Case Conference Summaries

UT Health Austin’s Post-COVID-19 Program aims to create an educational community in which healthcare professionals can come together to learn more about post-acute sequelae of COVID-19 (PASC) infection, an increasingly recognized syndrome in which patients continue to experience symptoms of COVID-19 months after initial infection.

The Dell Medical School at The University of Texas at Austin is hosting a case conference series known as the Austin PASC Collaborative during which community healthcare professionals can present cases to and receive feedback on diagnosis, management, and the emerging science of PASC from an expert panel consisting of specialists across internal medicine, neurology, pulmonology, and rheumatology as well as behavioral and mental health. See below for a list of case summaries presented at past conferences hosted through the Post-COVID-19 Program.

June 3, 2021

Written June 11, 2021 by: Faith Noah, MS4, Matthew Seghers, MS4, and W. Michael Brode, MD

Expert Panel: Esther Melamed, MD, Michael Shapiro, MD, George Rodgers, MD, Kevin Hackshaw, MD, Robin Hilsabeck, PhD, ABPP, David Ring, MD, PhD, Christopher Garrison, MD, Arlyn Thobaben, DPT, OCS

Summary

44-year-old man with history of ocular migraines presenting with anosmia and worsening anxiety after COVID-19. Patient was diagnosed with COVID-19 in June 2020 after presumed work exposure as a first responder, initial symptoms were headache and anosmia without respiratory symptoms and he recovered at home. He presents to workers compensation clinic with short-term memory difficulties and headaches. He had seen a neurologist noted a normal neuro exam and recommended a trial of mirtazapine, but patient was hesitant given stigma of mental illness at his job.

  • His labs show a normal CBC, CMP, CRP, TSH, vitamin B12, zinc, iron studies, homocysteine, folic acid, and methylmalonic acid. ANA with reflex panel was negative.
  • Total and free testosterone were also normal, Vitamin D level 25.
  • Imaging: MRI - minimal nonspecific white matter disease. EEG - normal.
  • Psychiatric screenings: MMSE 29/30, PHQ-9 (score 7 out of 27), GAD-7 (score 7 out of 21).
  • Current medications: Sildenafil. Testosterone. Nicotine patch 28 mg/day. Vitamin B12. Vitamin D. Fish oil. Mirtazapine (patient declines to start).

Teaching Points From Expert Panel

Headaches are common in patients with PASC and may be managed similarly to headaches in the primary care setting. No specific headache phenotype has been described in PASC, although patients have reported new daily persistent headaches and concomitant tinnitus.

  • Evaluation should focus on classifying the most similar headache type (migraine, cluster, tension, drug-related headache) and treating with existing evidence-based therapeutics for the type.
  • Many patients with PASC report difficulties with sleep which can exacerbate headaches, and primary care providers should screen for sleep hygiene issues.

PASC patients are at high risk for PTSD, providers may incorporate evidence-based psychiatric screenings including the PHQ9, GAD-7, and PC-PTSD-5. Patients who screen positive may be considered for treatment with psychotherapy and/or referral to psychiatry.

As individuals return to work, there is increasing understanding that some occupations may place employees at greater risk of acquiring COVID-19. Consequently, individuals may seek care for PASC under a worker’s compensation claim, which poses distinct challenges to the treatment process.

  • Providers should be prepared to assist patients in the claims process, as some employers may require documentation of pathologic sequelae of COVID-19 to cover treatment. The CDC recommends using the ICD-10 code B94.8 or B94.9 (Sequelae of unspecified infectious and parasitic disease), although a specific code for PASC is expected to be forthcoming.
  • Treatment of comorbid psychiatric disorders including anxiety and depression presents a challenge under worker’s compensation, as some patients may prefer not to disclose psychiatric diagnoses to employers through worker’s compensation.
  • For patients seeking treatment under worker’s compensation, early documentation of functional status and capacity to return to work is important to the claims process.

Physical therapy can play an important role in neurocognitive complaints in PASC, especially with a complaint of headache, and primary care providers should consider referral for a full evaluation of functional status.

Written June 11, 2021 by: Faith Noah, MS4, Matthew Seghers, MS4, and W. Michael Brode, MD

Expert Panel: Esther Melamed, MD, Michael Shapiro, MD, George Rodgers, MD, Kevin Hackshaw, MD, Robin Hilsabeck, PhD, ABPP, David Ring, MD, PhD, Christopher Garrison, MD, Arlyn Thobaben, DPT, OCS

Summary

69-year-old man with a history of chronic lower back pain and obesity hospitalized for 10 days with COVID-19. He presented to the ER in November 2020 with fatigue, malaise, fever, and was admitted for hypoxemia. He received 5 days of remdesivir and 10 days of dexamethasone during admission. He experienced a 20 lb. weight loss during his hospital stay and was discharged on oxygen which he required through January 2021. He began experiencing poor recall and memory during this hospitalization, which progressively worsened in the following months. In February, he experienced severe, unprovoked spastic lower back pain.

