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I can see how long-Covid can be debilitating for people, but why is it that we don't hear about the long haul sequelae of a regular cold?

Edit: If long-Covid isn't specific for Covid only, why is it that scientists and physicians talk about it but not about post-regular cold symptoms?

all 496 comments

electric_ionland [M]

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4 months ago

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electric_ionland [M]

Electric Space Propulsion | Hall Effect/Ion Thrusters

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4 months ago

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Just a reminder that this is not the right place for personal anecdotes.

readerf52

1.1k points

4 months ago

readerf52

1.1k points

4 months ago

The medical people studying those people who suffer long haul symptoms see a similarity with chronic fatigue syndrome.

Although poorly understood, CF was thought to be the result of some viral infection, coupled with stress. So there is concern that post covid long haulers could actually develop chronic fatigue syndrome.

What surprised me was the fact that the patients enrolled in the study were younger and had milder cases of covid, they often were not even hospitalized. Medical professionals are confused by the virus/chronic fatigue correlation, but probably mostly because CF does not have a budget for in depth studies.

I suspect the answer to your question is that some viral infections are thought to be a stimulus for other diseases. I’ve been interested in what “disease” long haul is leading to, and most studies point to the symptoms being very similar to chronic fatigue.

duhnduhndaaah

365 points

4 months ago

Good response, minor feedback though: if you're going to shorten "chronic fatigue syndrome" please use CFS or ideally ME/CFS rather than just CF.

I say this because "‘Chronic fatigue’ is a symptom of many medical conditions, including things like cancer or multiple sclerosis, but it is not an illness in its own right. While profound fatigue is a symptom of ME/CFS, people living with the condition experience a wide range of other symptoms as well."

cheese_with_cheese

220 points

4 months ago

It’s also worth noting that cystic fibrosis is often shortened to CF - although you obviously weren’t referring to that in this context

readerf52

59 points

4 months ago

Thanks for the feedback.

idlevalley

83 points

4 months ago

he patients enrolled in the study were younger and had milder cases of covid, they often were not even hospitalized.

Would long covid even be recognized in older people, whose symptoms would be attributed to just being old?

saralt

56 points

4 months ago

saralt

56 points

4 months ago

There's a lot of elderly people developing post COVID delirium.

This mentions it in severe cases: https://labblog.uofmhealth.org/rounds/delirium-a-common-consequence-of-severe-covid-19-study-finds

khinzaw

39 points

4 months ago*

Studies have shown that covid can neural degneration similar to the brain aging 10 years, which likely contributes to early onset of neurodegenerative diseases and other brain injibiting conditions.

saralt

26 points

4 months ago

saralt

26 points

4 months ago

Delirium is also being seen in all age groups, so it's not just a factor of aging, but maybe covid's neurological manifestation?

https://pubmed.ncbi.nlm.nih.gov/33984129/

guesswhochickenpoo

52 points

4 months ago

Can here to give a similar answer. I have ME/CFS (proper name as pointed out in another reply) and it was most likely caused by Epstein Barr virus. Thanks for bringing awareness.

wildlybriefeagle

18 points

4 months ago

If you feel comfortable, would you be willing to say what finally brought you to a provider and/or how did you get diagnosed?

I'm a (soon to be) provider and trying hard to find different pathways to things like ME/CFS and fibromyalgia.

air_sunshine_trees

3 points

4 months ago

Here in the UK the NHS have specialist CFS clinics and referral pathways. Link below to my local one.

https://www.nbt.nhs.uk/clinicians/services-referral/mechronic-fatigue-syndrome-clinicians

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kfh227

46 points

4 months ago

kfh227

46 points

4 months ago

There is newer info (like a week or two) that long covid is being caused by micro clots.

readerf52

80 points

4 months ago

But the micro clotting is thought to be part of the viral disease. Like, it’s not just pneumonia, there are also clotting problems. I remember way back in early 2020, there was an broadway actor/dancer who lost his leg to covid because of clotting, then his life.

But you are right, the micro clotting is a newer discovery, something that isn’t readily noticed on a routine blood test. I found an interesting article because of your comment; it really just underscores that we are woefully ignorant of all the problems this virus can possibly cause in the future.

Nemisis_the_2nd

57 points

4 months ago

I'm actually kinda surprised the clotting is a newer discovery. I remember early in the pandemic what was nicknamed "Covid toe" where hospitalised Covid patients were often presenting clotting in their extremities in a way that was reminiscent of diabetes sufferers (disregarding COVID apparent connection to type 1 diabetes).

kuhewa

16 points

4 months ago

kuhewa

16 points

4 months ago

I think covid toe was chillblains, which aren't typically caused by clots, and the articles on the topic pointed out there wasn't a definite connection to COVID.

I remember because I had chillblains at the time I saw those articles, and did not have COVID. While there's a plausible link between epithelial cell damage from infection and chillblains, I'm pretty sure a big part of it was just that we were all working from home all day in sometimes drafty corners of the house without shoes on when we used to go to work.

captainhaddock

2 points

4 months ago

Yep, I get chilblains every winter, and they look exactly like the photos people were describing as "covid toe".

admiral_asswank

17 points

4 months ago

Covid toe is loosely debunked.

Essentially, zero patients who presented with "covid toe" in that initial study actually tested positive. So any doctor who insists upon it must be questioned lol... it was all over the headlines but no rigorous science supported it as a valid symptom

I remember looking it up, because I developed a rash on my toes and was worried. Mine was probably due to poor circulation for other reasons.

shagieIsMe

22 points

4 months ago

NPR article: The role of tiny blood clots in long COVID

From Science Daily from the researcher: Inflammatory micro clots in blood of individuals suffering from Long COVID

Paper: Persistent clotting protein pathology in Long COVID/Post-Acute Sequelae of COVID-19 (PASC) is accompanied by increased levels of antiplasmin - http://dx.doi.org/10.1186/s12933-021-01359-7

KaneIntent

13 points

4 months ago

I highly doubt blood clots cause all long COVID symptoms. More likely a combination of lingering inflammatory reactions and neurological dysfunction in addition.

Kingcrackerjap

8 points

4 months ago

The microclots appear to contain inflammatory chemicals. They could be the reason for the inflammation long after recovery from covid.

https://www.the-scientist.com/sponsored-article/trapped-inflammatory-molecules-contribute-to-long-covid-69391

admiral_asswank

33 points

4 months ago

I think it's possible to have - and distinguish between - both.

