID-19 but have also travelled into an area where
malaria is potentially endemic should be investigated for
both COVID-19 AND malaria.
––
Malaria can certainly present with a headache, fever,
coughing and fatigue – remarkable considering it has
a completely different pathophysiology compared to
typically respiratory pathologies – and early diagnosis
and treatment are absolutely essential to avoid fatal
outcomes.
––
History of travel into malaria endemic areas is an
immediate risk factor but patients who live outside
of these areas and have not travelled should not be
ruled out purely based on clinical history without at
least a rapid malaria test within the African context.
• Within the South African context, the HIV status of any
patient who presents to a health care facility has to be
established at initial point of care. Thousands of dollars
have been spent to help identify patients with HIV and
start them on treatment as soon as possible; however we
are still seeing new infections every single day.
––
The pathophysiology of HIV significantly impairs the
body’s ability to fight infection and undiagnosed, immunocomprised
patients are particularly susceptible
to a host of infectious, of which respiratory infections
tend to play a significant role in their initial presentation.
––
Pneumocystis jiroveci (PJP) pneumonia is the most
common opportunistic infection in patients with HIV,
typically presenting with shortness of breath, fever,
dry/non-productive cough as well has a hypoxaemia
and the diagnosis is further supported by radiological
findings of a ground glass appearance. 14
––
All of these symptoms are in keeping with the clinical
findings one may expect for someone with acute
COVID-19 but an incorrect diagnosis as a result of
situational bias may prove fatal for a condition with
known treatments.
• Similarly patients who develop tuberculosis also may be
misdiagnosed as COVID-19 due to overlapping presenting
symptoms of cough, fever and fatigue. 15
• It is important to note that although these infections typical
presented as opportunistic infections in patients with
underlying HIV, they can and do occur in those who are
HIV negative due to other underlying immune-suppressive
states.
In patients where symptoms persistent or have worsening
symptoms, escalation of care to specialist level should be
considered, particularly in patients who continue to exhibit
significant cardiovascular, pulmonary and neurological system
involvement.
• Patients who have been diagnosed with COVID-19 are at
risk for the development chronic myocarditis, thromboembolic
disease and cerebrovascular disease; however,
more clinical research is necessary before definitive predictive
factors can be identified.
• Patients who present with typically unusual symptoms
for PASC such as weight loss or a previous medical history
or family history suggestive of cancer must be investigated
for neoplastic disease processes.
• It is imperative that all patients be thoroughly investigated
by means of a good clinical history, physical examination
and appropriate laboratory tests before a final diagnosis
of PASC is made.
Take Home Message
• PASC is an evolving condition of considerable concern
that requires significant investment into further clinical
research to better understand the epidemiology, pathophysiology,
disease course, outcomes and potential
means of management.
• Although we are still managing our way through a global
pandemic, we need to remember that COVID is not the
only problem patients may present with.
• Common, endemic communicable and non-communicable
diseases should remain high on the list of differential
diagnoses with PASC primarily a diagnosis of exclusion.
• General considerations to consider include the optimisation
of underlying comorbidities (chronic or newly diagnosed)
including HIV, tuberculosis, anaemia, diabetes
mellitus and mental health issues in order to limit their
contribution to ongoing symptoms.
References
1. National Institute for Health and Care Excellence (NICE). National
Institute for Health and Care Excellence (NICE). [Online].: National
Institute for Health and Care Excellence (NICE); 2020 [cited 2021
January. Available from: https://www.nice.org.uk/guidance/ng188/
chapter/Common-symptoms-of-ongoing-symptomatic-COVID-19-andpost-COVID-19-syndrome.
2. Mahase E. Long covid could be four different syndromes, review suggests.
BMJ. 2020; 370.
3. Wade D. Rehabilitation after COVID-19: an evidence-based approach.
Clinical Medicine. 2020; 20(4).
References 4-15 available on request.
9 Vol 3 No 2 - 2021