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DOI: 10.26347/1607-2502202105-06011-017
POST-COVID SYNDROME: DISEASE CHARACTER, PATHOGENESIS CONCEPT AND CLASSIFICATION
Background. Already the first descriptions of the clinical course of the new coronavirus infection COVID-19 included reports of frequent lesions of the nervous system — from strokes to necrotizing encephalopathy and Guinein—Barré syndrome. Later, descriptions of the delayed disorders appeared: long COVID, post-COVID syndrome. There is no generally accepted clinical picture, classification and epidemiology of this syndrome. At the same time for six months, the UK has seen the 4-time increase of re-hospitalization among those discharged from hospitals after an infection and the 8-time-increase of mortality among them.
Objective. Description of the symptoms of the post-COVID syndrome with the formation of a «disease character» and assessment of possible pathogenetic mechanisms of the development of this condition.
Methods. An analysis of the symptoms described by patients in social networks was carried out, a questionnaire was formed, including the most common complaints, in October 2020, a survey of participants in social networks was conducted, 1400 questionnaires were analyzed. Based on the results of the analysis in February-March 2021, a second revised questionnaire was uploaded to the MeDiCase platform, which was used by 194 respondents. Since 1st September 2020, 292 patients with the post-COVID have been consulted online. All participants received recommendations for a set of laboratory tests, which included an assessment of the inflammatory status and in-travascular blood coagulation. The results of information support allowed the authors to form a classification of this state.
Results. The image of the disease included 29 main symptoms and signs, which made it possible to substantiate the hypothesis about the relationship between the main symptoms ofthe post-COVID syndrome and the development of meningoencephalitis caused by thrombovasculitis. The post-COVID meningoencephalitis (thrombovasculitis), hypochondriacal variant, post-COVID vasculitis of micro- and macrovascular in the skin and its appendages, secondary, including iatrogenic, functional-morphological changes in tissues and systems, certain syndromes of autoimmune reactions, post-vaccination covid-like syndrome. To confirm this hypothesis, research should be directed towards the study of the morphology of the nervous tissue, including the use of immuno-histochemical methods, the assessment of the immunological status and processes of intravascular blood coagulation.
Interpretation. A group of 29 common symptoms and signs of post-covid syndrome was formed: 17 of them are associated with dysfunction of the nervous system, 8 signs may be neurogenic in nature, and 4 relate to manifestations of vasculitis. In the pathogenesis of the post-COVID syndrome, there is meningoencephalitis associated with thrombovasculitis. Highlighted in the classification of the scallop syndrome require the development of complex pathogenetic therapy.
Keywords: COVID-19, post-COVID syndrome, MeDiCase, SARS-CoV-2 The authors declare no competing interests. Funding: the study had no funding.
For citation: Vorobiev PA, Vorobyev AP, Krasnova LS. Post-covid syndrome: disease character, pathogenesis concept and classification. Health Care Standardization Problems. 2021; 5-6: 11-17. DOI: 10.26347/1607-2502202105-06011-017.
Prof. Pavel Vorobiev1, Andrey Vorobyev2, Lubov Krasnova3
1 Moscow City Scientific Society of Therapists, Moscow, Russia
2 NewdiamedMedical & Technology Company
3 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
A new coronavirus infection COVID-19 caused by the SARS-CoV-2 virus has stimulated active scientific study of this infection and many associated problems. The first months of the COVID-19 outbreak saw attention paid almost exclusively to severe pulmonary complications, pathogenetic features of immunological reactions (the «cytokine storm») and activation of the blood coagulation — disseminated intravascular coagulation syndrome
(DIC) [1]. However, already the first publications describing the clinical course of the disease reported frequent damage to other organs and systems, among which it is necessary to mention the damage associated with the nervous system pathology — from strokes to necrotizing encephalopathy and Guillain—Barré syndrome [2]. A few months after the onset of the COVID-19 outbreak, descriptions of delayed disorders appeared, which have several
names: long COVID, post-COVID conditions, post-acute COVID syndrome1. This heterogeneous group of conditions has been included in the International Classification of Diseases, Tenth Revision, [3] with Code U09.9 — Post-COVID-19 Condition. However, there is no generally accepted clinical picture and an unambiguous understanding of the ongoing processes leading to the development of symptoms. The epidemiology ofthis syndrome also remains unclear due, inter alia, to different interpretations of the syndrome. Out of 47,780 people with the acute COVID-19 who were discharged from hospitals in the UK before August 2020, almost a third were re-hospitalized within the next 140 days (14,060), and more than 1 in 10 (5875) died, which, respectively, 4 and 8 times more often than in the control group [4].
The objective of this work was to describe the symptoms of post-COVID syndrome, form a «disease character» and assess possible pathogenic mechanisms of this condition.
We form the scopes as follows:
1) To assess the symptoms of the disease and give them a quantitative characteristic.
2) To develop and scientifically substantiate the pathogenesis scheme for symptoms of the post-COVID syndrome.
3) To present the clinical classification of the post-COVID syndrome.
METHODS
To form the image of the disease in July-September 2020 the Moscow City Scientific Society of Physicians (MGNOT) analyzed messages of patients on social networks, primarily in the Russian Facebook group «Atypical Coronavirus», which includes over 40,000 members2. Based on the results of a qualitative analysis of the complaints filed, a primary e-questionnaire was formed. The FB group administrators e-mailed a link to the e-ques-tionnaire to about 20,000 members. The questionnaire had 38 questions, including the most common complaints among patients. The respondent should have checked one or another symptom from the offered choice. In addition, an additional field was included for free writing of symptoms that were not mentioned in the questionnaire. Statistical processing of manually entered symptoms was not possible.
1 Video lecture: The post-COVID syndrome and the second wave: fix the roof before it starts to rain. By Prof. Vorobiev Pavel https://www.youtube.com/ watch?v=7INJnT_WXOY
2 Atypical COVID (Post-COVID) Facebook Group. https://www.facebook.com/groups/1419040198282314
At the second stage, we accepted 1400 responses of respondents for analysis and did statistical processing of the information received. We estimated the frequency of response to the question and compiled matrices according to the frequency of symptoms. At the third stage, in February-March 2021, a second revised questionnaire was added to the MeDiCase symptom checker platform [5] and the participants of the above group2 were invited to go through it. The symptom checker allows one to answer «yes» or «no» to closed-ended questions, has extensions to clarify the situation according to the type of «decision tree». Besides, there are scales for a number of questions to assess certain symptoms — from 0 (no symptom) up to 10 (the maximum severity of the symptom). Unique IP-addresses confirmed that there were no persons who passed the primary survey among those who passed the survey using the symptom checker.
The second task required a study of the literature not only on the problems of COVID-19, but also on the similar clinical manifestations of post-infectious complications.
In early September 2020, the authors began consultations by correspondence with patients suffering from the post-COVID syndrome in the Pavel Vorobiev's Medical Bureau specially established for studying this condition. Consultations by correspondence are held in accordance with the Russian legislation2 as a part of the responsible self-medication: the Bureau employees provide an applicant with advice and information support, and the decision has to be made by the client himself. All clients have received recommendations for some laboratory tests, including an assessment of the inflammatory status and intravascular blood coagulation. The results of informational support of 292 patients with the post-COVID syndrome allowed the authors to form a classification of this condition.
RESULTS
An online survey of 1,400 social networks users with the post-COVID syndrome showed that 76% of respondents were immunologically tested for COVID-19 (PCR or antibody test), and 24% did not do tests. 51.4% of the respondents had the infection previously confirmed, 24.6% had a negative laboratory test result. There were no significant differences in the frequency of symptoms between patients with confirmed COVID-19 infections and without confirmed diagnosis.
The duration of the post-COVID condition was less than 1 month in 22.7%, 1-2 months in 19.5%, 2-3 months in 13.5%, and more than 3 months in 44.3%. 74.1% has the wave-like nature of the course of the disease and 25.9% has the persistent symptoms.
The most common symptom (80% of the respondents) was weakness, while 58.6% were unable to perform their usual physical activity.
Periodic fever syndrome was observed in 50.8%, 47.1% had shivers or chills, 44.9% had night or day sweats. The connection between chills, sweating and fever was impossible to establish.
Neurological symptoms were identified in almost all respondents: 50.8% had insomnia, drowsiness, and disturbances in the change of day and night, 18.4% noted the appearance of unusual and vivid dreams, 45.2% had signs of depression and 43.6% noted headaches.
47.1% of the respondents had a feeling of chest congestion and lack of air; 43% had non-cardiac chest pains; 41.5% had tachycardia attacks; 30.4% had an increase in blood pressure and in 14.9% — a decrease in blood pressure (these symptoms were regarded by us as a violation of the nervous regulation of the blood pressure).
A large number of patients had signs of cutaneous vasculitis and vascular lesions: more than a third (35.1%) complained of hair loss, 19.6% had skin rashes, 18.2% had «nodes» on the veins, and soreness of the veins. A frequent cutaneous manifestation of the disease was the presence of goose bumps and a burning sensation on the skin (32.9%).
28.1% suffered from visual impairment, 13.6% — hearing impairment, 17.9% — gait impairment.
25.4% of respondents had diarrhea.
Other symptoms were less common (<10%) or we could not estimate their frequency: panic attacks, seizures, polyneuropathy, a feeling of vibration in the head and chest (some figuratively called this sensation of a transformer), concentration difficulty, distraction, forgetfulness, «fog in the head», gyne-comastia, menstrual irregularities, libido and other sexual disfunctions, dizziness, tinnitus and ringing in the ears, bruising, nasal bleeding, emotional lability, patophagia and pathoosmia (no sense of smell or haunted by smells, aversion to meat, chocolate, alcohol), toothache, dental problems (some have cystic changes in the jaw bones)), allergic reactions, edema, lymphostasis, lymphadenopathy. The results of this work have been partially published [7].
At the third stage, in the process of creating a symptom checker on the MeDiCase platform, taking into account the first version ofthe questionnaire and the emergence of clinical experience of remote work with patients with the post-COVID syndrome, the questionnaire was significantly revised, new questions and clarifications on symptoms were added to
it. The total number of questions was 137, of which there were 36 basic (mandatory for all) questions and 101 additional questions of the 2 and 3 order. The questionnaire included symptoms that are often found in this pathology or have a specific character, which was assessed empirically.
After the creation of an automated questionnaire in the above group2, invitations to take a survey were posted several times. As a result, 327 respondents took part in the repeated survey, 194 questionnaires were statistically processed. A negative response to the distractor «Did you answer truthfully to the questions posed?» was considered a reason to remove a questionnaire.
According to the results of this survey, the post-acute COVID lasts 1-3 months in 44.3% of cases, 3-5 months in 29.4%, and more than 5 months in 26.3% of the respondents. Women clearly prevailed over men — 78.9%; under the age of18 it was 3.6%, in the age group 18—55 — 82%, and over 55 — 14.4%. Acute COVID-19 was confirmed by a physician in 62.9%, 82% were tested for COVID, the diagnosis was confirmed immunologically in 87.4% of them (71.7% of the total number of respondents).
