Four months into the Covid-19 pandemic, we are only just beginning to understand the full extent of the havoc being wreaked by the coronavirus on the human body. Now, preliminary results from a new EU and government-funded study show that up to one third of Covid-19 patients have sustained organ damage, with 30 per cent of patients scanned, using advanced magnetic resonance imaging, found to have measurable damage to their liver, heart or kidneys. Researchers don’t yet know if the damage will be long term.
“The point of this trial is to see what damage Covid-19 does to the internal organs,” says Dr Rajarshi Banerjee, a consultant physician at Oxford University Hospital NHS Trust Foundation and founder of Perspectum, the medical technology company conducting the research. “When we started this in April it was one of the big unknowns. In the acute stage we knew that Covid could cause inflammation and lung and heart damage, but what about afterwards? This disease didn’t exist six months ago, so the world needs to find out.
“This is the first study in the world using quantitative state-of-the-art scanning and the key finding is that a significant number of patients, up to one third of the subjects, have residual organ damage after the initial infection. Did they have the damage before the coronavirus? It’s hard to say because they weren’t scanned in the same way before, but they definitely have impaired hearts, livers and kidneys now. We need to see if that recovers, so we’ll scan them again in six months. Most people are recovering, but how quickly we don’t know yet and it’s important to say these people we are scanning were the worse cases of Covid.”
So far 60 patients, aged 25-65, have been scanned, with a detailed analysis performed on 30.
“If people who have had coronavirus have long-standing organ damage we need to know how to follow them up and how to minimise it. It’s not as simple as you get the infection, then it clears and then you are completely normal. That massively affects the modelling assumptions and ideas around herd immunity, because herd immunity comes at a price and if 20-30 per cent of the population have impaired organs, which can lead to chronic disease, that’s quite a big price.
“We need to look to see if Covid patients are getting better, so that we can honestly reassure them that they will get better or that we will be able to look after them long term.”
So what’s causing this damage?
“One of the main effects of coronavirus infection is uncontrolled inflammation in the body – this is why steroids (dexamethasone) work to ‘damp down’ inflammation or the cytokine storm (when the immune system goes into overdrive, causing damage to the body),” explains Dr Banerjee. “Secondly, patients with Covid have widespread clotting (thrombosis) in many organs.
“Both inflammation and clotting can cause organ damage and I believe, at this stage, that the organ damage we are seeing is most likely due to one or both of these occurring in Covid patients. No one knows if or how it recovers.”
And which organs are vulnerable?
“From early results, a third of patients who have had Covid-19 have depressed heart pumping function,” says Dr Banerjee. “In most people, every beat of the heart should pump out over 55 per cent of the blood, but we’re seeing lots of patients under 55 per cent, which is mild heart failure.” The youngest patient who had a mild heart impairment was 25 years old. “In the past, they had played football, but now they feel tired after a reasonably gentle walk. We hope it will get better.”
In other conditions, there are drugs, like beta-blockers, that can be used when the heart is damaged, but it’s too soon to say whether these will be effective. “In coronavirus we don’t know what damage it causes, let alone what trials or drugs we should use.”
So far the scanning results show that men are suffering from more serious Covid-19 heart damage. In cases of inflammation of the heart, recovery usually takes four weeks to six months.
The Coverscan study revealed liver damage in some patients. “The inflammation is quite profound,” says Dr Banerjee. “When you scan them you can see it clearly.” But what are the symptoms? “The key thing here is lethargy. Their symptoms are mainly non-specific – fatigue, susceptibility to infections, piles and bloating.
“The liver has many functions in the body, it stores blood and produces proteins and antibodies and is the main metabolism centre, so if it is damaged many of these general infrastructure functions are impaired.”
Dr Banjeree believes that Covid inflammation sends the liver’s clotting function into overdrive, which can then lead to widespread organ damage.
“Clotting is often driven by the liver, so if the liver goes wrong, you can either get too much clotting or too little clotting. In the case of Covid we are seeing too much clotting and one of the things this does is cause organ damage.”
It’s not clear yet whether damage to the liver is long term. “In the liver we do know that inflammation and fibrosis can recover in weeks and months,” says Dr Banerjee. “In terms of management, if someone has liver damage maybe they’ll need specific diets or they’ll need advice to abstain from alcohol.”
Early findings suggest one in five patients have some kidney impairment.
“The kidney is a ‘multitasking organ’ and even mild disturbances can knock it off kilter,” says Dr Sandeep Kapur of London’s Mayo Clinic, who is the kidney lead in the Coverscan study. “The kidney removes waste and balances fluid levels. Kidney damage typically causes fluid retention so you can become a bit swollen, if things go wrong. When the kidneys fail the body becomes more acidotic, which all cells dislike and it upsets their ability to function.” The kidneys also play a role in producing hormones, says Dr Kapur.
“For kidneys it’s harder to determine a recovery period. They can recover in a matter of weeks... sometimes they don’t fully recover,” says Dr Banerjee.
Many patients continue to feel breathless even after initial infection clears, with scans revealing residual damage in some. “It’s the same two major pathologies: inflammation and clotting, so you get inflammation in the lung tissue and you get clots in the blood vessels, that’s why lots of patients get anti-clotting injections,” says Dr Banerjee.
“Then, after the initial infection, we are seeing lung fibrosis (scarred and damaged tissue) and some impaired movement of the lungs.”
And what can we hope for in terms of recovery? “We genuinely don’t know because no one has seen lung damage like this in other conditions.’
Loss of sense of taste and smell (anosmia) is an early warning sign of the virus and this is often an issue for younger Covid patients who don’t have any other symptoms.
A recent study found an average loss of close to 80 per cent of normal smell function, 69 per cent of normal taste function, and 39 per cent of normal skin sensitivity (chemesthetic function) from Covid-19.
Doctors have suggested that the virus is likely entering the brain and attacking the parts responsible for the sense of smell. Most patients regain their senses within 14 days, though for others it can take up to six weeks.
Brain and mental health
The Coverscan study didn’t look at the brain but other UK scientists are noting that Covid-19 can lead to brain and mental health issues. One study, published in Brain: a Journal of Neurology, reported inflammation (known as encephalitis) and blood clots that block the flow of blood and oxygen to the brain, causing strokes, even in younger patients.
Other patients experienced nerve damage causing post-infectious Guillain-Barre syndrome, in which the body’s immune system attacks the nerves. “There’s something about Covid that sends the immune system nuts,” says consultant neurologist Dr Tom Miller, a co-author on the study and researcher at UCL, “and the brain is much more susceptible to that than any other organ.”
Confusion (delirium) and memory issues were common.
The Daily Telegraph