Summary

Through reading related medical papers on long COVID chronic fatigue so far, the author summarized the life performance of long COVID chronic fatigue, and provide an in-house self assessment to judge whether people develop these symptoms of chronic fatigue.

Then, the author analyzed the pathogenesis of the long COVID chronic fatigue, and concluded the approaches of western medicine treatment against long COVID chronic fatigue. Due to the limitation of western medicine treatment against long COVID chronic fatigue, this paper also recommended some traditional Chinese medicine, including Chinese medicine formula and acupuncture treatment, to treat the fatigue-related symptoms.

In addition, this paper made advises patients with long COVID chronic fatigue on taking health care products, as well as on exercise, diet, and sleep.

In the end, we hope that the treatment program for long COVID chronic fatigue suggested in this paper could benefit patients by improving their symptoms in the brain as soon as possible, and even cure the chronic fatigue caused by novel coronavirus infection.

Keywords: Long COVID, Post Covid-19,long COVID fatigue,Post Covid-19 fatigue, long COVID chronic fatigue, chronic fatigue syndrome, myalgic encephalomyelitis.

1.What are the manifestations of long COVID chronic fatigue?

Since the COVID-19 pandemic, after being infected with these coronaviruses, some people experienced severe fatigue. Such fatigue sometimes is continuous and sometimes intermittent, usually lasting for a long time, even up to more than a year. This condition is called post-COVID fatigue syndrome or chronic fatigue syndrome by the medical community and is commonly called chronic fatigue by the general public. According to statistics in the study report, approximately 10% of people infected with novel coronavirus developed long COVID, and patients with chronic fatigue accounted for one-fourth of all patients with post COVID-19 symptoms. That means about 2.5% of people infected with the coronavirus would experience chronic fatigue. According to published medical papers on long COVID chronic fatigue, we conclude that the manifestations of chronic fatigue are as follows:

(1)Chronic fatigue: feel that one is in a state of extreme fatigue, the body is low in energy and has a feeling of heaviness. Insufficient endurance, weakness, slight sweating, and breathlessness during exercise. Physical deficiency and shortness of breath are commonly used in TCM to describe this condition.

(2) Brain fatigue: feel that it is easy for the brain to be tired; feel listless; it is easy to feel tired when pondering; feel easily sleepy when reading, and feel sleepy easily during the day.

(3) Shortness of breath: shortness of breath, gazing and wheezing occur with slight exercise, only able to walk very short distances or climb a dozen staircases, and then mild asthma symptoms also occur.

(4) Muscle weakness: feel generalized weak, stiffness, muscle weakness, leg weakness, orthostatic intolerance.

(5) Muscle and joint pain: generalized muscle pain, systemic chronic mild pain, joint pain, limb pain, movement site pain, migratory neuralgia.

(6) Sleep disorder: difficulty in falling asleep, poor sleep quality, unable to recover the physical condition, and still feel fatigued after having sleep. it is easy to wake up or have insomnia, or feel drowsiness and it is difficult to wake up, and other conditions at the same time, while sleepiness and tiredness appearing during the day. The patient presented with the conditions of day and night reversal, staying up late, and feeling tired in the daytime and energetic at night.

2.How to judge whether people suffered the long COVID symptoms?

What are Post-COVID Conditions? According to the definition of the World Health Organization, Post-COVID Conditions, also known as Long Covid, long-haul COVID, post-acute COVID-19, It refers to the patient who is infected with the new coronavirus, the first PCR test is positive, and after 3 months, there are still symptoms of physical discomfort. For more detailed information on the latest statistics on the incidence of long covid according to the time axis, please refer to the following figure.

Post Covid-19 Symptoms are mainly concentrated in five aspects, including respiratory syndrome, cognitive system syndrome, chronic fatigue syndrome, chronic pain syndrome, and mental syndrome, such as long COVID of brain fog, which belongs to the cognitive system syndrome. long COVID chronic fatigue are one of chronic fatigue syndrome. According to medical classification, cognitive system syndrome includes fatigue symptoms, chronic fatigue syndrome, and brain fog. Moreover, two symptoms such as brain fog and fatigue will coexist in many patients with post long COVID-19, this coincident symptom of which we called brain fatigue. Of course, there is simple brain fog of non-fatigue, and physical fatigue with the brain awake.

