In this interview on The Empowering Neurologist, Dr. David Perlmutter talks with Dr. Carlos Del Rio, a distinguished professor of infectious diseases at Emory University, about the emerging problem of long‑haul COVID. They define long‑haul COVID as persistent cardiovascular, pulmonary, neurological, and psychological symptoms that continue weeks to months after the acute infection, affecting both hospitalized patients and those who were never hospitalized. Early reports from Italy and CDC data suggest 14‑20% of recovered patients, and up to one‑fifth of non‑hospitalized cases, experience lingering symptoms such as fatigue, cough, and shortness of breath. The discussion covers three major organ‑system impacts—cardiac (myocarditis, arrhythmias, ongoing inflammation), pulmonary (fibrosis after severe pneumonia), and neuro‑psychiatric (cognitive deficits, mood changes). They note that post‑ICU syndrome complicates attribution, but even young, healthy athletes show cardiac involvement on imaging. Predictive markers are currently lacking; underlying conditions like obesity, diabetes, and age increase risk of severe disease, which in turn raises the chance of long‑term sequelae. The conversation highlights the need for systematic cohort and immunologic studies, the role of emerging post‑COVID clinics, and the importance of NIH‑coordinated research. Finally, they discuss vaccine development, emphasizing that mRNA technology builds on a decade of research, that vaccination offers hope but will take time to impact population‑level outcomes, and that continued public‑health measures remain essential. The interview underscores long‑haul COVID as a potential “second health crisis” requiring greater awareness, research, and clinical infrastructure.
Chapters
Well, hello everyone. I'm Dr. David Perlmutter. Welcome again to The Empowering Neurologist. You know, a new term has entered our lexicon in relationship to COVID-19. It's called long-haul COVID, and what does that mean? Well, there's a lot in this term that I think we need to unpack. It means that people don't just get COVID, go through their symptoms, and then make a recovery, that there are a significant number of individuals, and we're going to talk about that today, who in fact may be left with persistent issues related to cardiovascular function, pulmonary function, neurological issues, and even psychological issues. and it's becoming more important. We are now recognizing that this may represent a second health crisis related to this virus. So we really want to explore this notion of long-haul COVID, what it's all about, what may be causing it, and what the future looks like. Our guest today is Dr. Carlos Del Rio. He's the author of a recent report appearing in the Viewpoint section of the Journal of the American Medical Association entitled, Long-term health consequences of COVID-19. Dr. Del Rio is a distinguished professor of medicine in the Division of Infectious Diseases at Emory University School of Medicine in Atlanta. So we're going to get right to this interview. Hello, Dr. Del Rio. Thank you for joining us today.
Delighted to be with you.
You know, we had this assumption that the COVID event was pretty much going to be a monophasic event for people that Most people who got it now, we have 74 million at least recorded infections globally, that most people who get this situation are going to have it, do a little bed rest, and pretty much recover and do pretty well. But you brought to our attention the notion that that isn't exactly what we are now seeing. So, when did this all change in terms of our perception?
Well, I think it started with some reports initially coming out of Italy and then coming out of other places. Suggesting that about 14 to 20% of people who recovered from clinical COVID, primarily hospitalized at that point in time, did— 3 months after they had recovered, continued to complain of some symptoms. And those symptoms were fatigue, arthralgias, cough, shortness of breath. And it was a little unusual to see people that long after hospitalization still having complaints. We then also started to see it ourselves. We started to see people that had recovered who continued to complain of symptoms. We have continued to see it. And there's a colleague of mine that actually wrote a perspective about this in JAMA, an emergency medicine physician saying, I just don't feel normal and I can't go back to work. And then we started to see other studies. There was a very important study from the CDC in which they called people who had tested positive and many of them had not been hospitalized. And 1 in 5 continued to complain of symptoms at least 3 weeks after they, quote unquote, had recovered.
Well, we know that the NIH just a week or two ago put together a meeting to really start to contextualize this, recognizing that exactly what you're describing may be affecting millions of people around the globe. And this, this may be kind of the second health crisis associated with this whole pandemic that You know, really hasn't gotten much recognition as of late.
Yes, I mean, I think the NIH is, you know, we have what I would call at this point in time descriptive data, we have anecdotal data, but we actually need now some science, right? We need some cohort data, we need some immunological data, we need some really science behind this. Because as you know, you know, we see long-term impact on respiratory system and others from people that have been very sick in the ICU regardless of any disease. So how do we separate what I would call the ICU, the post-ICU syndrome, to what could be the consequence of COVID And I think there's 3 major buckets that we all need to realize that are happening with COVID One is in the cardiovascular system. And again, the studies have been maybe biased, but we have seen descriptions of myocarditis and arrhythmias and heart failure in people who have recovered from COVID Ongoing myocardial inflammation. We see respiratory complications with, you know, I tell people that the lung only knows one way to recover, and that is through fibrosis, right? So if you have a lot of pneumonia and you were on a ventilator, maybe you'll develop fibrosis and therefore have that long-term effect. But to me, also very interesting are the neuropsychiatric impacts. And we're seeing these patients increasingly, and this is affecting their ability to concentrate and to do other things. And to me, That is very concerning.
