To the Editor,
We are delighted to see that Miglis et al. [1] share the same opinion as us about the possible physiopathology related to microangiopathy and endothelial injury which might be responsible for dysautonomia in patients with persistent symptoms following acute SARS-COV2 infection. Physicians must keep in mind that COVID-19 is not only a disease responsible for lung injury and its consequences but may affect other organs resulting olfactory and gustatory dysfunction and, as such, should inform the general audience, especially young individuals, who are the most concerned [2].
We did not state that these symptoms of autonomic impairment do not require specific treatment, but we believe in case by case management depending on the persistent symptoms. Therefore, as stated in the perspectives of our commentary [3], we believe that the first step of the management of patients with previous mild or moderate form of SARS-COV2 infection is cooperation between specialists, including neurologists, cardiologists, pneumologists and specialists in rehabilitation. Based on our experience, non-pharmacological therapies, including psychological support and explanation of the symptoms, partly help patients to better perform normal daily activities and carefully resume physical activity in gradual steps. Among the non-pharmacological therapies used are respiratory re-education, effort re-training and relaxation. Respiratory rehabilitation has proven to be effective in the treatment of hyperventilation syndrome [4] as well as exercise re-training in the treatment of postural orthostatic tachycardia syndrome [5].
A targeted pharmacological treatment can be considered in dysautonomia, including medication such as beta-blockers or alpha-mimetics, or even a dopamine antagonist such as domperidone [5]. Therefore after investigations to rule out a common disease in patients presenting persistent symptoms of COVID-19, a pharmacological strategy can be suggested and assessed. For instance, possible candidate therapies for research could be based on anti-depressors for their central nervous system action or low-dose aspirin for its anti-aggregant properties and/or statins for their antioxidant activity to promote reparative vascular remodelling.
Therefore, we are also pleading for prospective studies among patients with autonomic impairment secondary to COVID-19, to better quantify the burden of these symptoms inside the population and decide whether additional drugs for an unknown duration is deemed necessary.
Transparency declaration
Nothing to declare.
Funding
None.
Author contributions
B.D. and P.D.T. – drafting and revision of the letter; R.T., S.S. and N.B. – revision of letter.
Editor: L. Leibovici
References
- 1.Miglis M.G., Brent G.P., Kamal C.R., Lauren S. Response to Post-COVID-19 chronic symptoms: a post-infectious entity? Clin Microbiol Infect. 2020;3:30511–30515. doi: 10.1016/j.cmi.2020.08.028. [DOI] [Google Scholar]
- 2.Rojas-Lechuga M.J., Izquierdo-Domínguez A., Chiesa-Estomba C., Calvo-Henríquez C., Villarreal I.M., Cuesta-Chasco G. Chemosensory dysfunction in COVID-19 out-patients. Eur Arch Otorhinolaryngol. 2020 doi: 10.1007/s00405-020-06266-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Davido B., Seang S., Tubiana R., de Truchis P. Post-COVID-19 chronic symptoms: a post-infectious entity? Clin Microbiol Infect. 2020;26(11):1448–1449. doi: 10.1016/j.cmi.2020.07.028. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Jones M., Harvey A., Marston L., O’Connell N.E. Breathing exercises for dysfunctional breathing/hyperventilation syndrome in adults. Cochrane Database Syst Rev. 2013;2013 doi: 10.1002/14651858.CD009041.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Wells R., Elliott A.D., Mahajan R., Page A., Iodice V., Sanders P. Efficacy of Therapies for postural tachycardia syndrome: a systematic review and meta-analysis. Mayo Clin Proc. 2018;93:1043–1053. doi: 10.1016/j.mayocp.2018.01.025. [DOI] [PubMed] [Google Scholar]