Ask the doctors: Long COVID affects individuals differently

Q: Is there anything new on long COVID? I have it, and it hijacked my life. I get tired really easily, can't exercise like I used to and my heart often beats too fast. The worst part is the brain fog, which affects my work. Is there any progress on a treatment or on determining what causes it?

A: Your letter is one of many we continue to receive about long COVID. We hope our answer to you will be helpful to any other readers facing similar struggles.

Nearly four years since long COVID was first identified, most us are familiar with the condition. The term refers to the collection of symptoms that drag on after someone's initial bout of COVID-19 has ended. These often include the decline in stamina, changes to heartbeat and brain fog that you are experiencing. Also common are muscle and body aches, headache, difficulty breathing, an ongoing loss or diminishment of the sense of taste and of smell, gastrointestinal problems, extreme fatigue, insomnia, changes to cognition and depression.

The one thing all people with long COVID have in common is an initial SARS-CoV-2 infection. That's the coronavirus that causes the disease. Beyond that, it affects each person differently. At this time, more than 100 different symptoms and health problems have been documented in people diagnosed with the condition. And despite intensive study by researchers throughout the world, neither the cause of long COVID nor a specific treatment have been identified. Lacking that, doctors focus on managing each person's specific symptoms. Depending on the complexities of each case, this can involve specialists in the fields of neurology, cardiology, psychiatry, immunology, pulmonology and physical therapy.

Despite the lack of a definitive breakthrough, researchers are amassing a growing body of knowledge about long COVID. Several studies found that fragments of the SARS-CoV-2 virus can persist in the body long after an initial infection. This can cause ongoing inflammation and may contribute to some symptoms.

Another school of thought looks at long COVID as an autoimmune disease, in which the SARS-CoV-2 virus causes the body to attack its own tissues. A recent study highlights the potential role of immune cells known as monocytes, which alert other white blood cells to the presence of infection. It appears COVID infection can damage the structure of those immune cells, and thus scramble their behavior. There is also speculation that COVID infection may awaken existing viruses that had previously remained dormant in the body. These may include the Epstein-Barr virus, which has symptoms in common with long COVID. Each of these discoveries highlights potential avenues of treatment.

One thing has become clear: It is impossible to predict who will develop long COVID. Although a bit more common in those with severe COVID-19, it does occur in people who had a mild illness. It is now understood that Paxlovid, a medication effective in treating COVID-19, does not prevent long COVID. However, a new study links being vaccinated with a markedly lower risk of developing long COVID. This topic is firmly on our radar, and we will be back with updates as needed.

Elevated creatinine levels can impact kidney function

Q: My father has diabetes and high blood pressure. Sometimes he fails to follow medical care for these diseases. Now his level of creatinine has reached 2.6 mg/dL, which is very high. He is getting weak and has cramps at night. How do you decrease high creatinine?

A: Creatinine is a natural waste product produced by the activity of our muscles. It's a byproduct of creatine, an organic compound that supplies energy to the muscles. We recently wrote about creatine, which plays an important role in physical activity and has become a popular dietary supplement. We bring this up because creatine and creatinine sound similar. However, they are two distinct compounds and have very different effects on the body. It's important not to confuse the two.

Each of us produces and excretes creatinine in a continual cycle. It is filtered from the blood by the kidneys and exits the body via the urine. As a result, the concentration of creatinine that is present in someone's blood or urine is used as a measure of how well the kidneys are functioning. Among the conditions that can contribute to developing high creatinine levels is a common complication of Type 1 and Type 2 diabetes known as diabetic nephropathy. Sometimes referred to as diabetic kidney disease, it is estimated to affect up to one-third of people in the U.S. living with diabetes.

Over time, high blood sugar levels can damage the blood vessels that serve the kidneys and also the nephrons, which are tiny structures that serve as filters. Individuals with diabetes who fail to manage blood sugar levels are at particular risk of this type of damage. It leaves the kidneys unable to effectively clear the blood of waste products and other toxins, which can cause a cascade of increasingly grave health problems.