In terms of frequency, the symptoms were as follows (grouped the in descending order):
— weakness, fatigue — 84.5%;
— insomnia, daytime sleepiness — 77.3%. This symptom turned out to be quite painful, the overwhelming majority has various manifestations: 71.3% fall asleep poorly, 70% have superficial sleep, 78% often wake up in the early morning (especially it should be noted that many pointed to the time of waking up at 4 a.m.), 80 % wake up sleepy, broken, daytime sleepiness was noted in 72%;
— various manifestations of depression were noted by 68.6%, the same amount — anxiety, while a sense of guilt was in 50.5%, oppressive thinking about past mistakes — in 51.5% and suicidal thoughts — in 35.5% of the total sample;
— pain in muscles, bones and joints — 63.9%;
— palpitations, cardiac rhythm disturbances — 63.4%;
— impossibility to perform regular physical tasks — 60.3%;
— disorders of the blood pressure regulation was noted by 55.2%, an increase in blood pressure — in 76.6% and a decrease in blood pressure — in 37.4%; it should be noted that a small part of the respondents were worried about both the increase in blood pressure and its decrease;
— dizziness was observed in 52.6% (attacks of sudden dizziness in 67.6% and accompanied by gait disturbances — in 58.8%);
— chills was noted by 51.5% of respondents; this sign does not correlate with fewer and is an independent symptom of the disease: 34% had an increased body temperature, 34% had a decreased body temperature and 32% had a normal body temperature;
— violation of body temperature regulation was noted by 47.9%: 55.9% of the respondents noted an increase in temperature, and 90.4% had subfibril temperature (up to 37°C — 42.3%, up to 37.5°C 48.1%), febrile in 8.6% (up to 38.5°C in 8% and over 38°C in 3.8%); at the same time, a decrease in body temperature was noted by 47.3%, of which 52.3% — up to 36°C, 47.7% of respondents — below 36°C;
— night and day sweats worried 46.9% of the respondents, it is not possible to establish a correlation with hyperthermia: of those who noted sweating, the temperature was increased in 35.2%, decreased in 16.5% and 48.4% had a normal temperature;
— headaches, which did not manifest before — in 43.8%, and in 24.7% they were constant, and in 71.8% they were paroxysmal in nature (the rest did not give an answer about the nature of the pain; it should be noted that the respondent could indicate both characteristics at the same time);
— hair loss — 41.2%;
— visual impairment — 40.7%. Patients describe this condition in different ways: 84.8% as a focusing disorder (which, possibly, reflects dysfunction ofthe oculomotor nerves), subjective decrease in visual acuity — 83.5%, flashes in the eyes — 44.3%;
— chest pain was in 43.3%. This symptom worries patients very much and they give colorful descriptions of it, the frequency of which significantly exceeds that in the population: unbearable pain behind the sternum in 10.3%, pierces from front to back in 25.9%, accompanied by cold sweat, weakness, interruptions, shortness of breath in 62.1%. Such characteristics require the assumption of the acute coronary syndrome, but it is obvious that this is not the case. Respondents coexist with this symptom for a long time, many performed ECG and Echo without detecting pathology, which indicates the pseudo-coronary nature of this cardialgia;
— tinnitus, hearing impairment in 40.7%;
— weight loss 40.7% (up to 5 kg 58.2%, within 5—10 kg — 34.2%, and more than 10 kg — 7.6% of respondents;
— unusual vivid dreams appeared in 37.6%;
— chills on the skin noted 37.1%, burning, tightening of the skin — 35.1%;
— chest congestion, breathing problems were in 36.6%. Most often, it is not about shortness of breath, but about the inability to take a deep breath;
— skin rashes were reported by 25.3% (28.6% of them had had such rashes before, 71.4% had them for the first time);
— disrupted appetite in 28.4%;
— sexual dysfunctions: irregular menstrual cycle in 27.7% of women, and decreased libido and sexual vigor — in 7.2% of men;
— frequent urination was in 24.2%;
— gait disorder — 24.2%;
— loose stools — 22.7%;
— vein nodes resembling aneurysms, vein soreness, altered venous pattern were noted by 22.7% of respondents. This is a somewhat unusual feature that has not received sufficient attention before. The vascular mesh on legs was noted by 75% of the respondents in this subgroup; soreness, burning along the veins — 50%, knots or bulging in the veins — 50% (the latter are clearly visible in the photos provided by some respondents);
— an increase and soreness ofthe lymph nodes was in 18.6% ofthe respondents and may indicate immune processes, of which 77.8% in the submandibular region of the neck, in the axillary region — in 30.6%, in the groin region — in 19.4%; a quarter of the respondents had enlarged lymph nodes in various regions.
So, the symptoms and manifestations of the post-COVID syndrome — the disease character — are diverse and affect almost all organs and systems. At the same time, it is obvious that they do not signal any intoxication, tissue decay — most likely they reflect an active inflammatory process. We are well aware of systemic inflammatory, aseptic, chronic processes that are combined into a group of rheumatic diseases. However, the existing symptoms do not fit into any known nosology form. Thus, we likely talk about a relatively new post-infectious pathology, which, however, had been known for many infectious diseases, such as chikungunya, Ebola, borreliosis, etc. [8, 9].
When analyzing the above symptoms, we need to say that a significant number of them are associated with some pathologies of the nervous system (central, peripheral, sympathetic and parasympathetic, metasympathetic). These symptoms may include 17 out of 29 symptoms listed above. Four signs are definitely not associated with nervous regulation (enlarged lymph nodes, aneurysmal and other changes in
veins, skin rashes and hair loss). However, the remaining 8 signs (diarrhea, urinary disorders, sexual dysfunctions, weight loss, cardialgia, cardiac arrhythmias, myalgia and arthalgia) can also be neurogenic in nature. It is these functions that are regulated by the sympathetic, parasympathetic and meta-sympathetic divisions of the nervous system.
However, there is a question: How is the nervous system damaged? It is known that the tropism of the SARS-CoV-2 virus to nervous tissue is not high: its penetration into the nerve endings on the nasal mucosa is being discussed, which sometimes explains anosmia and augesia, migration along the olfactory tract or through the vagus or trigeminal nerves, [10] however there is no definitive and convincing evidence of this. A histochemical study found the SARS-CoV-2 protein in the endothelium of cerebral vessels, but not in the neurons or glia [11]. The authors note that the presence of the SARS-CoV-2 in the central nervous system (CNS) results in a local CNS response mediated by the HLA-DR+ microglia as effectors of the myeloid-induced inflammatory response. The authors correctly conclude that since they were able to detect the SARS-CoV-2 RNA in areas of the brain (for example, the cerebellum, which is not directly connected by any pathways with the olfactory mucous membrane of the nose), there may be other mechanisms for the virus penetration into the central nervous system, possibly, in addition to or in combination with the axonal transport. For example, migration of the leukocytes carrying SARS-CoV-2 across the blood-brain barrier or penetration of the virus along the endothelium of the central nervous system cannot be ruled out. In confirmation, immu-noreactivity to the SARS-CoV-2 protein was found in cerebral and leptomeningeal endothelial cells.
There are two interesting arguments of the authors of the cited work, which partly coincide with our assumptions: 1) The detection of some traces of the SARS-CoV-2 in the brain stem, which includes the main center of the respiratory and cardiovascular control, suggests that infection of the nervous tissue can aggravate or cause respiratory or heart failure mediated by the central nervous system; and 2) the SARS-CoV-2 in the endothelium of the brain tissue can lead to vascular damage and, a wider spread of the virus to other areas ofthe brain, which will cause a more severe course of the disease or its transition to a chronic form.
