Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- previous diagnosis of COVID-19 or history of suspected acute COVID-19 illness
Other diagnostic factors
- fatigue/weakness
- cognitive impairment (brain fog)
- impaired sleep
- headache
- dizziness
- dyspnoea
- cough
- anosmia/dysgeusia
- pain (including arthralgias and myalgias)
- chest pain
- post-exertional malaise
- anxiety/depression
- palpitations
- thirst/dry mouth
- loss of sexual drive or capacity
- numbness/tingling
- hair loss
- gastrointestinal symptoms
Risk factors
- severe COVID-19 illness (requiring hospitalisation or ICU admission)
- not vaccinated or only partially vaccinated against COVID-19
- female sex
- age >40 years
- BMI >30 kg/m²
- smoking
- anxiety/depression
- asthma
- chronic kidney disease
- chronic obstructive pulmonary disease (COPD)
- diabetes
- immunosuppression
- ischaemic heart disease
Diagnostic investigations
1st investigations to order
- clinical diagnosis
- full blood count
- comprehensive metabolic panel
- creatine kinase
- C-reactive protein
- erythrocyte sedimentation rate
- serum ferritin level
- thyroid function tests
- serum 25-hydroxy vitamin D
- pulse oximetry
Investigations to consider
- orthostatic testing-tilt table testing
- electrocardiogram
- pulmonary function testing
- chest radiograph
- chest CT
- B-type natriuretic peptide
- D-dimer
- anti-nuclear antibody
- rheumatoid factor
- anti-cyclic citrulinated peptide
- serum vitamin B12
- blood thiamine
- serum folate
- plasma homocysteine
- high sensitivity troponin
- transthoracic echocardiogram
- ambulatory cardiac monitoring
- cardiac stress test
- cardiopulmonary exercise test
- cardiac MRI
- autonomic function testing
- overnight sleep study
- MRI head
- neuropsychological testing
Treatment algorithm
all patients
Contributors
Authors
Benjamin Abramoff, MD, MS
Assistant Professor of Physical Medicine and Rehabilitation
Perelman School of Medicine
University of Pennsylvania
Philadelphia
PA
Disclosures
BA has served on medical advisory boards regarding long COVID for Axcella Pharmaceutical, AstraZeneca, Intrivo Diagnostics, and UnitedHealthcare. BA is an author of references cited in this topic.
Shawn Joshi, MD, PhD
Clinical Resident of Physical Medicine & Rehabilitation
Spaulding Rehabilitation Hospital
Clinical Fellow in Medicine
Harvard Medical School
Boston
MA
Disclosures
SJ declares that he has no competing interests.
Eric Herman, MD
Assistant Professor of Family Medicine
School of Medicine
Oregon Health and Science University
Portland
OR
Disclosures
EH serves as co-chair in the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multidisciplinary PASC Collaborative. EH has been invited to serve as an expert witness in a case involving long COVID. EH is an author of references cited in this topic.
Julie Silver, MD
Associate Professor of Physical Medicine and Rehabilitation
Harvard Medical School
Associate Chair, Department of Physical Medicine and Rehabilitation
Spaulding Rehabilitation Network
Massachusetts General Hospital
Brigham and Women's Hospital
Boston
MA
Disclosures
JS has participated in research funded by NIH and foundations on topics not related to COVID-19 including culinary medicine, prehabilitation, and chronic pain. JS is author of references cited in this topic.
Peer reviewers
Sarah Jolley, MD, MSc
Associate Professor
Division of Pulmonary Sciences and Critical Care Medicine
University of Colorado
Denver
CO
Disclosures
SJ receives NIH funding for work related to long COVID via the RECOVER consortium and AHRQ related to long COVID care delivery.
Trisha Greenhalgh, MA, MD, FRCP, FRCGP, FFPH, PhD
Professor of Primary Care Health Sciences
University of Oxford
Oxford
UK
Disclosures
TG is an author of references cited in this topic.
Differentials
- Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)
- Post-intensive care syndrome
- Postural orthostatic tachycardia syndrome (POTS)
More DifferentialsGuidelines
- COVID-19 rapid guideline: managing the long-term effects of COVID-19
- Post-COVID conditions: information for healthcare providers
More GuidelinesPatient information
COVID-19 (coronavirus)
Coronavirus (COVID-19): vaccines
More Patient information- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer