3 comorbid patients die after clearing COVID-19 and the lingering impact of COVID-19 on those who clear it

Of the 7 recovered Bhutanese COVID-19 patients contacted by the paper 5 still suffer from some lingering effects

Bhutan has so far got 859 COVID-19 cases of which  841 have recovered so far  with only 17 active cases and 1 death.

Despite the encouraging numbers, there is an increasing body of international medical data showing how patients continue to suffer months and even a year after testing negative.

Scientists and researchers are finding that this is mainly due to the significant long term damage that COVID-19 can cause to organs like the lungs, heart, kidney, digestive tract, brain and other systems, like the immune system.

3 comorbid deaths after clearing COVID-19

The Bhutanese has learnt that apart from Bhutan’s first official death due to COVID-19 reported on 7th January 2021, where a 34-year-old-man died due hepato-renal failure, there have been three other deaths- where comorbid patients who had cleared COVID-19 died in the COVID ICU ward.

These 3 deaths occurred in referral patients who had been sent to Kolkata for treatment, but they had tested positive when they came back.

The first death of a comorbid patient was that of a 30-year-old lady with lung cancer on 24th December 2020. She had cleared COVID-19 from her blood but she was kept in the COVID ICU ward on ventilation.

A doctor said that the plan was to even get her off ventilation as she seemed to be improving, but then her condition suddenly deteriorated and she passed away while on ventilation two weeks after she had cleared COVID-19.

The second well known death occurred on 25th December 2020 when a 52-year-old lady with an auto immune disease also died while on ventilation after she had tested negative for COVID-19 on 19th December. She could not be released from the ward and was in the COVID ICU ward on ventilation as she had difficulty breathing.

MoH officials had said that she had died due to her auto-immune condition and not COVID-19 as she had tested negative a few days ago.

The third death took place a day later on 26th December when an 84-year-old man who had a heart condition and a pacemaker inserted into his heart also died after clearing COVID-19. This man had also been placed on the ventilator machine in the COVID-19 ICU.

Of the four deaths, only the 7th January death was treated as a COVID-19 death as the man still had COVID-19 when he passed away.

A senior doctor at JDWNRH who is also a specialist and has been involved in two rounds of personally treating COVID-19 patients said that while COVID-19 may not be the direct cause of death in the three comorbid cases, the virus would have definitely made it tougher for all of them.

He said COVID-19 is already known to cause complications in people with comorbid conditions and the virus attacks multiple parts of the body. He said in the case of the death of the auto immune patient on 25th December 2020, she had been receiving immunotherapy which would have weakened her defenses even more against the virus.

Of seven patients who cleared COVID-19 five still suffer from its effects

The Bhutanese contacted a total of seven former Bhutanese COVID-19 patients who have recovered from the virus, and found that five of them still continued to suffer from various effects even months after clearing the virus. Their names are not being revealed to protect their privacy but their gender, general location and time period of testing positive and recovery are mentioned.

Patient 1, a 20-year-old college student, was one of the first few Bhutanese to test positive after she came back from abroad and was detected in the quarantine center.

She said that she tested positive on 29th March 2020 and was released on 8th April 2020 from the hospital for de-isolation after testing negative.

Patient 1 said that she was asymptomatic and the only thing she noticed was her loss of sense of smell and taste. She said her only difficulty in the COVID ward was that at the time patients were being given Hydroxychloroquine, normally used for treating malaria, but she reacted to it with nausea and vomiting.

The drug was given in the early days when it was said that it may be effective but it is no longer given to patients as it was later found to be ineffective.

She said that other then that she enjoyed fine physical health. However, even almost a year after her recovery she said that her sense of smell and taste fluctuates and sometimes she cannot smell or taste.

Patient 2 who is 30-years-old had been detected positive in Phuentsholing during the first outbreak. She was found to be positive in mid-August 2020 and was released on 30th September 2020.

She said that while in the COVID ward in Phuentsholing she had flu like symptoms, she lost her sense of smell and she experienced body aches.

Patient 2 said that even five months after testing negative, she does not feel well and experiences fatigue even with doing small tasks in the house. She said that she did not have this issue before COVID-19 but the change occurred after the virus.