  • Prior to his illness, medications included omeprazole 40mg, and testosterone cypionate 100mg/ml IM.
  • Prior medical conditions included GERD, bronchitis, spinal surgery with chronic back pain, hypotestosteronism, and obesity. He has a 20-pack year tobacco history, quitting >10 years ago.

He presented in late February to his primary care office for “brain fog,” shortness of breath, and severe fatigue. Physical exam was unremarkable at this visit. There was a small pleural effusion at the base of the left lung found on POCUS.

  • Labs from his initial visit showed normal CBC, CMP, ESR, TSH, Free T4, and Creatinine. He had a mildly elevated CPK and ALT.
  • Imaging ordered includes L-spine series and CPAP monitoring by ENT, referred due to obese body habitus. He was diagnosed with sleep apnea and began treatment.
  • Referred to PT for back pain, with significant improvement.

In April, he noted improvement of shortness of breath, but not yet returned to baseline, and persistent “brain fog” despite better sleep hygiene. Physical exam was normal and peripheral SpO2 was normal.

Teaching Points From Expert Panel

The experience of clinicians in the panel is that neurocognitive symptoms do not improve with treatment of sleep apnea by CPAP, despite the improvement in fatigue with treatment.

Exudative effusions have been documented in the literature as likely related to COVID-19 infection, confirmed effusions should be worked up with thoracentesis with strong consideration to refer to a pulmonologist.

There is no single test for evaluation of “brain fog,” but the Montreal Cognitive Assessment (MoCA) could prove useful in older patients, although this may not pick up subtle deficits in younger patients. Patients should also be evaluated for comorbid mental health issues (PTSD, anxiety, depression), especially since energy deficits and concentration difficulties are included in diagnostic criteria for depression (the 9 criteria can be remembered with the SIGECAPS mnemonic).

SNRIs (duloxetine, venlafaxine) or TCAs that target norepinephrine reuptake (preferably nortriptyline) can be used treat chronic fatigue syndrome, coupled with graduated exercise. SSRIs can be used in case of comorbid depression, with agents like fluoxetine or bupropion having a more energizing effect (whereas paroxetine and citalopram can be more sedating).

  • The expert panel recommends nortriptyline as the “go to” agent for a therapeutic trial for chronic fatigue or symptoms resembling fibromyalgia. The consensus was that stimulant medications (e.g., modafinil, dextroamphetamine) should only be used in refractory cases after trialing TCAs or SNRIs/SSRIs and patient has not improved with PT or graduated exercise.

Neurocognitive Functioning Post-COVID-19

Key Teaching Points from Robin C. Hilsabeck, PhD, ABPP, Director of UT Health Austin’s Comprehensive Memory Center

  • Please see Neurocognitive Dysfunction and “Brain Fog” for a detailed description of workup and treatment, this will be updated to reflect the key teaching points from Dr. Hilsabeck here.
  • “Brian fog” is a subjective complaint of trouble focusing, forming thoughts, thinking clearly, and remembering. It is presenting in approximately 2/3 of patients with PASC symptoms and is correlated with the degree of fatigue, isolation, depression, acute stress, and sleep deprivation.
  • Most patients perform well on neurocognitive testing, except in patients who had prolonged hospitalization with neurological complications (and are more similar to post-ICU syndrome). For the small proportion of patients who had mild to moderate disease and have persistent deficits, they are primarily in attention and working memory.
  • Therapy consists primarily of psychoeducation (reassurance in many cases), promotion of healthy lifestyle, and cognitive rehab/training. Mental health screening and psychotherapy are recommended to treat comorbid mood disorders.
  • There are no specific tests for “brain fog,” existing dementia screenings like MoCA are most useful in older adults but will not pick up subtle deficits. Subtle deficits can best be elicited by assessing impact of cognitive difficulties on ability to perform usual activities.

May 6, 2021

Written May 16, 2021 by: Matthew Seghers, MS3, Faith Noah, MS3, and W. Michael Brode, MD

Expert Panel: Esther Melamed, MD, Michael Shapiro, MD, Robin Hilsabeck, PhD, ABPP, David Ring, MD, PhD, Christopher Garrison, MD, Arlyn Thobaben, DPT, OCS

Summary

34-year-old man with no past medical history who had mild COVID-19 in December 2020 and recovered at home. He was then hospitalized January 2021 with presumed Guillain-Barré Syndrome and treated with corticosteroids.

  • Following discharge, he presented to his PCP with persistent fatigue, malaise, tinnitus, brain fog, and exercise intolerance. Prior to his COVID-19 infection, his baseline labs were normal at an annual physical. Medications include only over the counter antihistamines for seasonal allergies. Prior to illness, he was very active, and had no history of tobacco, alcohol, or illicit drug use.
  • His labs show a mild normocytic anemia. During hospitalization, his ferritin was elevated and LFTs were 4x upper limit of normal, but both have now normalized 2 months post-hospitalization. He has an ANA positive at 1:160 titer, but the reflex panel was negative.
  • On imaging, MRI brain was normal as part of a workup for “brain fog”, and TTE and EKG were normal to evaluate his fatigue and exertional malaise.