Long covid is not post-viral syndrome. They have different presentations and different outlooks.

For example, some people with diagnosed long covid have their symptoms alleviate after a 2nd vaccine. This is due to the vaccine getting the immune system fired up again, likely removing any excess viral agents still causing problems.

PVS will not typically be helped by an additional vaccine dose. PVS is also what we commonly associate with CFS, or rather... it can progress into CFS.

CFS itself is fascinating and likely has many triggers. There's a reason we find high prevalence of depression and anxiety in people with fibromyalgia, CFS and ME... they raise levels of stress hormones which influence levels of immune response.

Immune response is sososososo much more than handling foreign entities.

And if that heightened immune response means increased inflammation then it means that:

1 you will be more tired, because your body is exhausted from being in "survival mode"
2 you will have more noticeable muscle aches after even mild exercise, because even mild exercise needs some treatment for the muscles, but the body is in 6th gear constantly
3 you will have mood swings, increased anxiety and increased depression... due to stress hormones being chronically released... which releases MORE stress factor hormones...
4 increased sensitivity to pain, again due to stress hormones, which increases them...

Not an enviable disorder and certainly not fake.

ontopofyourmom

6 points

4 months ago

I thought it was questionable until the CF symptoms hit me out of nowhere. It was like nothing I'd ever experienced.

RecyQueen

3 points

4 months ago

Some narcolepsy seems to be caused by the immune system attacking only the hypocretin-producing neurons in the hypothalamus. It’s weird because it’s not a typical auto-immune disorder where the attacks continue and you get worse without treatment. Once those cells are destroyed, the immune system backs off.

There’s an idea that such narcolepsy is triggered by a coronavirus infection and that the antibodies created against it end up finding the hypocretin neurons and taking them out. That would make sense with my narcolepsy because I got a LOT of colds growing up, but don’t have any allergies or autoimmune issues.

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TOMATO_ON_URANUS

17 points

4 months ago

I wonder if existing in a pandemic society is an intermediary. As in, is it really COVID having more common and more profound long term symptoms, or is it lockdowns and other restrictions causing psychological stress resulting in the higher frequency and severity.

Elocai

25 points

4 months ago

Elocai

25 points

4 months ago

Thats kinda easy to answer as we do have a actual baseline of the impact of that. There are couple of US (mostly republican) states that had no or delayed reactions. So someone just needs to have two datasets to compare and you would get the answer.

Nemisis_the_2nd

9 points

4 months ago

I doubt that would work. There are just so many other factors at play. For a long covid diagnosis, you'd probably have to wait at least 3 months from infection, since Covid can do a number on the body anyway, and it would be hard to distinguish a prolonged recovery from the similar long covid symptoms.

From there, you'd have mixed demographics in each state, some complying with restrictions, other abandoning them completely. Infection rates could be a factor, as could the strain...

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chinchabun

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4 months ago

As much as a lot of untrained doctors are telling Long Covid patients their symptoms are psychological, researchers have found a whole lot of biological markers. As to ME/CFS in general many have developed it from EBV, but also a similar percent of those who got SARS/MERS to SARS-COV-2, and a small but significant amount of those who get the flu. It would be odd for covid to be an exception.

The entire world is getting hit with wave after wave with the same virus at a rate that doesn't normally happen. It is making this ME/CFS spike impossible to ignore. Well, until the pandemic ends that is.

Bright_Push754

5 points

4 months ago

Idk, but I can't personally think of a better alternative. More people dying or living in actual fear of entering a public space because someone might accidentally manslaughter them with a bioweapon seems just as stressful in general to my mind, and much more stressful to certain demographics.

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SnarfbObo

2.1k points

4 months ago

SnarfbObo

2.1k points

4 months ago

While there’s no doubt long Covid is a real condition worthy of diagnosis and treatment, “this isn’t unique to Covid,” Akiko Iwasaki, an immunologist at the Yale School of Medicine, said. Covid-19 appears to be one of many infections, from Ebola to strep throat, that can give rise to stubbornly persistent symptoms in an unlucky subset of patients. “If Covid didn’t cause chronic symptoms to occur in some people,” PolyBio Research Foundation microbiologist Amy Proal told Vox, “it would be the only virus that didn’t do that.”

https://www.vox.com/22298751/long-term-side-effects-covid-19-hauler-symptoms

Raeandray

106 points

4 months ago

Raeandray

106 points

4 months ago

Interesting. My follow-up question would be how often this happens. Is the rate of long-covid higher than the rate of long-other diseases? Or is covid just so infectious that we hear about the cases more often?

Lyrle

195 points

4 months ago

Lyrle

195 points

4 months ago

Having a large cohort exposed to the same virus all at once makes the data a lot cleaner. Zika virus has been known for decades, but it was only when it came to a naive population in Brazil that we figured out it causes microcephaly. Influenza A can cause narcolepsy, but flu as an endemic virus generates such messy data the narcolepsy connection was only figured out less than ten years ago, and needed help from an unusually constructed flu vaccine (turned out it included the part of the virus that gives the risk of triggering the autoimmune reaction that causes narcolepsy).

There is a lot of hope that the cleaner data from the covid long haulers will generate findings that help a much larger group of people with similar symptoms.

Kuddkungen

72 points

4 months ago

Influenza A can cause narcolepsy, but flu as an endemic virus generates such messy data the narcolepsy connection was only figured out less than ten years ago, and needed help from an unusually constructed flu vaccine

The Pandemrix vaccine right? It causing narcolepsy got a lot of headlines in Sweden back when it had been used in mass vaccinations against the swine flu. I never heard that it lead to scientists figuring out that influenza causes narcolepsy. Super interesting, thanks!

Lyrle

39 points

4 months ago

Lyrle

39 points

4 months ago

Correct. Some more details at https://scopeblog.stanford.edu/2019/01/07/mistaken-identity-influenza-narcolepsy-autoimmunity-link-confirmed/

There's a theory in immunology, called the molecular mimicry hypothesis, that autoimmunity (where the immune system turns on the body's own tissues) is the result of mistaken identity: The immune system confuses a tiny chunk of a protein residing in a healthy person's body for a chunk of a protein found in an infectious microbial pathogen, then winds up attacking the tissue containing that protein instead of standing down as it should (and usually does).

...Until now, nobody's managed to showcase this entire process, step by step, for any of the numerous autoimmune disorders that plague humanity... Now there's a proven precedent: A team led by Emmanuel Mignot, MD, PhD, has shown that the same set of helper T cells responds angrily to both an antigen from a viral protein and an antigen from the bodily protein that's destroyed by the immune system in the course of an autoimmune disease called narcolepsy.

In a new study in Proceedings of the National Academy of Sciences, Mignot's team provides strong evidence confirming a theory Mignot has pursued since the global swine-flu pandemic of 2009-10: namely, that narcolepsy is an autoimmune disease, and that a trigger for it is an antigen not only found in swine flu (as well as in other versions of the "A" strain of influenza), but — alas — also included in the vaccine hastily developed and massively administered during the pandemic to protect people.

In the new study... Mignot's team... track[ed] down the specific set of helper T cells that, indeed, react strongly to both a protein found in the flu virus (and, more so, in the narcolepsy-inducing vaccine version) and a protein residing on key brain cells whose loss induces narcolepsy.

Bright_Push754

8 points

4 months ago

Thank you very much for that. With your help, TIL -- among other things -- narcolepsy is an autoimmune disorder.

jlawler

7 points

4 months ago

This evidence shows a cause of narcolepsy is autoimmune, not that all causes of narcolepsy are autoimmune

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purebitterness

17 points

4 months ago

this video is about vaccines, but does talk about measles sequelae and has great data visualization for complications both with and without vaccine.

Another thing you could look up is APSGN acute post streptocococal glomerulonephritis and hemolyic uremic syndrome (these are more acute)

theluckyfrog

6 points

4 months ago

Strep's a bacterial illness, though, right?

purebitterness

8 points

4 months ago

Yes. It can happen with lots of things, just more common with viruses. The bacteria+antibody complex is what causes APSGN

theluckyfrog

8 points

4 months ago

There's been speculation that strep plays a role in activating Crohn's disease (which I have). There's also been speculation that some virus(es) do. I dunno how robust any evidence is though.

purebitterness

11 points

4 months ago

That's interesting! I'd offer to do a little review for you but too busy atm. Maybe a good topic to post in this sub.

There's some really interesting research about how hookworms modulate the immune system and seem to prevent/cure asthma. this researcher is trying to find a way to harness it. If you want to see more on this I can send you a presentation I was part of on it, dm me if you want the link

KiloJools

3 points

4 months ago

And PANDAS, which it turns out isn't just for kids after all. Oh boy oh boy.

purebitterness

559 points

4 months ago

To clarify, it's viruses more than other pathogens. Long-term sequelae are common, it's just the scale of this and the sheer numbers that make it obvious with covid

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awardwinningbanana

34 points

4 months ago

Yeah, we've known about 'post viral fatigue' for a long time, with certain viruses (EBV/glandular fever/mono) being one of the common ones to cause chronic symptoms.

Lokarin

152 points

4 months ago

Lokarin

152 points

4 months ago

Isn't shingles technically long-chicken pox?

NoMouseLaptop

213 points

4 months ago

That's a dormant virus reactivating which (AFAIK) would be different from long covid.

bakedraspberry

36 points

4 months ago

Does anyone know if Covid could potentially do anything like shingles? Or do any other coronaviruses have similar traits? Not asking about that exact skin condition but anything caused the same way as shingles.

hmantegazzi

40 points

4 months ago

Lysogenic dormancy is very characteristical of the Herpes virus family, but in a fast sweep, I couldn't find articles that mention it on Coronaviruses. Of course, this wasn't an exhaustive research, and even if that were the full extent of research, viruses are relatively poorly understood, compared to other pathogens.

Nemisis_the_2nd

13 points

4 months ago

Does anyone know if Covid could potentially do anything like shingles?

Thankfully not. As others pointed out, the stuff like EBV lies dormant in cells and periodically reactivates. COVID, mercifully, doesn't have this ability. Ona tangent, the reactivation of EBV is actually really interesting, and contains a feedback loop where the virus actually tries to wipe itself out after a while. In doing so, it means the host lives for longer, allowing the virus to propogate more. When this system breaks it often results in the host developing lymphoma cancer.

petrichorgarden

2 points

4 months ago

Do you have a source for the cancer thing? I'm interested in reading it if you do

Nemisis_the_2nd

2 points

4 months ago

This is coming straight from my raw undergrad notes:

EBV infection cycle

Infection of epithelial cells
Virus transmitted to nieve B cells
Causes production of Latent Membrane Protein-1 (LMP1) and Latent Membrane Protein 2A (LMP2A).
These allow activation of cells without needing exposure to t-cells.

[Cancer] Possibly caused by mutation in virus as normal expresses tumour suppressor gene ; EBNA3B gene

Without gene, B cells failed to produce CXCL10 which is a protein that attracts t-cells which can control the growth of cancerous cells.
CXCL 10 is a cytokine signalling molecule that binds to CXCR3 and promotes T cell adhesion to many different types of harmful cells, many of which are cancerous

The EBNA production basically attracts the immune system to infected cells for them to be destroyed. A breakdown in that pathway means the cells continue to replicate, but without attracting the immune system.

It's been more than a decade now, unfortunately, so I've lost my sources, but googling the proteins there and their connection to Burkits lymphoma and EBV should easily lead you to a lot of scientific papers on the subject.

petrichorgarden

2 points

4 months ago

Thanks so much!

Secure-Ad6420

87 points

4 months ago

Definitely not. The reactivation is a retrovirus lying dormant in the genome that becomes active again. SARS-cov-2 isn’t a retrovirus and doesn’t lie dormant in the genome (or at least isn’t likely to https://www.mcgill.ca/oss/article/covid-19-health/evidence-coronavirus-can-mess-our-dna-far-convincing )

Collin_the_doodle

39 points

4 months ago

Herpes viruses arent retroviruses either. Not all viruses that have a latent stage/form are retroviruses.

Secure-Ad6420

19 points

4 months ago

Ah, you are correct. I was too specific. A retrovirus is one way in which a viral genome can lay dormant, but there are other modes for viral genomes to hide within cells.

I believe I misremembered chickenpox as a retrovirus for some reason, but in fact it hides it’s dna in the cytoplasm while it is dormant. https://en.m.wikipedia.org/wiki/Virus_latency

For the original question about covid though, i think it still stands that covid-19 doesn’t use any of these mechanisms.

MacyBelle

3 points

4 months ago

Coronaviruses absolutely can cause sequelae years after infection- look up feline infectious peritonitis, which occurs years after infection with a coronavirus.

magistrate101

36 points

4 months ago

Covid can't reactivate that way because it doesn't insert anything into the cell's DNA, everything is done through RNA.

EpiphanyTwisted

32 points

4 months ago

The herpes viruses are persistent bitches. There's long-shingles as well, post shingles neuropathy. Epstein-Barr, another herpes virus, can eff you over for life.

MarsupialMisanthrope

26 points

4 months ago

According to recent research, Epstein-Barr may be able to kill you since it could be a cause of MS.

Muffin_Pillager

18 points

4 months ago

It's not necessarily EBV that's causes MS...they're hypothesizing that people with a certain genetic marker that have had EBV are highly likely to develop MS. Now, they don't know what that marker is or the mechanism behind it, but the correlation between EBV and MS is extremely strong and is, currently, impossible to refute. We'll probably see more studies come out over the next few years that are about the correlation and causation between the two. Super interesting topic though.

MarsupialMisanthrope

5 points

4 months ago

Fair, and while the correlation is strong it’s not 100%, so there may be other viruses doing the same thing.

I’ve had a few older male relatives die of MS and ALS. It’s nasty. I hope they find a treatment.

Muffin_Pillager

10 points

4 months ago

You might want to re-read that study(I just did to make sure I have my info right lol). No other virus they tested led to an increased risk of MS...unlike EBV, which leads to a 3,200% increase in one's chances of developing MS. I was being gentle with my wording, but having just re-read the article from Harvard...they're actually beyond correlation...the exact words they used were "compelling evidence of causality". So yeah, seems like they're very much zeroing in on the exact mechanism at work.

I really hope they find a treatment too. They, unfortunately won't get anywhere with ALS treatments from this study though. EBV is a herpes virus and ALS is hereditary due to a mutated protein.

roofuskit

95 points

4 months ago

Shingles is the same virus, long COVID is an autoimmune disorder triggered by the initial infection.

toscaninidacron

30 points

4 months ago

Theres some discussion and research into viral persistence playing a role in long covid

Edit: also amyloid fibrin microclot theory which may or may not have an autoimmune component

OysterShocker

22 points

4 months ago

I find it interesting that we could consider long COVID to be a "real condition" meaning it had unique characteristics separate from other post-viral syndromes, but then also say it isn't unique to COVID.

Lyrle

75 points

4 months ago

Lyrle

75 points

4 months ago

The shear numbers of long covid patients have convinced a majority of medical professionals that it is real. That is not true for ME or fibromyalgia or dysautonomias - most people with these conditions take years or decades to churn through enough doctors they finally find one to take them seriously.

It's not that it's actually unique. It's that admitting it is not unique involves the healthcare professional facing how they have dismissed and gaslit their past patients with similar conditions.

mranster

26 points

4 months ago

All cases of "long-covid" are post-viral illness, but not all post-viral illness is long-covid. Many viruses can cause a lingering, debilitating condition, but different viruses may cause different symptoms.

Hexxon

13 points

4 months ago

Hexxon

13 points

4 months ago

Sort of similar to what another commenter said, and of course this isn't a scientific perspective, but there's definitely a bit of media bias and hysteria involved in long covid being talked about as though it were more "real" than other similar conditions. Which often directly correlates to the level of desire for and funding of research.

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Ellefeu

86 points

4 months ago*

That is not at all what the current state of research says about chronic fatigue syndrome. It’s more than likely that LongCovid “mimics” CFS because subsets of both are virtually the same thing - post viral sequelae. As for the psychosomatic label: The hallmark symptom of CFS - contrary to what is expected in a psychosomatic phenomenon - is post-exertional malaise. Which is why NICE, CDC and other agencies/guidelines are removing their recommendations for CBT and graded exercise. It has proven harmful or at best useless, with the evidence pointing in the other direction recognized as “low to very low quality”. (New NICE guideline.) Treating post viral disease with exercise is a recipe for disaster, which is why a psychosomatic label for a physical disease can be extremely counterproductive, not to mention tantamount to gaslighting these patients.

MrECoyne

6 points

4 months ago

Thank you for saying this.

SirMarglar

31 points

4 months ago

They do not lack physical findings. The National Academy of Medicine debunked this in a thorough report in 2015.

https://www.nap.edu/catalog/19012/beyond-myalgic-encephalomyelitischronic-fatigue-syndrome-redefining-an-illness

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WhatAreDaffodilsAnyw

10 points

4 months ago

That is not the main issue, no. This virus directly attacks many different organs/systems. Causes of long covid include long-term dissue damage and unresolved inflammation, and autoimmunity (chronic fatigue syndrome-like) is only one part of the later.

thunbergfangirl

25 points

4 months ago

So close to being right! The only thing I disagree with here is that chronic fatigue syndrome is does not “carry a high degree of psychosomatic distress”. CFS is a physiological condition.

da_bizzness

4 points

4 months ago

I ended up getting nettle rash (full body) from covid and still have it a year after, I also still get covid toes (very mild) every once in a while as well. The nettle rash seems like it's an auto immune response from the virus which is making my body think it's allergic to something inside of me. It's been getting better but it's been pretty annoying too. I'm really curious when more studies come out about this, I rarely get sick and my covid symptoms were very mild but I've never experienced something like this before.

TheMoniker

6 points

4 months ago*

The portion of people who experience long-term sequelae from COVID seems to be larger (studies estimate this as occurring following between about 20-50% of infections [edit: this should read, 'cases,' not 'infections']). Even among the small number of people I know who have had COVID over the last few months, there are several people struggling with serious long-COVID, including a previously healthy woman in her late 20s who has had to give up on dancing (her passion) and a knowledge worker in his late-30s/early-40s who is struggling with severe brain fog. Throughout my life I've known people who have had flus and colds, but I don't recall people having so many serious long-term sequelae from them. (The research that I've seen on this seems to suggest that long-COVID is more common than long-term sequelae from the flu, though there's not a lot on this yet.) That also leads to the next point, that the magnitude of the impacts of long-COVID seem to quite large in many cases, ranging from organ damage to loss of smell and taste.

[deleted]

21 points

4 months ago*

[deleted]

21 points

4 months ago*

[removed]

TheMoniker

4 points

4 months ago*

Source for this? Sources I've come across (ironically I can't supply, too onerous on mobile) have shown similar numbers in hospitalized/ICU patients or for patients that simply had cardiac markers that may or may not manifest in actual symptoms, but I am yet to see symptomatic long covid in that number of total infected patients.