The histopathological analysis of the brain tissue showed microglial nodules and phagocytosis of neurons (neuronophagy) in the brainstem and, less com-
monly, in the cortex and limbic structures, associated with the lymphocytic infiltration, and no correlation between histopathological findings and viral messenger RNA levels in the same brain [10]. Brainstem involvement may explain persistent autonomic abnormalities and anxiety (panic attacks). Inflammatory reactions characteristic of the invasion of the SARS-CoV-2 may play a role in the damage to the brain structures. It is inflammation that plays a key role in the acute period of the disease in the development of complications triggering intravascular blood coagulation, having a direct negative effect on many functions, including brain tissue. The penetration of the virus into the endothelial cells of the vascular network of the brain activates neutrophils, macrophages, thrombin, promotes microthrombosis and impaired vascular permeability. Tumor necrosis factor (TNF-a), cytokines can cross the blood-brain barrier due to its increased permeability. The cy-tokines activate microglia and astrocytes. Macro- and, especially, micro-hypoxic ischemic damage and heart attacks in the brain tissue mediate pathological syn-aptic pruning by microglia (cells of macrophage nature) — a decrease in the number of synaptic connections. Microglia secrete specific inflammatory mediators, including quinolinic acid, which increases glutamate levels and regulation of the NMDA receptors, which can cause mnestic disorders — learning, memory, neuroplasticity, as well as cause hallucinations and nightmares, and disturbed sleep.
If for the acute period of the disease all the above reasoning and findings look quite convincing, then there is no such information for the post-COVID syndrome. Moreover, there are no signs of a viral infection. Therefore, recognizing damage to the brain tissue, it is necessary to look for other, non-infectious causes of its damage. This reason is most likely an immune chronic inflammation involving micro vessels, which can be called immunothrombosis, thrombovasculitis, endotheliopathy. The key role is played by the various antibodies that form immune complexes or have a direct damaging effect on the structures of the nervous tissue. The most known include antiphospholipid antibodies, antibodies to an-timyelin-oligodendrocyte glycoprotein [12].
An additional factor supporting the immuno-thrombosis theory is numerous other conditions — various vasculitis of the skin, visible damage to the venous vessels, degenerative changes in the nails (transverse striation, Bo lines) [13], Kawasaki-like syndrome with damage to the vasa vasorum, etc.
Thus, we propose the following definition of the post-COVID syndrome: a clinical condition that occurs several weeks after an episode of acute COVID-19 infection, ended with clinical recovery and is characterized by nonspecific neurological symptoms associated with meningoencephalitis, cutaneous vasculitis, and sometimes mental abnormalities and dysfunctions of individual organs and systems.
Based on the foregoing, using our empirical experience in the management of patients with post-COVID syndrome, we propose a clinical classification of the post-COVID syndrome:
1) Post-COVID meningoencephalitis (throm-bovasculitis)
— with damaged central, peripheral, autonomic metsympathetic nervous system (including motor and sensory disorders);
— with damaged cardiovascular metasympathet-ic division of the nervous system (cardiovascular manifestations, impaired peripheral heart function);
— with damaged enteral metasympathetic division of the nervous system (regulation of the digestive system);
— with respiratory dysfunction;
— with urination dysfunction;
— with hormonal dysfunction — thyroid gland, cycle disorders, sexual dysfunctions and
— with dysfunction of higher nervous activity (including depression, cognitive disorders, panic attacks, suicidal thoughts).
2) Hypochondriacal variant of the post-COVID syndrome.
3) Post-COVID vasculitis of micro- and mac-rovascular in the skin and its appendages (skin manifestations, hair loss, Bo lines).
4) Secondary, including — iatrogenic, functional and morphological changes in tissues and systems (pulmonary, renal, hepatic failure, consequences of deep vein thrombosis of the lower extremities, stroke, myocardial infarction, pulmonary thromboembolism, microbiota disorders).
5) Certain syndromes of autoimmune reactions: Guillain—Barré syndrome, Miller-Fisher syndrome, Kawasaki-like syndrome, etc.
6) Post-vaccination covid-like syndrome.