If you have a history of the novel coronavirus, which means your previous result of PCR test showed positive, and before infection with the novel coronavirus, you didn’t suffer from the long COVID fatigue, but now you are presenting these symptoms of fatigue, you are likely to afflict by Post Covid, which can be called post-infectious fatigue syndrome, chronic fatigue syndrome, and myalgic encephalomyelitis in medicine.

3.What are the causes of the long COVID chronic fatigue?

According to the published medical papers on the long COVID chronic fatigue, we concluded that there are six conditions in the pathogenesis of the long COVID chronic fatigue as follows:

(1)Coronavirus, a harmful antigen, causes persistent direct tissue damage, which produces chronic inflammation. The novel coronavirus antigen infects different organs, and each patient 's autoimmune system is different, which leads to different immune responses. Tissue damage can present with shed tissue proteins, coupled with the mutilated corpse of the coronavirus, which decompose slowly in the human body, and these protein fragments, in turn, can trigger autoimmunity. For example, Studies have found that autoreactive B lymphocytes remain activated in patients infected with novel coronavirus after negative PCR tests. This long-term autoimmunity is thought to be one of the main causes of chronic fatigue.

(2)There are too many variants of coronavirus. With the immune escape ability is getting stronger and stronger, the coronavirus and the patient’s human leukocyte antigen (HLA) mismatch ingenetic ability, leading to the human immune system unable to completely eliminate the coronavirus. Studies have found that among some patients infected with novel coronavirus, the virus do not clean up in the human body. This long-standing trace amount of novel coronavirus will also gradually make the immune system insensitive to the route of eliminating novel coronavirus, finally in a coexisting state. At this time, these trace viruses will continue to damage various organs and body tissues. This condition is medically known as post multi-organ symptoms of non-serious novel coronavirus infections. This reduces body function, which has been shown to be one of the causes of fatigue.

(3)Studies have confirmed that the coronavirus can destroy the immune system of the human body, leading to reduced immune capacity. At this time, although the coronavirus is eliminated, Epstein-Barr virus, cytomegalovirus and herpes virus, which were originally hidden in the human body in a dormant state, will become active again. These viruses reinfect tissue cells in vivo, causing chronic inflammation and autoimmunity. It has also been shown to be one of the causes of the long COVID chronic fatigue.

(4)Patients infected with novel coronavirus experienced dysregulated cytokine networks or disturbed cytokine signaling in their bodies. For some people infected with coronavirus,they developed systemic chronic inflammation.Studies also have shown that pro-inflammatory substances triggered by systemic viral infections, NLRP3, HMGB1, and interleukin 6, may also be one of the causes of the post long COVID chronic fatigue.

(5)For patients infected with novel coronavirus, the coronavirus invades tissue cells, resulting in disruption in cellular mitochondrial structure, cellular metabolism, and cellular energy cycling. Studies have shown that mitochondrial enzymes are involved in inflammatory and oxidative reactions from the onset of novel coronary, which may also be one of the causes of the post long COVID chronic fatigue.

(6)For patients infected with new coronaries, some people experienced the virus breaking through the blood-brain barrier and invading nerve cells in the brain. Because the brain is in charge of the entire body, there is general malaise occurring. Studies have shown that coronavirus can break through the blood-brain barrier, and also be transported to the forebrain through the olfactory bulb nerve, affecting the levels of serotonin and dopamine in the forebrain, resulting in psychological and emotional changes in patients, sleep disorders and post-anxiety stress disorders, which may also be one of the causes of long-term coronavirus symptoms sequelae of chronic fatigue.

Most people who suffered from the long COVID are characterized by brain fog, fatigue and pain. Mady Hornig, a psychiatrist at Melman School in Colombia, is known for her research on myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). She has made some of the most influential research on ME/CFS over the past decade to help establish ME/CFS as a biological disease rather than a psychological disease.She believed that research on the overlap between ME/CFS and Long COVID could help millions of people. In an interview with Columbia magazine last year, she said we could see an unprecedented wave of ME/CFS-like illness in the coming years and impose huge societal costs.