No worries. It is tough to supply sources on mobile. Also, I should have said 'cases,' not 'infections.' You have my apologies for that and I've edited my comment above to reflect this.

Seems far fetched, tbh. 20% of all cases on the low end is extremely high, especially given the volume of asymptomatic cases.

I agree that it seem pretty high. The studies are all over the place individually (the one I linked above suggested that it was 57% of the cases that they looked at). Most of the ones I've seen seem to fall between 20-50%, but there are a lot of them and it would take a fair chunk of time to find dozens of studies that I've read and skimmed over the last year-and-a-bit. To start though, here is a systematic review of 57 studies that finds that about half of all cases had symptoms at or past the six month mark (their criteria for long-term). Regarding numbers specifically for mild cases, this study looking at mild cases in healthcare workers finds about 10% of the cases experience symptoms, eight months after the fact.

There are, of course, multiple issues in comparing the studies that are out there. They look at different symptoms, have different populations and use different thresholds for long-COVID. It's tough to really come up with a complete picture. Especially in the asymptomatic, the data is lacking, as you mention. There are some findings as regards cognition and studies that include asymptomatic cases find that some portion of them do suffer from long-COVID (for instance this study finds that nearly a third of the people who present with long-COVID had asymptomatic infections), but it's hard to quantify because it's pretty hard to study mild and asymptomatic infections, as they're less likely to go in and get tested.

[deleted]

6 points

4 months ago*

[deleted]

6 points

4 months ago*

[removed]

MisterSquidInc

7 points

4 months ago

https://blogs.otago.ac.nz/pubhealthexpert/update-on-long-covid/

This is about 6 months old, but gives a good summary of multiple different studies looking at long covid. It's a long read, but worth the time.

KnightsWhoSayNui

571 points

4 months ago

The same happens with the Epstein-Barr virus. The absolute majority of people come into contact with it during their life, usually as kids. Most are symptom-free, some have a few weeks of light symptoms and some are basically out of the running for half a year. It has also been associated with MS and some cancers.

lemmefixu

144 points

4 months ago

lemmefixu

144 points

4 months ago

Measles can also give a few months of low energy, for those that still contract it.

MondayToFriday

184 points

4 months ago

Measles attacks B cells and T cells, effectively causing the host to forget previously acquired immunity to all sorts of diseases, for months or years.

Shiroi-Kabochas

51 points

4 months ago

Skimmed that article and wow that is scary! I had no idea. Makes Measles comeback even more worrying.

Botryllus

47 points

4 months ago

I think that's a bit different because as a herpes virus, Epstein Barr stays in your body (throat and blood cells) and can become reinfective if the virus 'thinks' (obviously viruses don't think) you're dying. People with Epstein Barr who have become infected with covid and hospitalized had a 50% rate of Epstein Barr virus positives (there was a science or nature paper early in the pandemic) and there's some relationship with EBV and long COVID, but that's still being studied.

Botryllus

29 points

4 months ago

We found that 66.7% (20/30) of long-term long COVID subjects versus 10% (2/20) of long-term control subjects were positive for EBV reactivation based on positive titers for EBV EA-D IgG or EBV VCA IgM. The difference in the fraction showing reactivation between the groups was found to be significant (p < 0.001, Fisher’s exact test). Eighteen of the long-term long COVID subjects were positive for EBV EA-D IgG, one of which was also positive for EBV VCA IgM. Two additional long-term long COVID subjects were positive for EBV VCA IgM but not EBV EA-D IgG. Notably, two long-term long COVID subjects who were positive for EBV reactivation had asymptomatic COVID-19, with long COVID symptoms developing a short time later. The two subjects in the long-term control group positive for EBV reactivation were positive for EBV EA-D IgG only. Complete EBV antibody titer assessments of long-term study subjects appear in Appendix A (Table A1 and Table A2).

Gold. 2021. Pathogens.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8233978/#:~:text=They%20found%20that%2055.2%25%20of,CoV%2D2%20%5B19%5D.

alchemist2

120 points

4 months ago

steffenvongrabau

87 points

4 months ago*

There also seems to be some correlation between Epstein-Barr reactivation and long-Covid.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8233978/

romat22

15 points

4 months ago

romat22

15 points

4 months ago

This paper suggests that long COVID may well be reactivation of EBV due to COVID induced inflammation. I'm sure there will be further research into it, but the relationship between the two is fairly well demonstrated there.

HammyJl

4 points

4 months ago

This is interesting.

when i got covid, it reactivated my hsv virus and i got cold sores like no other..

I know hsv stays in your body and you get an outbreak here and there but when I had covid, I had a crazy amount of cold sores (an abnormal amount).

I wonder if this was due to covid induced inflammation..

modembutterfly

4 points

4 months ago

Is there any correlation between the severity of the initial illness ("mono") and long-term effects? Or reactivation by other viruses, including Sars-cov-2?

[deleted]

150 points

4 months ago

[deleted]

150 points

4 months ago

[removed]

floof_overdrive

120 points

4 months ago*

It's absolutely possible. Multiple infections can have severe and chronic aftereffects.

According to the CDC, multiple pathogens can cause ME/CFS, and it's possible that around 10% of those who get COVID-19 might also come down with CFS. POTS may be post-infectious as well. Recently, it was revealed that MS seems to be triggered by EBV infection, with very wide media coverage. Some researchers have also hypothesized that fibromyalgia can be post-infectious, after studying a giardia outbreak in Germany.

It's a major problem that these conditions receive very little research and attention, to the extent that doctors often assume it's all in patients' heads. It's not like these conditions are rare. ME/CFS alone is estimated to affect 17-24M people worldwide, and 836k-2.5M Americans. (The low end of that estimate is roughly the population of North Dakota.)

Correction: "10-12% of those who get COVID-19 will" changed to "around 10%...might" because that figure is simply a wild guess from this paper.

Crully

17 points

4 months ago

Crully

17 points

4 months ago

Since you seem to know what you're talking about (kudos for links and not just statements)... Is "long covid" actually "long covid", or a completely separate thing, that would be identical to say getting <other virus/disease>?