Well, you know, you do talk in your article about the idea that it's not uncommon for people getting out of the ICU, especially those who are on assisted ventilation, mechanical ventilation, to in fact have issues, as many as 46%, down the line for a number of weeks, if not months. But one of the points that you made that I think is really has a lot of traction is the notion that many of the people who are being involved with this are people who did not end up in an ICU and may not have even been hospitalized, may have had a symptomatology done, taken care of at home, and yet don't fully recover. So is there a way that we can predict, because of this dichotomy with respect to our previous understanding of post-illness events, Is there a way we can predict who might be more at risk for developing long-term consequences?
There's a lot of interest in developing data, in understanding, doing more predictions. But at this point in time, I don't think there's anything that clearly suggests the ability to predict this. Obviously, if you have underlying conditions, you're most likely to not recover fully. But, you know, we've seen athletes, we've seen people that are just doing fine. and have long-term impacts. So I think at this point in time, I think that's part of the science that we need is how do we, is there any predictive model, is there any immunological marker, is there something else that we need to look at?
I mentioned in the introduction a bit about what you were saying about athletes. And these are individuals who do post-COVID undergo either imaging of their heart or clinical evaluation of heart function. And what you reported was really a significant percentage of those young, healthy college athletes who have evidence of post-COVID damage.
Yeah. And, you know, again, we need a denominator, but each one, every one of those cases, I mean, you know, young people who then develop myocarditis and that could impact their career, I think everybody pays attention to, right? And so, These cases are something that to me are very interesting, incredibly puzzling. And we see in some biopsies evidence of viral infection in the myocardium, and others we see evidence of cytokine storm, cytokine damage to the myocardium. So I think understanding fully the pathogenesis is gonna be really critically important because is there also anything we can do to prevent it?
Well, you mentioned in terms of the neurologic issues, how common that is and how concerned you are about that. When you multiply that times the number of people who may ultimately be experiencing this, what are some of the proposed mechanisms that may be at play here? You just mentioned the cytokine storm, of course, and we know that the brain does not respond favorably to various cytokines, both acutely and certainly long-term as it relates to chronic neurological degenerative conditions. But what are some of the other mechanisms that are proposed that might at least Well, one is clearly, you know, direct impact of the virus.
And we see that, for example, in HIV, HIV-associated dementia and others. The other one is obviously, you know, whether this is mediated by immune cells like macrophages and other cells that may be causing this. I mean, the reality is that we need a lot of research in this area, and we really need a more in-depth understanding of what exactly happens. But I think what is clear is that this is a very serious disease. What this is showing us is that COVID in some individuals, it's a systemic illness, right? It's not just a viral respiratory infection. And I think that to me is a really important concept to get across because for many of us initially, as we said, we thought COVID is gonna be like other coronaviruses, just a respiratory infection. But obviously it's more than that and it has systemic implications.
You know, one of the important points that your article brings up and that I really want to emphasize today is there seems to be this sense among younger, healthy individuals that, you know, well, whatever, if I get it, I'll get it and I'll recover and sort of that's it. What's the big excitement about? It's nothing more than a hard flu. So this really challenges that whole mentality, doesn't it?
Well, it does. And again, it's absolutely true, the great majority of people are going to do fine. But I make it similar to saying driving fast or driving under the influence, the great majority of people are not going to die, right? But increases your risk significantly. And I think that's what is so hard to communicate to people. It's not that it's going to happen to everybody. But your risk of this happening goes up, and it goes up significantly. And, you know, there was even a paper yesterday in JAMA talking about, calling to attention the excess mortality in young people. And we see young people, again, having a significant, almost a 38% increase in excess deaths. So that becomes significant.
When it comes to symptoms, I mean, bad outcome, let's say, as it relates to this infection, And we know that there are certain groups at risk for that bad outcome, such as individuals with existing cardiovascular disease, diabetes, obesity, and certainly chronological age. What is it about these individuals that really paves the way for them to have a bad outcome? And further, if I may, would these people be at increased risk, in your opinion, for— with respect to long-term issues related to this infection?