Mady Hornig found striking similarities between Long COVID and ME/CFS. First and foremost, it is a remarkable overlap of symptoms, particularly fatigue, lack of sleep, or "discomfort after exercise." Movement discomfort refers to physical discomfort that can be affected by even minor physical or cognitive movements, which is general discomfort. Viral infections can be traced to the onset of both Long COVID and up to 75% of ME/CFS cases.

Mady Hornig started with how SARS-Cov-2 impacts the nervous system and whether it continued to remain latent, infecting parts of the body that were invisible to testing. Her research on ME/CFS revealed how this happens. Because the immune response was hyperactive in the early stages of the disease, a state of immune failure ensued in response to chronic viral infections.

New research has confirmed that before the novel coronavirus infection, if patients have developed psychological diseases, such as insomnia, anxiety, depression, etc., after patients were infected with novel coronavirus, they are more likely to suffer from chronic fatigue. There is also evidence that infection with novel coronavirus can exacerbate this condition if the patient has a history of a similar chronic fatigue syndrome before the novel coronavirus infection.

4.How to treat the long COVID chronic fatigue?

At first, we need to take a thorough physical examination of our bodies, and besides taking routine examinations, we need to do another four examinations.

The first item: do several more PCR tests, and nasal and throat secretions should be dipped enough to check whether the result shows positive. If it shows positive, it means there is still some active novel coronavirus in the body.

The second item: evaluate whether diseases completely belonging to chronic fatigue syndrome according to the special examination of chronic fatigue syndrome. This test should be done more comprehensively, including specific assessment tests for fatigue, cognitive dysfunction, and pain. For example, complete blood cell differential examination, erythrocyte sedimentation rate examination, serum glutamate pyruvate transaminase examination, trace elements, blood glucose examination, serum creatinine, elevated urea nitrogen examination, electrolyte examination, thyroid function test, urinalysis, X-chest imaging.

The third item: further serum tests will be performed to check mainly which several viruses are still present in the body. Neuroimaging will also be performed to check if there are lesions in the brain.

The fourth item: further immunological tests should be performed. Test should be performed to check specifically whether the amount of p-tau217 protein in the blood exceeds considerably the person's average criteria. The result of excess means the brain is in the early stages of Alzheimer's disease.

Then, the results of the above comprehensive physical examination and four special examinations should be handed over to the doctor, and then the person should communicate with the doctor to describe one‘s own long COVID chronic fatigue in detail.

Additionally, the doctor can design the best treatment for you. Because the situation varied from person to person, after the interview the treatment plan given by the doctor is also different, so this paper cannot give a general treatment plan in this article.

The rough ideas for designing the treatment plan are as follows:

(1) According to the results of the patient's comprehensive physical examination and four special examinations as well as the communication with the patient, find out the most likely pathogenesis of the patient's long COVID chronic fatigue.

(2) Prescriptions are prescribed for treatment according to the pathogenesis and the patient's physical condition.

(3) For the main direction of medication, if novel coronavirus remains in the body, antiviral drugs such as Paxlovid should be used as a priority. If there is no virus in the body, the drug is used from the perspective of reducing or eliminating the chronic inflammation of the patient, improving the metabolic circulation and immune mystery of patients. For example, rintatolimod (immunomodulator) and coenzyme Q10 + NADH (mitochondrial modulator) can be used to improve the immune system of patients,.

(4) For the symptoms that seriously affect the work and life of patients, some drugs for improving the experience of symptoms can also be used according to the specific symptoms, such as drugs for invigorating the brain, refreshing the brain, stimulating the nerves, and other effects. Studies have shown that long covid chronic fatigue patients taken low-dose amitriptyline will achieve better efficacy.

(5) Oxygen therapy and brain physical massage can also be tried, and studies have shown that these two methods are also beneficial in removing chronic fatigue.