Teaching Points From Expert Panel

Brain fog is a persistent cognitive symptom of PASC, and while screening tools such as the MoCA or MoCA-blind are helpful at detecting/diagnosing a gross cognitive impairment, they may not detect more subtle findings. Physicians should consider checking reaction time and testing individuals’ ability to process information quickly (although no standardized tool for primary care use is widely available).

  • Questions to ask on history for brain fog evaluation to identify more subtle deficits should focus on functional limitations, including: whether patients are able to work, whether they are making mistakes at work, whether others are noticing any deficits.
  • If the evaluation is indeterminate, and patients have persistent and debilitating cognitive symptoms that affects their daily functional abilities, full neuropsychological evaluation may be warranted.

Positive autoantibodies have been commonly identified in PASC patients, but it is unclear whether it represents a true autoimmune condition or post-infectious inflammation. Antibody panels should be ordered based on the presenting symptom and how common the autoimmune syndrome is (ANA with reflex panel is very reasonable). Antiphospholipid antibodies should be checked as some reports have found 50% positive in post-COVID-19 patients. Once again, the clinical significance is unclear, but will informed shared decision making about anticoagulation or antiplatelet therapy.

Patients in rehab may have both functional and psychosocial components to the limitations they are facing, and rehab should include a graded program with functional milestones, but also confidence building. Physical therapy is an excellent starting point to diagnose or problem solve these issues for patients with fatigue or deconditioning.

  • Pulmonary rehabilitation is excellent, goal-directed and evidence-based. Unfortunately, it requires specific pulmonary diagnoses and/or PFT abnormalities for insurance to cover, so it will only be available to PASC patients in very specific cases.

Written May 16, 2021 by: Matthew Seghers, MS3, Faith Noah, MS3, and W. Michael Brode, MD

Expert Panel: Esther Melamed, MD, Michael Shapiro, MD, Robin Hilsabeck, PhD, ABPP, David Ring, MD, PhD, Christopher Garrison, MD, Arlyn Thobaben, DPT, OCS

Summary

45-year-old man with a history of type 2 diabetes and obesity who was hospitalized with COVID-19 pneumonia in June of 2020. His hospital course was complicated by severe ARDS requiring prolonged mechanical ventilation and a tracheostomy. He received dexamethasone, convalescent plasma, remdesivir, and antibiotics before being discharged to a LTAC in August, with tracheostomy removal in October of 2020.

  • Prior to his illness, his medications included lisinopril and carvedilol. He had no history of drug, alcohol, or tobacco use.

He presented to his primary care clinic with PASC-related symptoms in November, noting a persistent dry cough, dyspnea, and new right foot drop with peripheral weakness. Throughout the proceeding months, dextromethorphan cough syrup, albuterol inhalers, and Tessalon Perles have not alleviated his cough, and he has also endorsed symptoms of orthopnea and persistent chest pain.

  • Labs from monthly follow-up visits revealed a normal CBC, BMP, BNP, and D-dimer. His CXR, TTE, and EKG were also normal, with PFTs and an EMG for the foot drop still pending.

Teaching Points From Expert Panel

For PASC patients presenting with dyspnea, pulmonary diagnostics should be limited to a CXR on the initial visit. If dyspnea persists, pulmonary function tests should be pursued in addition to baseline labs outlined in the algorithm below.

  • If the workup is normal and dyspnea or cough persist, check oxygen saturation at rest and upon ambulation in clinic. Hypoxemia even with normal CXR and PFTs merits referral to pulmonology.
  • If PFTs are normal, a trial of empiric corticosteroids is NOT recommended as it will likely have little benefit. Ruling out other causes of chronic cough (upper airway cough syndrome from allergies, GERD, etc) is recommended and continuing symptomatic treatment with OTC cough medications.
  • The utility of ordering D-dimer as a screening test In the outpatient setting is uncertain, but reasonable to many experts. Although much of the morbidity/mortality from acute COVID-19 illness is from diffuse microthrombosis and rates of VTE in the ICU are estimated at 24%, for patients with mild disease or who have recovered from acute illness, the preliminary literature suggests rates of VTE are similar to that of the general population (~0.5%).

The etiology of dyspnea in the PASC setting can be multi-factorial. For this patient, in particular:

  • Anxiety could lead to dyspnea and palpitations, especially after coping with a life-threatening hospitalization.
  • For patients who underwent tracheostomies, granulation tissue could lead to mild obstruction, which could be diagnosed by PFTs.
  • Obesity could lead to increased dyspnea in this patient, and providers should consider evaluating for sleep apnea or obesity hypoventilation syndrome.
  • Recovering from a long period of ventilation could lead to overall deconditioning, presenting as weakness in this patient. Although unilateral foot drop is likely from a peripheral nerve, may also consider critical illness myopathy (proximal weakness) or neuropathy (distal weakness) if symptoms are symmetric.
Dyspnea Workup PASC