When It's Not Long, but Medium COVID?

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Symptom timelines surrounding COVID infection tend to center on either the immediate 5-day quarantine protocols for acute infection or the long-COVID symptoms that can last a month or potentially far longer.

But some patients report a "middle-range" COVID that will resolve before it becomes long COVID, yet still lasts longer than is typical for viral infections. People may return to work or daily routines, but something is off: What had been simple exercise regimens become onerous. Everyday tasks take more effort.

Does this ill-defined subset point to a "medium COVID?"

Dr Farha Ikramuddin

Farha Ikramuddin, MD, MHA, a physiatrist and rehabilitation specialist at the University of Minnesota Medical School in Minneapolis and M Health Fairview points out there is no definition or diagnostic code or shared official understanding of a middle category for COVID.

"But am I seeing that? Absolutely," she told Medscape Medical News.

"I have seen patients who are younger, healthier, [and] with not so many comorbidities have either persistence of symptoms or reappearance after the initial infection is done," she said.

Some patients report they had very low infection or were nonsymptomatic and returned to their normal health fairly quickly after infection. Then a week later they began experiencing fatigue, lost appetite, loss of smell, and feeling full after a few bites, Ikramuddin said.

Part of the trouble in categorizing the space between returning to normal after a week and having symptoms for months is that organizations can't agree on a timeline for when symptoms warrant a "long COVID" label.

For instance, the Centers for Disease Control and Prevention (CDC) defines it as 4 or more weeks after infection. The World Health Organization defines it as starting 3 months after COVID-19 symptom onset.

"I'm seeing 'medium COVID' — as one would call it — in younger and healthier patients. I'm also noticing that these symptoms are not severe enough to warrant stopping their job or changing their job schedules," Ikramuddin said.

They go back to work, she said, but start noticing something is off.

"I am seeing that."

"I discharge at least two patients a week from my clinic because they have moved on and no longer have symptoms," Ikramuddin said.

In a story from Kaiser Health News published last month on Medscape, WHYY health reporter Nina Feldman writes: "[W]hat I've come to think of as my 'medium covid' affected my life. I couldn't socialize much, drink, or stay up past 9:30 p.m. It took me 10 weeks to go for my first run — I'd been too afraid to try."

She described a dinner with a friend after ending initial isolation protocols: "One glass of wine left me feeling like I'd had a whole bottle. I was bone-achingly exhausted but couldn't sleep."

Medical Mystery

Ikramuddin notes the mechanism behind prolonged COVID-19 symptoms is still a medical mystery.

"In one scenario," she said, "the question is being asked about whether the virus is staying dormant, similar to herpes zoster or HIV."

"Right now, instead of getting more answers, we're getting more questions," Ikramuddin said.

Mouhib Naddour, MD, a pulmonary specialist with Sharp HealthCare in San Diego, California, said he's seeing that it's taking some patients who have had COVID longer to recover than it would for other viral infections.

Some patients fall between those recovering within 2-3 weeks and patients having long COVID. Those patients in the gap could be lumped into a middle-range COVID, he told Medscape Medical News.

"We try to put things into tables and boxes but it is hard with this disease, " Naddour said.

Dr Mouhib Naddour

He agrees there's no medical definition for "medium" COVID, but he said the idea should bring hope for patients to know that if their symptoms are persisting they don't necessarily have long COVID — and their symptoms may still disappear.

"This is an illness that may take longer to completely recover from," he said. "The majority of patients we're seeing in this group could be healthy young patients who get COVID, then 2-3 weeks after they test negative, still have lingering symptoms."

Common Symptoms

Some commonly reported symptoms of those with enduring illness, which often overlap with other stages of COVID, are difficulty breathing, chest tightness, dry cough, chest pain, muscle and joint pain, fatigue, difficulty sleeping, and mood swings, Naddour said.

"We need to do an extensive assessment to make sure there's no other problem causing these symptoms," he said.

Still, there is no set timeline for the medium COVID range, he noted, so checking in with a primary care physician is important for people experiencing symptoms.

It's a Continuum, Not a Category

Fernando Carnavali, MD, coordinator for Mount Sinai's Center for Post-COVID Care in New York City, said he is not ready to recognize a separate category for a "medium" COVID.

Dr Fernando Carnavali

He noted that science can't even agree on a name for lasting post-COVID symptoms, whether it's "long COVID" or "long-haul COVID," "post-COVID syndrome" or "post-acute sequelae of COVID-19 (PASC )." There's no agreed-upon pathophysiology or biomarker.

"That creates these gaps of understanding on where we are," Carnavali told Medscape Medical News.

He said he understands people's need to categorize symptoms, but rather than a middle ground he sees a continuum.

It doesn't mean what others may call COVID's middle ground doesn't exist, Carnavali said: "We are in the infancy of defining this. Trying to classify them may create more anxiety."

The clinicians interviewed for this story report no relevant financial relationships.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

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