(6) If patients suffer from psychiatric symptoms such as insomnia, anxiety, and depression, they should seek help from psychologists and TCM to eliminate these psychological symptoms. This method is also helpful in removing long-term COVID-19 chronic fatigue.

5.How to treat long COVID chronic fatigue from a traditional Chinese medicine(TCM) perspective?

From the theory of syndrome differentiation and treatment of TCM, the treatment of long COVID chronic fatigue can obtain more accurate TCM syndrome differentiation and more suitable TCM formulas from the following three steps.

(1) Perform the observation, smelling, hearing, and inquiring of traditional Chinese medicine diagnosis, and consult the comprehensive physical examination report and four special examination reports of western medicine in the previous section at the same time. Only in this way can TCM doctors obtain the most detailed disease information of patients to support them to make the most accurate syndrome differentiation and treatment of patients' conditions.

(2) TCM doctors will classify and summarize the main symptoms, accompanying secondary symptoms, physical condition, and sick parts of the internal organs of the patients according to the most comprehensive disease information of the patients.

First, the main symptoms are the most unbearable symptoms of patients at present, such as long COVID chronic fatigue.

Second, accompanying secondary symptoms are that suffered from the main symptoms, the patient is experiencing other uncomfortable symptoms, such as feeling fatigued in a short time when using the brain, suffering from insomnia, anxiety, depression, and so on.

Third, to find out the physical condition of the patient, which means the patient's current physical health status, belongs to which category in the TCM constitution. For example, For example, yang-deficiency constitution, phlegm-dampness constitution, qi-deficiency constitution, blood stasis constitution, etc.

(3) TCM doctors, according to the above summary, combined with the internal organs and meridians related to symptoms, comprehensively use the theory and practical experience of TCM to make TCM prescriptions for patients. If acupuncture and moxibustion are required, these programs will also be prescribed.

Traditional Chinese medicine (TCM) theory is mainly based on: Zhang Zhongjing’s “Treatise on Febrile Diseases”, “Synopsis of Golden Chamber”, Huang Yuanyu's “Four Sacred Hearts Source”, “Typhoid Fever Suspension”, “Jinkui Suspension”, “Changsha Yao Jie”, Li Dongyuan 's “Treatise on the Spleen & Stomach”, and Zhang Jingyue' s “Jingyue Quanshu”.

TCM Practical experience, which can be found in Google Scholar (Fig. https://scholar.google.com/), and search for keywords for TCM treatment of long-term novel coronavirus symptoms. For example， COVID-19 Traditional Chinese Medicine, Long Covid Traditional Chinese Medicine. A large number of academic papers on medical research on the treatment of Long Covid by traditional Chinese medicine can be found in this way.

In order to make it easier for everyone to understand the treatment process of TCM, the following is a TCM treatment case of a patient with long COVID chronic fatigue.

Case 1:

Name: Zhao, female, aged 32 years, height 170cm, weight 60 kg.

MEDICAL HISTORY:PCR was positive for novel coronavirus on 17 Jan 2022, followed by typical symptoms of novel coronavirus infection: fever, cough, sore throat, sputum with blood streaks, ageusia, and anosmia. Two weeks later, the symptoms of novel coronavirus infection gradually relieved and disappeared. Later, long COVID chronic fatigue appeared successively.

Physical examination report of western medicine: (1) PCR test for novel coronavirus showed positive results again. (2) The special examination of chronic fatigue syndrome completely meets the criteria. (3) Fatigue PET (positron emission tomography, which can determine the occurrence and development of diseases by detecting the metabolic level of the human body) imaging analysis revealed images of decreased metabolic levels. (4) Pro-inflammatory markers were high and there was slight systemic chronic inflammation. (5) Immune system examination items revealed abnormal lymphocyte subset determination, C-reactive protein, and immunoglobulin data.

Main symptoms: fatigue, meeting the criteria of chronic fatigue syndrome.

Accompanying secondary symptoms: anxiety, insomnia, easy to wake up, dreaminess.

Prescriptions given by Western physicians:

(1) Paxlovid (paxlovid, antiviral drug, use to prevent the replication of novel coronavirus in vivo).