Patient 3 who is in her 30s and also from Phuentsholing was one of the people to test positive from the community. She went into quarantine on 17th August and only left 49 days later on October 3rd.

She said that while in quarantine she felt out of breath for the first three days, and she also experienced fatigue and loss of smell.

Patient 3 said that a change that she has noticed since her recovery from COVID-19 is that she has become forgetful compared to the past and cannot concentrate mentally like before.

She said that she keeps forgetting where she has placed her things in the house which was not the case before.

Patient 4 who is a 50-year-old driver detected from Thimphu on 3rd January 2021 and he was asymptomatic. He was released on 19th January 2021. He said that given his asymptomatic nature he was never put in the COVID-19 ward but in isolation in a hotel. He said that he feels fine and he has not suffered from any effects.

Patient 5 is a 34-year-old from Paro and he tested positive in late December and was released on 17th January after recovery. He said he also did not have any symptoms while in quarantine and did not see any changes in his health after his release.

Patient 6 who is a Bhutanese college student in his 20s in the USA had to be contacted via a friend in Bhutan.

Patient 6 was very sports oriented before getting COVID-19 around November 2020. However, after the recovery he gets short of breath while going for runs and he also suffers from anxiety attacks and feels light headed. 

Patient 7 in her 20s is also one of the first Bhutanese to be detected with the virus around March 2020. She is a college student who had been studying abroad and had come back and was detected in the quarantine.

She said that even around a year later her sense of smell is not as sharp it used to be though it is functional enough for her to get by.

The specialist doctor from JDWNRH said that he is aware of the long term effects of COVID-19 going by international literature on the subject, but Bhutan is yet to do a study or survey of the long-term health impact of COVID-19 on recovered patients.

The doctor said the reason COVID-19 affects so many parts of the body is because cells in many different locations have the ACE2 receptor that is the main target of the virus, and at the same time the infection can harm the immune system, which also impacts the entire body.

He said that one requirement for all Bhutanese COVID-19 patients was to do an X-ray of the chest to check on the lungs. He said in up to 25 percent of the cases changes were seen in the lungs developing into pneumonia like conditions which ranged from mild to severe with around 5 percent being severe. The doctor said that the surprising thing was that even asymptomatic patients who appeared to be normal had these changes in the lungs.

There are many cases internationally of lungs showing scarring or fibrosis after recovery from COVID-19.

However, here the doctor said that in Bhutan the focus is basically on the clearance of the virus and if the virus has been cleared then the patient is let go and there are no X-rays done later to check for lung scarring or fibrosis.

Another major change that the specialist doctor observed in Bhutanese patients was a high level of inflammatory markers like Ferritin, CRP, Interleukin 6 and LDH in the blood showing high inflammation in the body. He said around 99 percent of the Bhutanese patients had these very high markers.

WHO Representative to Bhutan Dr Rui Paulo de Jesus said that it is true that there are long term effects of COVID-19 on various parts of the body but detailed analysis and research will be required to show the proportion of people affected by this.

He said it would be wise for Bhutan to follow up on the recovered cases and see how they are doing.

WHO recognizes long term impact of COVID-19

The World Health Organization, in a presentation, has said that COVID-19 can sometimes result in prolonged illness, even in young adults and children without underlying chronic medical conditions. It said that there are many case reports from people who do not regain their previous health following COVID-19.

WHO in the same presentation says that COVID-19 may increase the risk of long-term health problems.

WHO giving a list of body systems and organs that can be affected in the long term lists the damage to heart muscle, and heart failure; damage to lung tissue and restrictive lung failure; impact on the brain and the nervous system through loss of sense of smell, consequences of thrombo-embolic (blood clotting) events such as pulmonary embolism, heart attack, stroke and cognitive impairment like memory and concentration; impact on mental health through anxiety, depression, post-traumatic stress disorder and sleep disturbance ; and musculoskeletal and other issues like pain in join and muscles and fatigue.

However, the long term health impacts of a serious viral infection are not entirely unknown to doctors and researchers. 

