Post-Acute COVID Syndrome, the Aftermath of Mild to Severe COVID-19 in Brazilian Patients

  1. Ana Paula Andrade Barreto
  2. Lucimeire Cardoso Duarte
  3. Thiago Cerqueira-Silva
  4. Marcio Andrade Barreto Filho
  5. Aquiles Camelier
  6. Natalia Machado Tavares
  7. Manoel Barral-Netto
  8. Viviane Boaventura
  9. Marcelo Chalhoub Coelho Lima

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Abstract

Objective

To describe persistent symptoms after acute COVID-19 in different spectrum of disease severity in a population from an upper/middle income country, and identify the main clinical features impacting the quality of life.

Design

Cross-sectional study.

Setting

Outpatient clinic from a public post-COVID-19 health center (CPC) at Bahia-Brazil, a state where 80% are black or mixed race.

Participants

Patients admitted between August 2020 and February 2021 with symptoms at least one month after the onset of COVID-19.

Main outcome measures

PACS and related disorders such as hospitalization one month or later after disease onset, biochemical dysregulation and reduced quality of life (EQ-5D-5L questionnaire).

Results

Among 683 individuals assisted at CPC in this period, 602 were recruited. Patients had average of 52 (±14.6) years, 355 (59%) were female, 528 (88%) black/brown. Individuals were classified as mild (39.9%), moderate (27.9%) or severe (32.2%) during acute illness if outpatient, hospitalized non-UCI or UCI, respectively. Most patients reported a polysymptomatic profile, in median eight (IQR=6-9) acute symptoms. The most frequent residual symptoms were dyspnea (66%), fatigue (62%) and chest pain (43%). Women were more affected regardless disease severity at acute stage: presented more residual symptoms [4 (2-6) vs 3 (2-4)] and a higher impact in quality of life. Altered HbA1c [(184/275 (66.9%)], high CRP levels [195/484 (40.3%)] and anemia [143/545 (26.2%)] were the most common abnormalities in laboratory exams. 76 patients presented HbA1c above 6.4% although only 42 referred previous diagnosis of diabetes mellitus. After one month of disease onset, 30 patients required hospitalization, including seven cases with mild acute illness. Hospital admission after acute disease was required on 30 patients, seven (23%) were mild. Quality of life had been affected for 357/404 (88.4%) patients according to EuroQoL (EQ-5D-5L), mainly the domains of anxiety/depression [severe or extreme anxiety for 79/401 (19.7%)] and pain/discomfort [severe or extreme pain for 71/403 (17.6%)]. The median EuroQoL Global Score was 70 [IQR 50-80]. PACS symptoms such as dyspnea, chest pain, and fatigue, was associated with decreased quality of life.

Conclusions

PACS, such as dyspnea, chest pain and fatigue, occurred after variable degree of disease severity. Among this majority black/mixed-race patients, woman seemed to be more affected. Other consequences included post-acute hospitalization, and abnormal glucose metabolism and reduced quality of life.

Summary Box

Section 1: What is already known on this topic:

  • ✓ Post-Acute COVID Syndrome (PACS) comprises a set of persistent or new-onset symptoms after illness onset.

  • ✓ As far as we know, there are no studies describing PACS in a population principally black and mixed-race. Additionally, few studies have addressed PACS among outpatients.

    • Section 2: What this study adds:

  • ✓ Similar PACS were reported after mild, moderate and severe illness. Dyspnea, fatigue and chest pain were the most prevalent symptoms in this population presenting majority of black/mixed-race patients.

  • ✓ Women presented more residual symptoms, a higher frequency of myalgia and worse score for mobility, usual activities, anxiety/depression, and pain.

  • ✓ Hospitalization may occur one month or later after mild or moderate/severe acute infection due to respiratory and vascular disorders. Abnormal glucose metabolism was detected in the absence of previous diagnosis of diabetes mellitus.

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    1. ScreenIT

      SciScore for 10.1101/2021.06.07.21258520: (What is this?)

      Please note, not all rigor criteria are appropriate for all manuscripts.

      Table 1: Rigor

      EthicsIRB: The present study was approved by the institutional review boards of the Bahia State University (UNEB; protocol no. 38281720.2.0000.0057) and the Santo Antonio Hospital (
      Sex as a biological variablenot detected.
      Randomizationnot detected.
      Blindingnot detected.
      Power Analysisnot detected.

      Table 2: Resources

      Software and Algorithms
      SentencesResources
      Data were collected and managed using Research Electronic Data Capture (REDCap) software, with hosting provided by the Gonçalo Moniz Institute (IGM-FIOCRUZ), located in Bahia, Brazil[10,11].
      REDCap
      suggested: (REDCap, RRID:SCR_003445)

      Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

      Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
      Our study has several limitations, although sleep disorders and neurological sequelae has been extensively reported in PACS, we did not address these sequelae. The CPC is located in a reference hospital for respiratory diseases, and cases with respiratory complaints may have been preferentially referred to this health unit, therefore cases of mild COVID-19 may not be representative of outpatients with PACS. Additionally, it is not possible to compare PACS on mild and moderate/severe cases due to differences in the recruitment strategy. Hospitalized patients were referred to the CPC after discharge while outpatients attended by spontaneous demand, probably selecting patients with more severe residual symptoms and/or with comorbidities. Indeed, 53% of patients with mild disease reported at least one comorbidity. In conclusion, we described PACS among hospitalized and non-hospitalized patients from Brazil three months following SARS-CoV-2 infection with a few cases of complications requiring hospitalization late after disease onset. Similar lingering and debilitating symptoms were detected in the spectrum of disease severity. Morbidity due to painful and physical-respiratory symptoms negatively affects quality of life, mainly in women who seem to be more affected regardless of disease severity. Considering the impact of PACS in daily activities and the high incidence of COVID-19 in Brazil, further studies should be performed to evaluate the magnitude of the problem and its impac...

      Results from TrialIdentifier: No clinical trial numbers were referenced.

      Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

      Results from JetFighter: We did not find any issues relating to colormaps.

      Results from rtransparent:
      • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
      • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
      • No protocol registration statement was detected.

      Results from scite Reference Check: We found no unreliable references.

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    2. Version published to 10.1101/2021.06.07.21258520v1 on medRxiv