(2) Coenzyme Q10 + NADH (mitochondrial modulator).

(3) rintatolimod (immunomodulator).

(4) Vitamin C, vitamin E, and β-carotene. (Use to reduce the inflammatory reaction in vivo.)

TCM constitution: the body presents phlegm-dampness constitution and qi deficiency constitution.

TCM diagnosis evaluation: The body before being infected with the novel coronavirus was in a sub-health state with obesity, and the sub-health state deteriorates with the infection with novel coronavirus, presenting phlegm-dampness congestion, chronic fatigue and other symptoms.

Prescription given by the TCM doctor:

(1)Atractylodes lancea Baihu Tang is used to clear away heat and toxic substances, dredge meridians, and reduce chronic fatigue.

(2) Mailuotong capsules are used to dredge meridian vascular congestion.

(3) Chaihu plus Longgu oyster Tang are used to improve insomnia anxiety.

(4) Dabu Tang for deficiency of both qi and yin is used to remove phlegm and dampness and supplement vital energy.

Acupuncture program given by the TCM: Using an electronic moxibustion device, moxibustion on the following acupoints.

(1) Baihui, Neiguan, Quchi, Hegu, Taichong points are stimulated by moxibustion to improve cerebral blood circulation and metabolism.

6. Which kind of health products are beneficial to improving long COVID chronic fatigue?

Taking the patient above as an example, we give the following health product recommendations based on her condition:

(1) Omega 3 (Ω3) fatty acids, containing high amounts of DHA and EPA, are used to improve fatigue and protect against cardiovascular and cerebrovascular diseases.

(2) VC and VE are used to scavenge free radicals, anti-oxidation, and reduce systemic chronic inflammation.

(3) Curcumin is used to scavenge free radicals, anti-oxidation, activate NRF2, and reduce systemic chronic inflammation.

(4) Sulforaphane is used to scavenge free radicals, anti-oxidation, activate NRF2, and reduce systemic chronic inflammation.

(5) Melatonin is used to improve sleep quality.

(6) American ginseng is sliced for making tea or taken American ginseng capsules to replenish qi.

7.What exercises are beneficial to improving long COVID chronic fatigue?

Taking the patient above as an example, we give the following exercise advice based on his condition:

(1) Take moderate aerobic exercise at least three times a week, such as walking and jogging to remove phlegm-dampness.

(2) With the utility of gym equipment, strength training is performed for the major muscle group to improve insulin activity and lower blood glucose.

(3) Assist head massage.

8.What is beneficial to improving long COVID chronic fatigue in terms of diet and sleep ?

Taking the patient above as an example, we give the following diet and sleep advice based on her condition:

(1) Control carbohydrate intake, which means reducing the amount of staple food such as rice and noodle, to control of animal fat intake.

(2) Bubble bathing until slightly sweating before sleeping, and lie in bed to do general muscle tightness and relaxation training, improving sleep quality.

9.Patients with long COVID chronic fatigue are welcome to contact with our Long Covid Care Center

If there are similar symptoms among readers, contact our Long Covid Care Center for assistance.

Phone: +852 5765 5768

Whatsapp: +852 5765 5768

WeChat: longcovidcarecenter

Email: support@longcovidcarecenter.org

【Disclaimer: The treatment of diseases is a very complex and professional affair. Due to the limitation, Long Covid Care Center can only carry out remote simple interviews, unable to face-to-face offline interviews and obtain comprehensive physical examination results. Therefore, the suggestions, guidance, protocols, and documents conveyed by our Long Covid Care Center to patients can only be used as a reference for patients to understand their diseases in many aspects, but cannot be directly used as a treatment plan. Patients must discuss their symptoms with doctors in local hospitals through face-to-face communication. After the patients completed the physical examination required by doctors, they would get a prescription issued by doctors and get the treatment under the guidance of doctors. Therefore, Long Covid Care Center hereby declares that our center is completely exempted from liability when any adverse consequences are caused by self-treatment of the patient for applying any contents convoyed by the center, that is, we do not bear any responsibilities.】