The results of your father's creatinine blood test are indeed quite high. The normal range for an adult man is 0.7 to 1.3 mg/dL (that's milligrams per deciliter). For women it is 0.6 to 1.1 mg/dL. The symptoms that you say he is experiencing — feeling weak and experiencing cramps — are among those that high creatinine levels, and the impaired kidney function they suggest, can cause. Additional symptoms include high blood pressure, feeling nauseated, vomiting, chest pain and fluid retention.

When it comes to lowering creatinine levels, there is no single solution. Because meat is a source of creatine, from which creatinine is derived, lowering the amount of meat in the diet is important. Several studies have found that adding high-fiber foods to the diet can have a beneficial effect on elevated creatinine. Dehydration can raise creatinine levels, so drinking enough water is also important. Avoid tobacco products, reduce salt and limit the use of NSAIDs, each of which can put a strain on the kidneys.

In your father's case, with uncontrolled diabetes and high creatinine levels, we urge him to seek immediate medical care. The doctor will evaluate your father's kidney function and screen him for kidney disease. Based on a physical exam, test results and a medical history, your father will be advised of the appropriate path forward.

Several treatments available for nosebleeds

Q: I am a 76-year-old woman not prone to nosebleeds. However, I recently started having heavy ones. Thrombin spray helped, but only for a week. A CT scan was normal. What can be done? A friend with nosebleeds had his nose cauterized. Might that be helpful for me?

A: When viewed from the outside, our noses look fairly basic. But peek inside, and things get remarkably complex. The bones, flesh and cartilage of the visible nose serve as a protective entryway to a series of hidden passages and chambers. These include the airways that moisten and filter the air we inhale and the olfactory system, made up of the nerves, cells and organs that enable us to smell. Lining the interior of the nose are specialized cells and glands, known collectively as the mucosa, which keeps these inner surfaces moist. This layer is served by a rich network of tiny blood vessels, which, if ruptured, cause a nosebleed.

Nosebleeds (the medical term is “epistaxis”) often occur due to physical injury, such as a bump or a fall, or blowing the nose too hard or too often. Inflammation from a respiratory illness, infection or allergy can cause a nosebleed. So can dry air, which dehydrates the tissues of the mucosa and can cause them to crack. The physical changes that take places as we age can also make blood vessels in the nose more fragile. In fact, nosebleeds are fairly common in older adults.

The thrombin spray you were treated with is one of several medications used to encourage what is known as a coagulation cascade. It works by activating proteins known as clotting factors, which stanch the flow of blood. But sometimes blood vessels in the nose grow fragile and are easily damaged, which leads to repeated nosebleeds. When this occurs, cauterization, the treatment your friend underwent, can be helpful. Your ENT will let you know if you are a good candidate.

Cauterization involves the use of either a chemical swab or an electrical current to seal off the affected blood vessels in the nose. This creates scar tissue, which helps prevent further nosebleeds. The doctor begins with an exam to identify the cautery site. On the day of the procedure, the inside of the nose is numbed with an anesthetic. The doctor will then cauterize the affected area, a process that takes about 10 minutes. Aftercare often includes an ointment to keep the interior of the nose moist and to prevent infection. Healing occurs over the course of two weeks. After the procedure, mild pain and itching can occur. The scent organs are located deeper in the nose than the site of cautery, and thus are not adversely affected.

Nosebleed aftercare is important. Always be gentle when blowing your nose. Keep nasal tissues moist with humidifiers. The saltwater used in nasal lavage can have a drying effect, so use sparingly. So can the chemicals in swimming pools. Nonsteroidal anti-inflammatory medications, such as aspirin, can also add to risk of bleeding, so when pain meds are needed, choose an alternative.

• Dr. Eve Glazier is an internist and associate professor of medicine at UCLA Health. Dr. Elizabeth Ko is an internist and assistant professor of medicine at UCLA Health. Send your questions to askthedoctors@mednet.ucla.edu.

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