The WHO in its presentation pointed to a study done to study the long term impact of the 2003 Severe Acute Respiratory Syndrome (SARS), coronavirus that hit some Asian countries. The study, revealed that 40% of people recovering from SARS still had chronic fatigue symptoms 3.5 years after being diagnosed.

Both COVID-19 and SARS are caused by coronaviruses.

US CDC study shows long term impacts in 35% of patients

The US based Center for Disease Control and Prevention (CDC) in July 2020 published a survey of 274 patients 2 to 3 weeks after they tested positive for COVID-19. The report said that in case of the flu more than 90 percent recover after two weeks. The study found that 35 percent of the respondents had not returned to normal health after this period and in the age category of 18 to 34 one in five had not returned to normal health.

On 13th November 2020 the CDC said that the most commonly reported long-term symptoms are fatigue, shortness of breath, cough, joint pain and chest pain.

Other reported long-term symptoms include difficulty with thinking and concentration, depression, muscle pain, headache, intermittent fever and heart palpitations.

CDC said more serious long-term complications appear to be less common but have been reported. These include inflammation of the heart muscle, lung function abnormalities, acute kidney injury, rash and hair loss, smell and taste problems, sleep issues, difficulty with concentration, memory problems and depression, anxiety and changes in mood.

The risk factors for persistence of symptoms are high blood pressure, obesity and mental health conditions.

Nature, Lancet and Harvard point to other long term impacts

An article published in Nature Journal on September 2020 talked about the long term damage of COVID-19 on lungs with tissue scarring. It said people with more severe infections might experience long-term damage not just in their lungs, but in their heart, immune system, brain and elsewhere. 

It said that although in some cases the most severe infections also cause the worst long-term impacts, even mild cases can have life-changing effects — notably a lingering malaise similar to chronic fatigue syndrome.

The article says some people who have recovered from COVID-19 could be left with a weakened immune system. It says an increasing number of people have reported crippling exhaustion and malaise after having the virus. 

An article published in the Harvard Medical School website on October 2020 says new research is now suggesting that there may be long-term neurological consequences in those who survive COVID infections.

COVID can cause damage to the brain directly by encephalitis, which may have devastating or subtle consequences.

Autopsy data from COVID patients in Finland showed that several of the patients who were autopsied did not show any signs of brain injury during the course of their COVID infection — yet all had brain damage.

It said a Chinese group of doctors and researchers examined several aspects of cognitive function in 29 individuals who were thought to have fully recovered from COVID infection. They found persistent impairment in sustained attention — the ability to attend to important information for as long as it is relevant.

The Harvard website article said that one recently published paper from a group of German and American doctors concluded that the combination of direct effects of the virus, systemic inflammation, strokes, and damage to bodily organs (like lungs and liver) could even make COVID survivors at high risk for Alzheimer’s disease in the future.

An article published in The Lancet on September 2020 says 78 of 100 patients in an observational cohort study who had recovered from COVID-19 had abnormal findings on cardiovascular MRI around 71 days after diagnosis.

The cardiology website dicardilogy.com says evidence for pericarditis (inflammation of the fibrous sac surrounding the heart) and myocarditis (inflammation of the heart muscle)was also found in a Spanish study of 139 healthcare workers who had COVID. About 10 weeks after infection, the prevalence of pericarditis or myocarditis was found in up to 40% of cases. 

It says a German MRI study of 100 COVID-19 recovered patients revealed ongoing myocardial inflammation in 60 patients (60%). This was independent of pre-existing conditions, severity and overall course of the acute illness, and time from the original diagnosis. 

Mayo Clinic says heart damage caused by COVID-19 is believed to stem from very small clots that block tiny blood vessels (capillaries) in the heart muscle.

It says other parts of the body affected by blood clots include the lungs, legs, liver and kidneys. 

COVID-19 can also weaken blood vessels and cause them to leak, which contributes to potentially long-lasting problems with the liver and kidneys.

Many institutions and research bodies around the world are launching a series of long term studies to study and better understand the many long term effects of COVID-19.

The Bhutanese repeatedly tried to contact the Technical Advisory Group (TAG) under the Ministry of Health for their inputs on this story but despite calls and official emails there was no response.

Note: This story has been updated to reflect Patient 7 and the latest COVID-19 recovery figures.

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