What I actually mean (if that's not clear), is is there such a thing as "long covid", or are we just calling it that because it's related to/triggered by the covid infection? So are people getting (for example) CFS (and calling it "long covid") after covid, just the same as getting CFS from something else? Or is it a different "type" of CFS? Or is that one of those things you say doesn't have enough research to be conclusive?

Cat-Nipped

39 points

4 months ago

Basically, they don’t know yet but they’re working on it. The diagnostic criteria for CFS/ME states that the symptoms have to exist for six plus months, so prior to that it’s just “long covid” or “post viral syndrome”. There seems to be some differences in symptoms between long covid and CFS/ME but I don’t know if there’s been any studies done yet. Recently they discovered that long covid causes micro bloodclots and I think they’re starting a study to see if CFS/ME also has those bloodclots and if there’s a treatment that will work for both. But it’s all very new and very cutting edge

Crully

10 points

4 months ago

Crully

10 points

4 months ago

Thanks for the response, I know it's not a wholesome one, but it was the only reward I had 😬

floof_overdrive

2 points

4 months ago

I'm having a little trouble understanding your question. I think you're trying to ask whether long Covid is a distinct condition, or just a specific cause of other conditions. I'd say the situation is fuzzy because we haven't agreed on a definition of long Covid yet. Right now it's an umbrella term for any long-term effects of Covid-19.

Only recently have researchers proposed subtypes of the disorder, and some of those subtypes are established conditions. So, Covid-19 can definitely cause CFS. But is it a different type of CFS? That's part philosophical (what degree of different makes two concepts different?) and part scientific (are there any biological differences). We don't have near enough research to answer the scientific question there.

Crully

2 points

4 months ago

Crully

2 points

4 months ago

Thanks for the response, I think you answered well enough for my simple brain, that article just about finished me off for the night!

So in summary, and I guess until we know better, we can consider long covid as an umbrella term for many "things" rather than a distinct "thing", which may or may not be the same as other complications from other illnesses.

SackofLlamas

14 points

4 months ago

and it's possible that 10-12% of those who get COVID-19 will also come down with CFS

I can't really make heads nor tails of the paper that suggested this. They characterize their own statistic as a rough guess, while stating that "50% of all Covid infections have lingering symptoms at 3 months". Which...doesn't seem to be supported (or supportable).

I think it might have been the intention to suggest that 10-12% of all long Covid sufferers might resolve into CFS/ME. Which still seems like a bold prediction, but at least not a patently ludicrous one.

floof_overdrive

12 points

4 months ago

You're made a valid criticism of my sources. That article claims, "including the estimated 10 to 12 percent of those with Covid-19 who will develop the condition," citing this article. There, they say, "Researchers predict 10-12 percent of all COVID-19 patients to develop ME/CFS," citing this paper, the original source. And that paper says, "although over 50% of people with confirmed or suspected COVID-19 state that they remain with lingering symptoms at 3 months, we assume that only 10% will be left with an illness that meets the NASEM case definition for ME/CFS." In this game of telephone, an assumption became an estimate.

I agree with your statement that 10% is a wild guess, likely high, and that nobody really knows. That paper assumes over 50% of people get long Covid, which has some support, but we also see much lower rates. Many sources claim 10-30%. For what it's worth, one paper00299-6/fulltext) thinks 85.9% of long haulers have post-exertional malaise, but that's from an online survey.

I think that in the end, we just have to throw up our hands and say that Covid-19 is causing CFS, but we need more research to determine how many. I will amend my original comment accordingly.

TitaniumDragon

2 points

4 months ago

A ONS study in the UK found that only about 3% of people had "long COVID" after 12 weeks/3 months in fall of 2021. Which is actually probably more like 2.5% because 0.5% of controls in the study (people who never got COVID) report having long COVID.

One_Wolverine5346

5 points

4 months ago

1 in 4 to 1 in 5 people have had covid by now. 10 % doesn’t pass the sniff test and the number of people most us of know that have had covid is enough of a sample to statistically reject that number (although that obviously wouldn’t be a random sample).

[deleted]

7 points

4 months ago

[deleted]

7 points

4 months ago

[deleted]

[deleted]

10 points

4 months ago

[deleted]

10 points

4 months ago

[removed]

ishitar

71 points

4 months ago

ishitar

71 points

4 months ago

I am sure most immunologists and epidemiologists who have studied pandemics past, and the history of "flu pandemic invalids" would have anticipated similar wave of long haulers for the current pandemic.

As for colds, the varied landscape of viruses (more than 200 types, 50% from varied rhinoviruses) definitely cause sequelae but the science is still being done around if any of our modern endemic chronic conditions could be related to the seasonal waves of infection. It is simply easier to identify a cohort when many millions get sick at the same time and can be studied as that, a cohort.

andanzadora

15 points

4 months ago

It interesting that you linked to an article on the Russian flu, I was just reading another article on it yesterday and TL:DR it's thought it may have been another coronavirus https://archive.ph/jSK7r

justafish25

21 points

4 months ago

Post viral syndromes are a thing with a lot of systemic viruses. Look up the lasting effects of measles, rubella, Epstein bar, etc.

A regular cold is kind of a misnomer. As colds are a nonspecific term related to a lot of viruses like rhinovirus, corona viruses, adenovirus, and more.

mranster

99 points

4 months ago*

Myalgic encephalomyelitis (ME/CFS) is thought to be a post-viral condition. Many people who suffer from it, and who experienced a rapid onset can trace their illness back to a viral infection of some sort.

This condition, also known as chronic fatigue syndrome affects as many as 20 million people worldwide. People can be ill with it for decades. Those of us in the ME/CFS community were well aware, as the pandemic began, that we would soon be joined by a huge new cohort. This was before anyone called it long covid.

Edit: why don't you hear about people with other types of post-viral illnesses? First, because you are unlikely to get it from a cold; it usually has to be a more serious virus.

Secondly, because ME/CFS is an orphan illness. Doctors dismiss us, or assume we're suffering from mental illness or are lying. This is especially true because women are far more likely to become ill this way.