Well, I think the fact that this virus has a much higher mortality the older you get, I think it's something that— it's not unexpected, but it's been so consistent throughout this crisis that I think makes it very hard to fully appreciate the impact. The mortality, the case fatality depends on really on your age. But I think there are 2 things, diabetes, but in particular also morbid obesity. That drives a lot of this. And, you know, I tell people that if you are 20 or 30, but your BMI is 40, then your risk of severe disease, death, and complications is more like a healthy 70-year-old person. And I think it really emphasizes the impact of this so-called noncommunicable diseases in a communicable illness. And what we have seen this in other diseases, I mean, this we've known in flu for a long time. People with influenza that have morbid obesity are more likely to have complications and death. I think really COVID has really brought that to the forefront, and we really need to start paying attention to better management and addressing hypertension, diabetes, obesity as public health issues and really bringing those problems down under control. But the other issue is really around, does that increase your risk of long-term complications? I'm not aware of any data that suggests that, but it certainly increases your risk of getting severe disease. And as you get severe disease, you're more likely to have complications.
And finally, why does it seem that aside from, you know, the journals and some of the popular press, that this notion of long-term consequences has generally been overlooked by, you know, the vast majority of population?
Well, I think, you know, you're all— we're all like drinking from the water hydrant, right? I mean, in the ERs and the ICUs, we're just trying to basically keep people alive and do the best we can. So we still have not sat down to see what happens when people start showing up in clinic. But as post-COVID clinics are opening up across the country, we're beginning to see this. And I think those post-COVID clinics are clearly the place where these cohorts and these multicenter studies can be set up. And I think NIH is really very interested in understanding this at a population level and really giving us a better description of the syndrome and understanding the pathogenesis and possibly some intervention studies, which I think are going to be critical.
I think it's really important that we be in a position to appreciate the nuances that become obvious about this event as time evolves. I remember early on there were some concerns about one form of treatment versus another. Would acetaminophen versus a nonsteroidal anti-inflammatory increase your risk of bad outcome, et cetera? So I think, you know, an important message here is that people should in general be available and open to kind of a changing narrative as it relates to this novel experience that we're having.
I think so. I think one thing that coronavirus has done is challenge our conventional wisdom, right? And made us think outside the box. And I think we need to do that. I think we need to start thinking. And when we think about chronic long-term COVID, start thinking about what could it be and what things can be done. And I hope that the research is done early as opposed to wait and start trying things without protocols and without, you know, sort of experimental approaches.
Well, that said, it's certainly clear that immunizations have been expedited in a way that we've never seen before. It looks as if, you know, based on the mechanisms of how these mRNA immunizations work, that it's probably going to turn out to be an appropriate expedited approach. What is your sense in terms of where we are currently on immunization and How might that ultimately be, in your opinion, effective long-term with respect to not just COVID as we see it now, but perhaps some of the permutations that may come down the line?
Well, I think, let me just say that the technology that has allowed us to have these vaccines is, while it's new in the world of vaccinology, is not new. mRNA and DNA vaccine technology have been, you know, researched for the last 10 years. And again, emphasizes the importance of basic science research that led us to develop these techniques and these approaches that then were tested in COVID and work effectively. And I think it really emphasizes the importance of research and basic research in getting us there, giving us the tools that we're using. The second thing is I think that the way that the vaccines are now ready to start rolling out and they're rolling out in different places across the country and across the world is incredibly exciting, gives us all hope, you know, that there's a light at the end of the tunnel. But I think about it more about, you know, We just started the hike to the peak of Everest. It's going to be a long road ahead. It's going to take a while to get there. And many are going to die on the way up there because there's still ongoing transmission. There's still thousands of people dying in our country. So while the vaccines are going to give us hope, it's not going to be immediate. It's going to take some time to get to where we need to. I think by the summer, it's going to be in a different position. I think by the summer, we're going to see the true impact of the vaccine at the population level. But for the time being, we still have a long road ahead with a lot of disease happening.
I think that for 2 reasons. A, the possibility of these long-term issues, symptoms that we've talked about today. And B, because of the— I wouldn't say delay, but just the fact that there's a timeline associated with immunization, that now is not the time to cash in the chips. And I've been saying we really need to double down on our efforts to do all the things that we know are Proven effective in terms of reducing our risk. You know, I wouldn't say we see the light at the end of the tunnel just yet, but we know it certainly looks like it's coming.
I would agree with you, and I think it's exactly right. You don't want to— this is the time to double down and actually get to the time you get vaccinated alive and not infected.
Terrific. Well, listen, thank you so much for your time and also for all that you're doing there. in Atlanta to move the ball down the field. So we really appreciate it.
Delighted to be with you.
Well, we certainly learned a lot today, didn't we? There's a lot more to COVID-19 than we had first appreciated. It really tends to shed a new light on this problem affecting a significant percentage of people globally. So we're talking about Millions of people who right now have persistent symptoms, where the future will go with these individuals is unclear. So it really does represent something that we're going to have to pay close attention to, and certainly here on The Empowering Neurologist, we will do our best to keep you informed as it relates to this ever-evolving story. Well, thanks for joining us today. I'm Dr. David Perlmutter. We will be back soon.
