Long Covid

 Long Covid

PKGhatak, MD

Long covid is a new disease. The precise definition of Long covid is lacking. A cornucopia of symptoms lasting for weeks to 18 months or more experienced by people who had a covid illness and recovered are thought to be the sequel to covid infection and named Long Covid.

There is no reliable way to determine the percentage of the world population developed Covid-19. In January 2022 one estimated the rate was 57 %, another source reported it was over 75% in January 2022 (6+ billion out of 8 billion).

The vast majority of covid-19 illness produces symptoms that are very similar to the Common cold and symptoms last only 3 to 5 days. The number of seriously ill patients worldwide will remain unknown because the variable of public health standards prevails in the vast number of developing countries and local politics prevented notification.

Who developed Long Covid.

The wide spectrum of people with mild symptoms or no symptoms but who had a positive PCR test to more seriously ill patients with a variety of symptoms are considered to have Long Covid. Even those who were fully vaccinated and boosted contact with the virus also report long lasting symptoms. It appears severity of symptoms is not a factor in acquiring Long Covid. It is estimated that 35 to 20 % of patients who recovered from covid-19 infection developed Long Covid.

What are the symptoms of Long Covid.

General. Loss of weight. Lethargy. Palpitations, Pain in joints, skin rashes,

Respiratory. Unproductive cough, shortness of breath, worsening existing asthma and COPD

Neurological. Loss of smell or taste and both, weakness, numbness, lightheartedness, brain fog (difficulty in thinking and concentration), disturbed sleep,

Psychological. Depressive mood, lack of energy, pain and tenderness in many areas of the body, anxiety.

GI. Lack of appetite, intermittent diarrhea, vague abdominal pain, bloating sensation.

Cardiac. Variable BP and sudden surge of BP, palpitation, chest pain.

Urinary. Dysuria and frequency.

Metabolic/ Hormonal. Out of control blood sugar, thyroid function, menopausal symptoms, lack of libido. 

Worsening of symptoms that remained after recovering from severe covid-19, like heart failure, asthma, paralysis of limbs, etc. Weakness and brain fog are mostly responsible for absenteeism at the workplace in the long covid.

Many researchers noted that these symptoms are not unlike symptoms of chronic fatigue syndrome also known as Myalgic encephalomyelitis and PTSD (post-traumatic stress syndrome)

What are the reason/ reasons for Long Covid.

No one reason stands out among several put forward so far. In general, people who are immunodeficient are more prone to Long Covid. It is theorized that immunocytes in these groups fail to clear the virus but the virus is weakened and continues to infect new tissues. This model fits with the observation that patients treated with a cocktail of antibodies during the early phase of infection have higher instances of Long Covid.

Another interesting theory is the virus takes sanctuary within the immunocytes and waits for an opportunity to re-emerge like HIV/ASIDS virus and Paxlovid breakthrough infection. Recent discovery points to Langerhans cells of the skin which engulf the virus but fail to digest because the virus directs anti-enzyme to neutralize the digestive enzymes of the Langerhans cells.

Long covid has emerged as a major disabling illness putting a drag on the economy and untold suffering for people eager to return to work but unable to.

Initially, it appeared booster covid shots were beneficial in terms of lessening the symptoms and the length of the period of disability. But subsequent studies failed to find any benefit of the booster shots.

Covid -19 pandemic caused havoc to humanity. It continues to evolve as a major health risk factor worldwide. One reliable source report 6 million deaths from covid-19, others think that number is way short of the actual number, citing India as an example. The WHO reports one million covid deaths since January 2022 alone.

Sooner or later a plateau will be reached in the rate of new covid-19 infections which can be managed like Influenza outbreaks with vaccines given every year. Antiviral drugs against the covid-19 virus may prove to be as elusive as HIV/AIDS virus. And hopefully, the Long Covid will be just another cause of Chronic Fatigue Syndrome or Myalgic Encephalomyelitis for those who prefer Latin names.

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Bell's Palsy

Bell's Palsy.

PKGhatak, MD

Sudden onset of paralysis of one half of the entire face is called Bell's palsy. In medical terms, it is a lower motor neuron paralysis of the facial muscles of one side. Bell is Sir Charles Bell of Scotland (1774-1842). He was a Neuroanatomist cum surgeon. He gained first-hand knowledge of facial injuries while working as a surgeon in the Battle of Waterloo (1815).

The term “Palsy” is derived from the Anglo-French word “Palseie”. The Greek word “Paralysis” means loosening, it is derived from the verb “Paralysia” meaning to disable/ enfeeble.

Although Sir Charles Bell was the first to provide the anatomic basis for the condition that bears his name, in recent years researchers have shown that other European physicians provided earlier clinical descriptions of peripheral cranial nerve 7 palsy. History of facial distortion by Greek, Roman, and Persian physicians, culminating in Razi's detailed description in al-Hawi (9^th centure CE). Razi distinguished facial muscle spasm from paralysis, distinguished central from peripheral lesions, gave the earliest description of loss of forehead wrinkling, and gave the earliest known description of bilateral facial palsy. In doing so, he accurately described the clinical hallmarks of a condition that we recognize as Bell palsy.