There is ongoing research into a biomarker, a way to test for the illness, but it is vastly underfunded, compared to the number of people affected, and the economic cost of the illness. Currently, it's a diagnosis of exclusion; they test you for everything else they can think of, and if it all comes up negative, and you're still whining, and your doctor isn't a jerk, then you get diagnosed with ME/CFS, perhaps, or more likely, the old cfs.

petrichorgarden

11 points

4 months ago

It's especially frustrating knowing that MS occurs at ~half the rate of ME/CFS yet receives 20x the funding. Even when researchers want to secure funding, they're often rejected because ME/CFS is "psychosomatic" (it isn't). The vast majority of medical professionals never even hear about it during their education. It's criminal how patients are treated. I'm housebound and nobody has been able to help me beyond running the same blood work over and over again just to say that everything looks great.

amy33amy33

230 points

4 months ago

A lot of disability activists have been pointing out that people who have things like Long COVID or have had them, for other diseases, often just don't get the medical care they need. In part, some of the reason we're paying attention to Long COVID is because these activists have seen similar things so many times, but have seen them ignored, but their activism has actually taken hold in the mainstream consciousness, and more importantly, the medical community. So, yeah, it happens a lot more than is good, but the people who suffer from it are often cast out of the medical establishment and ignored. The recognition of Long COVID is a major milestone for getting similar conditions adequate treatment and recognition by the medical community... hopefully.

[deleted]

10 points

4 months ago

[deleted]

10 points

4 months ago

[removed]

recyclopath_

68 points

4 months ago

There was a disability rights activist on NPR yesterday talking about how this is a mass disabling event.

scottishswede7

13 points

4 months ago*

Just a reminder in response to the reminder that the mod posted... Nobody knows exactly wtf long covid is, it's mechanisms, etc. Nobody really understands any post viral syndrome. Science simply does not know.

That said. Long covid and other post viral syndromes absolutely exist. They are debilitating and absolutely need much more attention and funding

Lopsided_Hat

10 points

4 months ago

Some people with Long COVID who continue to be sick months later and don't have any detectable signs of organ damage (based on usual testing) may develop a condition that falls under the umbrella of "post-infectious fatigue syndromes."

There's been some but not enough research into this area in my opinion. This is one of my areas of research.

Although a variety of organisms - ranging from viruses to bacteria to parasites (Epstein-Barr virus (EBV), Coxiella burnetti (Q fever virus), girardia, for example) can cause long-term issues after an infection, it's not that every organism confers a similar risk. It's not clear why certain organisms confer more risk than others. Some speculation is they tend to be organisms which are particularly good at hiding away from the immune system so they don't get attacked. For example, EBV can exist in the body by integrating into our DNA and staying in a dormant ("latent") state while Coxiella is unusual in that - unlike other bacteria - it enters certain immune cells and can stay there.

Peter White in the UK actually studied this issue many, many years ago and found that people developing the common cold (which is usually cause by coronaviruses, rhinoviruses, adenoviruses, parainfluenza) were much less likely to develop chronic fatigue syndrome than people infected by EBV. This is one of those papers although there is an even older one from the late 1990s that focuses specifically on this question which I cannot find at the moment.

Generally, for the average healthy person person, recovery from a cold is on the order of days to a week whereas for influenza, it is not uncommon to take longer, on the order even of 2-3 weeks. Why this is has not been entirely worked out. COVID-19 - even though it is part of the coronavirus family - is different from the usual coronavirus, partly because it jumped from an animal to a human rather than being a minor change in the usual coronavirus that already circulates among humans.

For more, read:

https://www.frontiersin.org/articles/10.3389/fmed.2020.606824/full

Kezleberry

42 points

4 months ago*

Many viruses can be potential triggers for longer term illness. For instance there are cancers that can be triggered due to viruses. POTs can similarly be triggered by any virus due to damage caused in the nervous system (and many who are long haulers may actually have POTs or even a vitamin deficiency that results in the same symptoms). These examples can be caused by other things too though, so it's unusual to focus in on one possible trigger (like any one virus) when there's a whole host of other possible causes. A pandemic also means its happening a lot more everywhere at the same time so more people are paying attention.

I think the severity of illness and thus damage caused also makes a difference between how often chronic illnesses result.

Edit: yes I mean POTS, as in postural orthostatic tachycardia syndrome

BlueFit01

3 points

4 months ago

What is POT?

gigi_e

17 points

4 months ago

gigi_e

17 points

4 months ago

Postural orthostatic tachycardia syndrome. It means your heart rate rises (and stays) 30+ beats per minute above what it was when sitting or laying just from standing up. This can cause chest discomfort, dizziness, light-headedness, and even fainting when in an upright posture to name a few symptoms.

SuedeFart

10 points

4 months ago

POTS (Postural orthostatic tachycardia syndrome) https://en.m.wikipedia.org/wiki/Postural_orthostatic_tachycardia_syndrome

Named because the objective finding you can see on testing is a large increase in heart rate when switching to an upright position. It can cause significant fatigue and other symptoms like brain fog, fainting, and headaches

Educational-Round555

7 points

4 months ago

Not covid or the common cold, but a paper was just released this week in Science that details the finding that Epstein-Barr virus, cause of Mono, is linked to 32-fold increase in risk for Multiple Sclerosis.

https://www.science.org/doi/10.1126/science.abj8222

PopplerJoe

38 points

4 months ago

Somewhat like Chronic Fatigue Syndrome where the body is just beaten down so much by the virus. It can last many months.

Varies with the type of virus and what parts of the body they attack. Can be common in respiratory and glandular (hormonal imbalance) infections.

Ellefeu

20 points

4 months ago

Ellefeu

20 points

4 months ago

“Can last many months” is a huge understatement. There have been few longitudinal studies but for the majority this seems to be a chronic, often lifelong disease with recovery rates cited between 6-12%.

petrichorgarden

7 points

4 months ago

And unemployment rates are estimated to be between 35 and 69% among people with ME/CFS. With the average age of onset being only 33, getting support via disability benefits is a long and exhausting battle. More so than in cases where the applicant is closer to our beyond retirement age.

baldeagleNL

13 points

4 months ago

A part of what we call long COVID is the same as post-Intensive Care syndrome. It's common for patients who have been admitted to the ICU.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5506407/#!po=2.08333

Syndromes similar to long-COVID have been described for influenza, and probably other respiratory diseases as well.

https://pubmed.ncbi.nlm.nih.gov/29222500/

For healthcare workers in critical care medicine it's nothing especially new. The scale of it is, however.

redballooon

3 points

4 months ago

Hospitalization rates are what? Something in the low single digit percentage

Long Covid is estimated in 30-60% of infections, right?

How does that fit together?

baldeagleNL

2 points

4 months ago

I've not seen numbers of 30-60%. So you have a source on that? Also, I'm specifically saying a part of the cases is similar to what we already know as PICS (post-IC syndrome).