It is desirable to indicate additional features for each facet of the classification
— with laboratory or instrumental confirmation of an acute episode of COVID-19;
— with laboratory confirmation of inflammation, intravascular coagulation of blood, presence of other markers, for example, changes in hormonal status;
— with instrumental confirmation (morphological and functional markers of changes in brain tissues and functions);
— without laboratory and instrumental confirmation.
The international classification of diseases (ICD-10) is not a clinical classification and is used for the purposes of statistical analysis of diseases and causes of death. Direct use of ICD-10 in clinical practice is not provided. It should be noted that this classification is changing rapidly, so what was true until recently may have already been canceled or replaced. As of January 2021, there are several codes in the ICD-10 relating to the post-COVID syndrome:
U08.9 Personal history of COVID-19, unspecified. This additional code is used to record an earlier episode of COVID-19, confirmed or probable, that affected a person's health, but the person is no longer sick with COVID-19.
U09.9 Post-COVID-19 Condition. This optional code allows one to link their condition with COVID-19. It should not be used in cases where there are signs of acute COVID-19 infection.
U10.9 Multisystem inflammatory syndrome associated with COVID-19, unspecified.
Time-linked to COVID-19:
— cytokine storm;
— Kawasaki syndrome;
— multisystem inflammatory syndrome in children (MIS-C);
— Pediatric Inflammatory Multisystem Syndrome;
— Excludes: mucocutaneous lymphatic syndrome [Kawasaki] (M30.3).
U12.9 COVID-19 vaccine causing adverse effects in therapeutic use, unspecified. This code is to be used as an external cause code (i.e., as a subcategory under (Y59) Other and unspecified vaccines and biological substances). In addition, a code from another chapter of the classification should be used to indicate the nature ofthe adverse effect—«Correct administration of COVID-19 vaccine in preventive therapeutic use as the cause of any adverse effect».
CONCLUSION
The creation of an image of the disease using automated questioning systems makes it possible to formulate and substantiate a hypothesis about the
connection between the main symptoms of postcoid syndrome and the development of meningoencephalitis, which in turn is caused by thrombovasculitis. To confirm this hypothesis, scientific research should be directed towards the study of the morphology of the nervous tissue, including the use of im-munohistochemical methods, the assessment of the immunological status and processes of intravascular blood coagulation. An important limitation of our study is the formation of a sample exclusively from individuals — users of social networks on the Internet. Patients limited in the use of the Internet did not fall into the field of view of this study: they, quite naturally, may constitute a cohort of patients with other, more severe postcoid complications described in [4]. For such patients, a separate facet is allocated in the proposed classification.
INTERPRETATION
1. A double survey of patients with the post-COVID syndrome made it possible to form a group of 29 most common symptoms and signs, and 17 of them are associated with dysfunction of the nervous system (central, peripheral, sympathetic and parasympathetic, metasympathetic), 8 signs can be neurogenic in nature, and 4 refer to the manifestations of vasculitis.
2. Based on the analysis ofthe clinical picture and literature, a scheme of the pathogenesis of the post-COVID syndrome associated with the meningoen-cephalitis against the background of thrombovasculitis was formulated.
3. On the basis of a mixed facet-hierarchical approach to the classification of the scallop syndrome, several forms of this condition are identified, signs associated with additional examination methods are identified, similar approaches from the current version of the ICD-10 are presented, which allows one to develop a pathogenetic therapy.
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Received: 29.04.2021 Accepted: 12.05.2021
About the authors:
Prof. Pavel Vorobiev — Sc.D. in Medicine, Chairman of the Moscow City Science Society of Physicians, Moscow, Russia. E-mail: paanvo@me.com
Andrey Vorobyev — Ph.D. in Medicine, President of the Newdiamed Medical & Technology Company; Project Director of the Moscow City Science Society of Physicians, Moscow, Russia. E-mail: a.vorobiev@newdiamed.ru.
Lubov Krasnova — Ph.D. in Medicine, Assistant Professor of the Department of General Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia. E-mail: aelita8@yandex.ru.