Dr. Bell of Bell's palsy fame, had suffered a right sided facial of himself before he became famous.

A question:

Mona Lisa. Whoever has seen the world famous painting of Mona Lisa by Leonardo da Vinci must have pondered what that smile is all about. At a conference in Vienna, a group of researchers said Mona Lisa had right facial paralysis during her pregnancy and recovered after childbirth.

Anatomy of motor nerve of the face.

The above diagram is an outline of the 7^th nerve motor nerve supply to facial muscles. The pyramidal cortex sends signals to the upper division nucleus of both 7^th cranial nerve motor nuclei. (Facial nerve). The lower division of 7^th nerve motor nucleus, on the other hand, receives signals from one side only (contralateral side). In a stroke due to pyramidal cortex disease, only contralateral side of the face is paralyzed and muscles of forehead remain functional.

In Bell's palsy the entire facial muscles, including the forehead muscles are paralyzed.

Common causes of Bell's Palsy.

Chill wind blowing against the face in a long drive.

Herpes zoster. Herpes simplex. Epstein-Bar and covid-19 virus infection.

Lyme disease from spirochete infection.

Acoustic neuroma (tumor of 7^th nerve fibers in the ear), Schwannoma (cells that make myelin) and cholesteatoma.

Injury to Facial nerve.

During surgery of the parotid gland, Knife wound behind the ear. Fracture of the base of skull. Nerve block during dental procedures.

Pregnancy and diabetes mellitus.

Critical areas of the path Facial nerve where disease likely produce Bell's palsy.

1.Narrow canal inside the Temporal bone.2. The neck of mandible. 3.Parotid salivary gland.

Causes of paralysis of the Lower part of face only.

A.  Strokes from blocked blood supply to mid brain.

B. Blood clot emboli originates from heart valves, heart chambers, from atrium in atrial fibrillation.

C. Infectious vegetation from heart valve or artificial valve disease.

D. Intracerebral heeding from use of anticoagulants.

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Dizziness and Vertigo.

 Dizziness and Vertigo

PKGhatak, MD

Dizziness is not an uncommon symptom, specially in the elderly. Patients describe the symptoms in various ways - lightheartedness, feeling unsteady while walking, a sense of not being able to keep an upright posture while trying to get up from a bed or a chair, head spinning, about to faint and like.

Vertigo symptoms are related to a false sensation of motion of the surroundings.  Generally, head movements precipitate an attack of vertigo. Fear of falling on the ground from a bed or upright position and often associated with nausea and jerky movements of the eyes.

The distinction between dizziness and vertigo is important from diagnostic and treatment points of view. But often one term is used for the other. The task falls on the physician to get a clear history from the patient and only then proceed with the investigation.

What causes dizziness:

Many medical conditions may cause dizziness, chief among them are postural hypotension, irregular cardiac rhythm, disturbed blood flow to the hindbrain (lower posterior part of the brain) and low blood sugar.

Other conditions less commonly associated with dizziness are alcohol intoxication, antidepressant drugs, migraine, and carbon monoxide poisoning.

What causes vertigo:

Vertigo is due to abnormal signals fed to the brain from the semicircular canals of the inner ear called the vestibule.

Each vestibule contains 3 semicircular canals, positioned at 90 degrees to each other. The canals are filled with a viscous fluid called endolymph, floating on the endolymph there are tiny pebble like structures called otoconia, connected with the vestibular division of the 8^th cranial nerve. Any movement of the head displaces the otoconia and initiate signals from both ears and the signals are reciprocal to each other. The brain integrates these signals and accurately calculates the coordinates of the head position in relation to the horizon.

Diseases affecting the inner ear are the cause of Vertigo.

Common conditions causing vertigo:

Viral infection of the balance organ is commonly known as Labyrinthitis, motion sickness due to overstimulation of the brain from the constant change of head position – a common experience of passengers on a boat in a choppy sea, benign paroxysmal positional vertigo and head injury. Other conditions are:-

   Neuronitis, Meniere's disease, Tumors like meningioma pressing on the hindbrain, Vestibular migraine, and Brain cancers. Cerebral strokes, and Multiple sclerosis.

The medication also can cause Vertigo, a few examples are -  certain antibiotics, water pills, cancer drugs, and aspirin in heavy doses.

Meniere's disease:

A combination of tinnitus (low volume high pitched noise like the chirping of crickets), some loss of hearing and vertigo is known as Meniere's disease. The reason for this disease is not known. Symptoms are generally episodic but tend to be recurrent. After each attack, the hearing loss increases.

Benign Paroxysmal Positional Vertigo (BPPV):

Sudden head movement or turning the head to a certain position causes BPPV. It is very disturbing to the patients but it causes no permanent harm to the body. The sensation of the horizon tilting up and down causes the patient to grab whatever they can to avoid falling to the ground. The condition is self-limited but may be prolonged. A certain maneuver of the head position can stop vertigo and the patient can learn the technique and can self-treat. 

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