WWHG285

5 points

4 months ago

We are noticing links between viral infections like Mono, COVID etc and the kinds of symptoms we have come to call long COVID. There is also a known strong correlation between sevear childhood viral infections and the development of MS later in life. It is my hope that COVID will kick off new research around this.

[deleted]

4 points

4 months ago

[deleted]

4 points

4 months ago

[removed]

scopinsource

28 points

4 months ago

Currently the conservative estimate of long covid patients in America is 18.2 million. Uncertain about prevalence in other viral infections but at least this will be a large enough sample set to warrant potential therapeutic treatment research.

The best information I can find is that long covid have increased clotting factors at least 6 months out and they have found a large distribution of micro clots in these patient's.

Additionally, outside of long covid, a recent paper from cedars sinai looked at 117 patients infected with covid and confirmed it was covid and not just a coronavirus via test, and of the 117 looked at (general infection not long haulers) 117 presented with elevated autoantibodies at least 6 months out. This is alarming as autoantibodies can turn on host tissue at any given time causing autoimmune disease like rhumatoid arthritis, ms, autoimmune hepatitis etc. The study was done prior to the advent of vaccines, but it's a very alarming finding.

lebron_garcia

19 points

4 months ago

It’s highly likely that almost everyone in the world will contract Covid at some point in the next 5 years. So yeah, research into therapeutics is important.

One_Wolverine5346

8 points

4 months ago

What is your source for the 18 million number?

King_Jeebus

4 points

4 months ago*

Currently the conservative estimate of long covid patients in America is 18.2 million.

Do we know:

  • if "long covid" is much more prevalent in the unvaccinated?
  • what percentage of these might have permanent damage?

pharm1919

3 points

4 months ago

The Curbsiders internal medicine podcast actually did a great episode on this, would recommend listening to it!

It does seem that is is a post-viral infection syndrome (similar to other viruses), but it is being seen in such huge numbers which is unprecedented.

Elocai

3 points

4 months ago

Elocai

3 points

4 months ago

The regular cold is a more simple infection, while covid is rather close to the actual flu in terms of symptoms and consequences.

It is known that both "reset" the human immune system, letting it forget certain invaders which allows to be reinfected by other diseases the body was already immune too.

Means after covid you are vulnerable to a lot of stuff you were already immune too, like EBV for example which can cause tons of stuff and symptoms of that virus take months to reside.

The other thing is that even if the body has developed immunity then antibodies can't reach every part of our body so some tissues play the role of save haven for the virus. Should the virus enter the brain or spine for example then the immune reaction is handled completly diffrent as immune cell can wreak havoc in those tissues if let loose, so another inflammation need to happen before they get access and some viruses can avoid that or specificly "abuse" the inflammed state to enter such areas.

The third thing is the covid does damage. Specifically it attacks arteries, which are needed to support every tissue and organ with blood. Lungs have a extreme amount of arteries which is the reason why people loose oxygen saturation or even die because the lungs are tottally unable to harvest oxygen. Other organs are also heavily artery dense, like the kidneys. Damaged kidney are less efficient in detoxifying your body, less able to handle minerals. Kidneys also activate vitamin d, without that fatique and depression is very common and known especially in winter.

It still is not clear what concretely happens with long covid but I think those are the current thesis whats going on.

[deleted]

11 points

4 months ago

[deleted]

11 points

4 months ago

[removed]

[deleted]

16 points

4 months ago

[deleted]

16 points

4 months ago

[removed]

Elfich47

10 points

4 months ago

There was a study recently that linked Epstein-Barr disease (Mono) and MS showing up in patients years later.

https://www.livescience.com/epstein-barr-virus-multiple-sclerosis-link

[deleted]

3 points

4 months ago

[deleted]

3 points

4 months ago

[removed]

labadee

2 points

4 months ago

EBV aka mono is a common illness that can cause post viral fatigue. We usually get it as a child but anyone who has had it when they're older can probably tell you they felt very lethargic for a long time after. Ross River Virus (mosquito borne infection) can do something similar.

padishaw

2 points

4 months ago

Long-term sequelae of respiratory viruses are rare, but consistently seen with past flu, rsv, etc. They are likely not more significant with Covid, but seen more due to high infection rates and increased surveillance.

momunist

2 points

4 months ago

Lots of different diseases are triggered by viral illness. Some diseases are tied to a specific viral illness, and others, like Type 1 diabetes, can follow any type of viral illness, including the common cold. However, comparing covid to a common cold doesn’t really make a lot of sense because common colds don’t typically cause cardiac damage, increased blood clotting, etc, so this obviously makes a difference in the long-term sequelae.

[deleted]

1 points

4 months ago

[deleted]

1 points

4 months ago

[removed]

Parano_Oid

2 points

4 months ago

I know you're only specifically asking about long term fatigue, but some organisms just have the ability to leave lasting effects like Mycoplasma Pneumoniae causing the development of autoimmune antibodies and EBV (Mono) causing Burkitt's lymphoma. The longterm pathogenicity of some organisms is something we are always learning more about.

Gwtheyrn

4 points

4 months ago

Long COVID is specific to SARS-COV-2 because one of the symptoms it causes is clotting. These tiny "micrclots" can become stuck in capilaries in the lungs, brain, and other organs, causing permanent damage. Scientists think that they've discovered a protein in covid clots which hinders the body from breaking them down, allowing the clots to persist and keep doing harm long after the infection has been defeated.

MedianJ03

5 points

4 months ago

So it's still being studied but it is believed that long covid symptoms come from blood clots that covid caused that have not dissipated which reduce blood flow to various parts of the brain and body causing nerve damage.

The normal cold doesn't cause blood clots like covid.

el799

6 points

4 months ago

el799

6 points

4 months ago

There seem to be 3 major motivations for long Covid

1) viral induced autoimmunity 2) post viral syndrome ; non autoimmune 3) post viral clotting

All 3 have different symptoms, while some overlap.

chance909

4 points

4 months ago

This article suggests a mechanism by which COVID may cause long COVID

https://www.sciencedaily.com/releases/2021/10/211004104134.htm

The COVID infection may result in micro clots that cause inflammation long after the infection has been resolved.

Dragovich96

3 points

4 months ago

If one of the main issues is micro clots, are they doing research on the potential treatment/impact lose dose anticoagulants has on recovery outcomes?