July 11, 2022

It’s 7-11 and no Slurpee… Do they even have 7-11 stores anymore? I haven’t seen one in years but they may be a West Coast thing. They certainly aren’t here in Alabama. We have our own versions such as Kangaroo Mart and the ubiquitous Family Dollar and Dollar General stores. But 7-11 is always going to mean something a bit different to me. It was my and Tommy’s legal anniversary. It’s not the date we celebrated as our anniversary (that was October 27th, the day of our first date) but the day, some eleven years later that we stood in front of the judge at the King County criminal court, right after the grand theft auto trial, and said our ‘I dos’ and emerged with a legal document declaring us husband and husband. It was a year before Obergefell so same sex marriage hadn’t yet arrived in Alabama but it was after Windsor so the federal government was recognizing a valid state marriage for tax and other purposes so Tommy and I decided on one of our trips to Seattle to visit family, to tie the knot for mutual protection as Washington had recently legalized same sex marriage. I got hold of an old high school friend who put us in touch with a judge and the pieces fell into place. We knew we didn’t want a wedding… we’d been together too long so a simple courtroom ceremony with a couple of witnesses and a family dinner to follow was about right. Tommy has now been dead longer than our legal marriage lasted, cut short by his untimely demise.

Covid numbers continue to increase across the country, fueled by the fast spread of omicron BA 5. It’s more contagious than prior, more apt to elude immunity, and even outdoor events are becoming super spreaders. The hospital numbers are beginning to increase in New York City and other urban areas so I expect death numbers to begin going up as well. Should we be concerned? I don’t know that I can completely answer that. Most people are coming down with mild disease and recovering with minimal difficulty but I don’t know that things will remain that way. And then there’s the prospect of long covid.

If you do much reading regarding COVID and its symptoms these days, you eventually run into the terms ‘Long Covid’ or ‘Post Covid Syndrome’ being applied to people still experiencing symptoms of the disease months after the acute infection or, in some cases, having entirely new symptoms and problems that can be traced back to an initial COVID infection of some months previously. It appears to be an issue in all sorts of people and can occur whether the initial infection was mild or life-threatening.

Long Covid Issues

It’s a tricky issue to study. How do we make determinations about chronic disease with an infectious agent that’s only been present in human beings for less than three years? How do we even define which cases fit a definition of Long Covid when neither the CDC or the WHO, or any other major public health body, has standardized any sort of definition for what constitutes the disease and what does not? Enough data has been coming in over the second year and into the third of the pandemic to suggest that Long Covid is a real entity. It’s not at all clear what causes it.

One theory is that in some people, the immune system is ineffective at fully clearing the virus from the body, and that there are small pockets of viral load hidden within various internal organs which are continuing to infect cells and creating new symptoms. Another theory is that there is a cross-reactivity between the immune system and normal tissue. The virus stimulates the immune system to attack normal body tissues and cells in an autoimmune response creating the symptoms. Either is possible and we’ll likely eventually figure it out but who knows at this point?

How many people have Long Covid? No one knows as no one can even agree on what it is. The UK has put out studies estimating that about 3% of those who catch and recover from the disease will have long term sequelae. Some groups in the USA have suggested that this is a gross undercount and that upwards of 25-30% may have some sort of long term issues. This means that somewhere between two and 20 million Americans currently have Long Covid. What sort of treatments and supports they might need now and in months to come are anybody’s guess. Most large health systems, especially those with an academic component, have established specialty Post-Covid Clinics for long term monitoring and symptomatic therapy. As they collect and publish data over the next few years, we’re going to learn a lot more.

What tissues are involved? Well, the angiotensin converting enzyme (ACE) receptors which act as the doorway to the cell for the virus (it’s the thing in the cell wall that the spike protein is able to grab onto and anchor down) are found throughout the body. They are especially prevalent in the heart and vascular system. One of the more common groups of blood pressure medicines, the ACE inhibitors like lisinopril and enalapril also work through these proteins. It’s thought that the propensity of the virus to induce clotting may be somehow related to this concentration in the vasculature. The big issue here is the heart, which has the highest concentrations of ACE receptors. Data coming out of the VA suggests that prior COVID infection is a significant risk factor for later heart and cardiovascular complications with rates of stroke, heart attack, inflammation of the heart muscle, and arrhythmias all much higher in those who had infection versus those who did not. Serious infections requiring hospitalization or ICU stay increased risks of heart issues astronomically after recovery with rates four or five times those of control populations. Exactly what mechanisms are involved aren’t known as of yet.

Studies out of Europe show that the patterns of Long Covid vary significantly by sex and age. Women, especially younger women, seem to be at highest risk. Some of that may be due to women’s more frequent seeking of health care and encounters with the health care system leading to higher levels of reporting but there’s also some thought that the immune systems of women of reproductive age, being somewhat more active so as to protect the potential fetus, might be working slightly differently when they encounter the virus. Younger people of both sexes are more likely to report altered taste and smell over prolonged time than older people, while older people are more likely to have GI effects.

In about 40% of people, Long Covid presents as a relapse several months after the initial infection has been cleared. They may be well for three or four months and then start to have fatigue and other significant issues that may limit activity. These kinds of symptoms aren’t unique to Covid. Other viruses can cause post-viral symptoms, including the closely related SARS and MERS, but even more common things like the flu can do it, too.

What does all this mean? It means the coronavirus is not a great thing to have in your body and should, therefore, be avoided. If you do get it, you want it to be the mildest case possible. A case that puts you in the hospital may have unpleasant side effects down the road. How can you ensure that? Get your vaccine and your boosters. It’s by far the best weapon we’ve got to keep people as hale and hearty as they can be.

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