Persistent fatigue in patients with COVID-19

Editor – We read with interest the review by Sullivan who described the long-term sequela of patients who acquired severe acute respiratory syndrome coronavirus infection and Middle East respiratory syndrome coronavirus infection.¹ Based on the previous experiences with the two epidemics, the author suggested that patients who recovered from COVID-19 may also suffer from the similar long-term complications which include cardiopulmonary sequelae and fatigue.

We wish to discuss the condition of persistent fatigue following the recovery of COVID-19. In fact, available studies have reported fatigue as the most prevalent symptom that persists in patients who recovered from COVID-19, which has now been termed as ‘long COVID’. An Italian study of 179 patients reported that 87.4% of patients had persistence of at least one symptom in 60 days after their initial COVID-19 diagnosis, with fatigue being the most prevalent symptom (53.1%).² Likewise, Townsend et al which evaluated 128 patients who recovered from the acute phase of COVID-19 reported persistent fatigue in 52.3% of patients at 10 weeks after initial symptoms.³ Moreover, an analysis of data from 4,182 incident cases of COVID-19 logged in the COVID Symptom Study app revealed that 13.3% of cases had symptoms lasting >28 days, with fatigue being the most commonly reported symptom (97.7%) among those who had long COVID.⁴

We agree with Sullivan that clinicians will need to monitor for long-term complications in patients who recover from COVID-19, especially persistence of fatigue.¹ In patients who are particularly troubled with persistent fatigue, drug therapy including glucocorticoids and methylphenidate could be offered on a case-by-case basis after evaluating risks and benefits. A double-blind, randomised, placebo-controlled trial of 25–35 mg/day of oral hydrocortisone for 12 weeks in 70 patients with chronic fatigue syndrome (CFS) showed modest improvement at the expense of adrenal suppression.⁵ In another randomised crossover trial, improvement in fatigue level was observed in response to 5–10 mg/day of hydrocortisone among 32 CFS patients.⁶ A double-blind, randomised, placebo-controlled crossover study of 60 CFS patients evaluated treatment with methylphenidate (10 mg twice daily) compared with placebo and reported clinical improvement in 17% of patients.⁷