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Coronavirus Disease 2019

What After Surviving COVID-19? Brain Fog, Fatigue, and Pain

Neurological and cognitive deficits may last for years after recovery.

It is true that COVID-19 is a new disease and we don’t know enough about it. It is true that the virus has not been around long enough to learn about its specific long-term effects. However, we can certainly extrapolate from available data on past similar pandemics and viruses. Revisiting the existing research on the trajectories of similar viruses is essential for devising a prevention program.

For example, there is data on survivors of previous public health emergencies. One study conducted in Ontario, Canada investigated the one-year outcomes in survivors of Severe Acute Respiratory Syndrome SARS (another type of coronavirus), a global epidemic in 2003. Of 117 survivors, 17% did not return to work by the one-year mark. Fifty-one percent of survivors required 668 visits to psychiatry or psychology practitioners and 33% reported a significant decrement in mental health. Although most of the survivors had good physical recovery, some patients and their caregivers reported notable reductions in mental health one year after SARS-related hospitalization. Another study on SARS reported that one year after hospitalization, survivors had higher levels of stress, depression, anxiety, and post-traumatic symptoms.

Research on Acute Respiratory Distress Syndrome (ARDS) shows that complications such as muscle weakness, reduction in the ability to exercise, and emotional distress may last for many years after recovery. Other research shows clinically significant symptoms of fatigue at 6 and 12 months following ARDS. These findings strongly point to a concomitant mental health crisis for at least these respiratory viruses. It is only responsible to learn from the aftermath of public emergencies such as SARS to circumvent potential COVID-19 (also a coronavirus) psychological burdens.

Obviously, COVID-19 has not been around for years to investigate long-term effects. Nonetheless, various avenues point to potential non-pulmonary long-term complications. The CDC lists a range of symptoms for COVID-19 including fever/chills, cough, shortness of breath, fatigue, muscle aches, headache, loss of taste or smell, sore throat, congestion, nausea/vomiting and/or diarrhea. While the list does include some neurological symptoms such as headache and loss of smell, recent evidence suggests that there may be many other neurological and cognitive deficits that plague survivors for months after recovery.

In one recent study conducted in China, the researchers found that nearly 40% of COVID-19 patients suffered various neurological symptoms such as nerve damage, muscle injury, conscious disturbance, and confusion. Strokes in young patients in the USA and in China have also been reported. According to one study, about 5% of hospitalized young COVID-19 patients had strokes. Unfortunately, many of these patients delay going to the hospital because of fear of the pandemic, and social isolation further complicates the recovery and leads to long-term issues.

Why would a respiratory virus cause neurological problems? Because coronaviruses activate a receptor called angiotensin-converting enzyme 2 (ACE2). The receptor is also found in the nervous system and skeletal muscles. This would explain neurological and muscular symptoms found in many COVID-19 patients beyond recovery. Also, the virus may damage the brain through the nose, blood circulation, or indirectly as a result of an aggressive immune system response.

The more severe the symptoms, the more likely that the patient will develop ongoing neurological pathology. In a study examining autopsies of COVID-19 patients, they found neuronal degeneration in deceased patients. Also, researchers found the virus in the cerebrospinal fluid of patients (the fluid circulating in the spinal cord and brain). It is worth mentioning that coronavirus antibodies were found in the CSF of people with Parkinson's disease (coronavirus has an affinity to attach to the brain area directly implicated in Parkinson's). Also, some inflammatory factors such as interleukin (IL-6) have been positively correlated with the severity of COVID-19 symptoms. In addition, COVID-19's activation of the immune cells in the brain may cause chronic inflammation and brain damage.

Documented trajectories of COVID-19 have also been non-empirically published across various online outlets. For example, more exhaustive lists of issues (beyond CDC's list) have been discussed in various Facebook and self-help groups. Some of the symptoms frequenting many online groups (even with mild to moderate severity) include:

  • Memory loss
  • Difficulties in focus, concentration, and attention
  • General malaise
  • Mental/brain fog (very common)
  • Neuropathy (such as pins-and-needles sensations)
  • Muscle pain
  • Anxiety, depression, and exacerbation of pre-existing psychological disorders

In conclusion, positivity over recovered cases ought to be tempered by emerging studies of the long-term effects of COVID-19. Currently, the numbers reflect patients who have it, ones who died from it, and ones who recovered. We need to redefine recovery beyond categorical mortality codes. Quality of life beyond "recovery" must be assessed. Health care professionals should encourage more comprehensive ways of treatment and probe for mental health concerns.

I have not even addressed the lurking mental health epidemic; there is "very limited data available for COVID-19 related psychiatric symptoms" (p. 36). Here is one troubling reliable finding, exposure to viral infections in utero has been associated with an increased risk of developing schizophrenia. Current research and stories suggest that even when COVID-19 departs, its ghost will remain for years. The public needs to be aware of a much longer list of potential symptoms and their effects on quality of life. This may be the case for even asymptomatic individuals with COVID-19.

Can we stop saying that people with no pre-existing conditions don't need to worry? We are simply lying and do not know—at least that is what research suggests. Wear a mask and frequently wash your hands.


Troyer, E.A., Kohn, J.N. & Hong, S. (2020). Are we facing a crashing wave of neuropsychiatic sequelae of COVID-19? Brain, Behavior, and Immunity, 87, 34-39.

Wu, Y., Xu, X., Chen, Z., ... Yang, C. (2020). Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain, Behavior, and Immunity, 87, 18-22.

Mao, I., Wang, M.D., Chen, S.H., et al., (2020). Neurological manifestation of hospitalized patients with COVID-19 in Wuhan, China: a retrospective case series study. MedRxiv. 02.22.20026500,

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