A Short History of Long COVID
From hearts and minds to teeth and toes.
The following is adapted from Chapter 7 of my book Fear of a Microbial Planet: How a Germophobic Safety Culture Makes Us Less Safe.
As the reality of the steeply age-stratified and co-morbidity amplified disease continued to frustrate the worldview of many COVID maximizers, there was a popular drumbeat to expand the COVID threat beyond cases and deaths, and the most mysterious, terror-inducing phenomenon that could be exploited was Long COVID. Long COVID isn’t a single phenomenon, but rather many phenomena, a catch-all term which could be summarized as “anything bad that happens after you’ve had COVID.” As with pandemics in the past, when millions and even billions of people are infected with a virus over a period of months to years, there will be a seemingly rather significant group of people with long-term issues, and some of them will be quite nasty. And if the definition is broadened, then so can the size of the group of long-term sufferers.
Since the symptoms of acute COVID often mimic those of many different respiratory viruses, an initial diagnosis is difficult to make without a positive test result. However, with Long COVID, anything unusual could be attributed to the virus. Some early articles about Long COVID told anecdotes of individuals that hadn’t been confirmed cases (due to low availability of testing in many places), but were certain they were suffering from effects solely due to SARS-CoV-2. As the concept gained steam in traditional and social media, articles equating an endless number of symptoms of chronic disease began to proliferate in media outlets. The British tabloid the Daily Mirror cataloged a grand total of 170 symptoms, with everything from seizures to “hearing strange sounds at night” to “white tongue,” incontinence and hair loss. It might’ve saved time to list symptoms that weren’t associated with Long COVID.
One of the more interesting COVID-associated problems didn’t even make it on that list—unexplained tooth loss. On November, 26, 2020, a New York Times headline posed the question, “Their teeth fell out. Was it another COVID-19 consequence?” The story profiled a woman who had been experiencing several of the more common long-haul symptoms, including “brain fog, muscle aches, and nerve pain.” But in the autumn, something unusual happened. She lost a tooth. It just “flew out of her mouth and into her hand. There was neither blood nor pain.” Doctors and dentists who were interviewed agreed—her experience was highly unusual, although the article did mention it happening to a few others in a Long COVID support group. One thing they couldn’t prove—that their tooth loss was genuinely due to COVID or the immune response to SARS-CoV-2 infection, or something else entirely.
Another strange post-COVID symptom—dubbed COVID toes—gained notoriety when NFL quarterback Aaron Rodgers joked about his broken toe being a result of his recent bout with COVID. Not surprisingly, media outlets took it seriously, with articles appearing all over U.S. media. Rodgers later had to clarify that it was only a broken toe, and not COVID-related. Yet COVID toes was considered a real thing—COVID toes even had their own WebMD page, explaining common manifestations of CT as “The skin on one or more of your toes or fingers may swell up and look bright red, then gradually turn purple. Skin of color can look swollen and purple, and brownish-purple spots may appear.” What’s even more impressive is the acknowledgement of uncertainty, which is spot on: “Other scientists say early research suggests that there isn’t a connection between the coronavirus and this skin problem.” The page also acknowledged that COVID toes have appeared on people who had tested negative for COVID as well as those that had tested positive, perhaps the most important information on the page.
This underscores the main problem with any attempts to understand Long COVID--it’s very difficult to study something that’s based on the subjective belief of patient self-reporting. There is simply no common biological marker of Long COVID and even a previous positive test wasn’t necessary for some claims to be investigated. This issue was highlighted by a study published in JAMA Internal Medicine that found the only persistent symptom associated with laboratory-confirmed COVID-19 was the loss of smell. In contrast, self-reported infection was associated with a host of issues like chest pain, breathing difficulties, heart palpitations, fatigue, dizziness, and digestive problems. In other words, belief of infection was highly associated with persistent symptoms, but not in people who could prove they had COVID-19. In another study, adolescents were more likely to report Long COVID symptoms if their parents also did, even in the absence of a positive test. Even more fascinating was an NIH study of self-referred adults six weeks after appearance of symptoms for a lab-confirmed infection, which found that of 35 potential risk factors of Long COVID, the only statistically significant risk factors were female gender and a history of anxiety disorders. Perhaps being terrified and anxious about COVID makes one more likely to experience symptoms afterwards that may or may not actually be related to the infection itself, but simply another manifestation of the nocebo effect. These three studies serve as a warning to anyone looking for a clear answer about Long COVID, since the smaller number of people truly affected by long-term problems may be lost in a cloud of psychosomatic, belief-driven noise.
As I mentioned before, any virus that infects billions of people will cause long-term effects in a smaller yet very visible minority. One of the more common long-term problems of post-viral infection is inflammation of the heart tissue, most specifically the heart muscle, also called the myocardium. Inflammation of the heart is referred to as myocarditis, and early on in the pandemic COVID-19 infection was thought to be a significant risk factor for developing myocarditis. A July, 2020 paper in JAMA Cardiology sent the media world into a frenzy about post-COVID myocarditis—the paper itself was covered by over 400 media outlets and viewed over 1 million times, and that doesn’t happen to just any old paper about viral myocarditis. In the paper, the authors claimed that 78 percent of people who had recovered from COVID had abnormal heart MRI results, with 60 percent exhibiting myocarditis. If this bombshell were true, this would mean that millions of COVID-recovered people could already have irreversible damage to their heart, with billions more threatened by unchecked viral spread.
Because of this study, many doctors became more likely to look for myocarditis post-COVID than they would have otherwise. This was true of healthy people, specifically athletes, which sometimes experience myocarditis and need to rest for up to six months to prevent permanent scarring. Then came stories of post-COVID myocarditis in five college athletes from the Big Ten conference, causing the conference to cancel its fall season. Other college football conferences followed suit. The risk of athletes from post-COVID myocarditis was seemingly confirmed by another JAMA Cardiology study that reported that 15 percent of the COVID-recovered athletes showed abnormal MRI results. This result was an absolute dream to COVID maximizers, because now COVID wasn’t just a disease that threatened the old and infirm, but confirmed what they already believed—that also the young and healthy were threatened with long-term damage, even from mild disease. The only problem—none of it was true.
The original study of non-athletes was heavily criticized for errors in its statistics and methods, errors that the authors acknowledged were serious enough for the paper to be revised significantly. Although the authors maintained their conclusions weren’t changed, the new analysis told a different story, with only a modest increase in long-term effects in COVID-19 recovered patients compared to uninfected controls.
Even more revealing, the study of myocarditis in a small number of athletes didn’t feature a control group, and their results matched other studies that found similar effects among athletes that had not recovered from COVID. These studies had glaring holes that went almost completely ignored—the media were happy to report on the bombshell story of COVID-related myocarditis, but unwilling to acknowledge that all of their attention might be overblown.
And overblown it was. Subsequent studies with larger groups of athletes found very small numbers of myocarditis and even fewer incidences of hospitalization. Another study of healthcare workers found no differences in heart function related to SARS-CoV-2 infection. Even in severe cases of COVID, one study reported that 9 out of 10 patients still had normal heart function. The initial panic-inducing studies simply couldn’t be replicated.
One month after canceling the entire season, the Big Ten announced its season would go on after all, starting almost two months later, on October 23rd, 2020. In their decision, league officials cited increased availability of testing as the primary reason for the change. The growing realization that they were pressured into a massive overreaction to unsubstantiated claims about the unique ability of COVID-19 to result in myocarditis wasn’t mentioned. The irony that football itself was clearly more dangerous to healthy players than COVID-19 also went unacknowledged.