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Coronavirus cases are going down in the U.S. but for some people, COVID may never go away. They've been maimed by it, changed, hurt, possibly forever. These "long haulers"—anywhere from 10 to 30% of those who caught even a mild case COVID—have "what we refer to as post COVID-19 conditions," said Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, on Wednesday. "Now that can be divided into two general categories, one that are readily explainable by organ system damage. For example, if you have acute respiratory distress syndrome with a considerable amount of damage, the lung tissue, you can expect that it is likely that your pulmonary functions would have a residual negative impact on them. However, there's another syndrome, a constellation of signs and symptoms, which are not completely explainable by readily apparent pathogenic processes. This has been referred to as 'Long COVID.'" How do you know if you have Long COVID? Read on for 22 key symptoms Dr. Fauci mentioned—and to ensure your health and the health of others, don't miss these Sure Signs You've Already Had COVID.

A symptom linked to Long COVID frequently is extreme fatigue, says J. Wes Ulm, MD, Ph.D. Physician-scientist. "This is indeed one of the most common symptoms, if not the most common, being reported thus far in 'long-hauler' patients with diagnosed or suspected Long COVID syndrome," says Ulm. "Full duration is as yet unknown given the relative newness of COVID-19 in general on the medical radar, but retrospective analysis of cases thus far indicates that up to a third of patients with a bout of acute COVID-19 may suffer from persistent fatigue 6 months out from initial diagnosis, for which another clear diagnostic basis (i.e. something else causing the fatigue) has been ruled out."

It can ruin lives. "The fatigue can be quite overwhelming for patients, and many report difficulty in carrying out tasks associated with even moderate exercise—defined as exertion with elevated heart and respiratory rate, but for which it's still possible to carry on a conversation (such as gardening or climbing stairs)—though both the frequency and severity of these long-hauler fatigue bouts appear to be increased for those who had serious acute COVID cases (especially with hospitalization) to begin with. All ages are vulnerable though for the same reason, elderly patients and those with co-morbidities do seem to be more affected."

Those who have "fatigue and poor endurance" should prioritize "adequate rest, good sleep hygiene and specific fatigue management strategies (four P approach to energy conservation: planning, prioritizing, pacing and positioning)," says Dr. Suman Radhakrishna MD FACP, Director of Infectious Diseases at Dignity Health California Hospital Medical Center.

"As a Long COVID symptom, dyspnea, the medical term for shortness of breath (or more generally labored or difficult breathing), appears to show a similar profile as described above for long-hauler fatigue as far as frequency, severity, and duration," says Dr. Ulm. "Though perhaps not lasting as long as the post-COVID fatigue in many patients, it can be quite debilitating and of course exacerbate the sense of exhaustion if patients have to engage in extra effort to simply breathe. In fact, limited data thus far suggest that dyspnea may be in a special class of symptoms along with fatigue, chest pain/heart palpitations, and joint pain as far as being particularly common hallmarks of Long COVID syndrome, and lasting longer (at least two months and often surpassing the six-month mark) than other symptom clusters."

Who gets this most? "As with fatigue, dyspnea does seem to be more common in COVID patients with increased age and comorbidities, and who endured more severe bouts of disease (especially those with ICU courses or multiple overnight hospital stays). However, a worrisome sign of some studies from early 2021 is that dyspnea is also one of the more common symptoms observed in children who had COVID-19, even those without hospitalization."

This symptom can occur for several months after initially contracting COVID says Dr. Radhakrishna. "Some patients require supplemental oxygen for several months after discharge from hospital. This can affect resumption of regular activities and lifestyle. Symptoms such as this often have profound effects on psychological recovery."

Post-exertional malaise and/or poor endurance is "also a very common manifestation of Long COVID and, again, is often grouped under the same symptomatic umbrella as fatigue and dyspnea," says Dr. Ulm. "It may result from the same underlying causes—particularly damage to the heart and lungs, both by viral replication itself and the immune response (particularly in the event of cytokine storm)—and it may both aggravate, and be aggravated by, the other two common symptoms, with a similar risk, frequency, and duration profile."

Another sign of Long COVID is not remembering small things you normally would, explains Dr. Tom Yadegar, Medical Director of ICU at Providence Cedars Sinai Medical Center. "Ranging from simple forgetfulness to volatile personality shifts, the spectrum of cognitive impairment resulting from a previous COVID-19 infection is extremely variable and unpredictable. Affecting men and women equally, this debilitation is often experienced for several months and manifests in a variety of ways. Many patients express the loss of their concentration ability, and often have difficulty remembering simple tasks, such as why they opened a refrigerator door."

According to Dr. Ulm, "This is another hallmark of both acute and chronic COVID-19, and it's a source of significant anxiety for many patients worried about Long COVID. Unfortunately at the present time, it's also one of the symptoms that we're least sure about as far as epidemiology and duration. It is known that perhaps a third of diagnosed COVID patients (as reported by e.g. Andrade et al. in the Viruses journal, in April 2021) do report some degree of cognitive impairment, which again may ensue partly from viral replication, as SARS-CoV-2, the virus that causes COVID-19, is now known to be able to create breaches within the so-called tight junctions (something like a biological retaining wall) of the blood-brain barrier, which may be even more severe for virulent strains like the delta variant. However, many such cases appear to be due more to the immune response and sheer exhaustion than from the infectious bout itself. Thus what's colloquially called 'brain fog' is likely to be an umbrella term for a wide array of neurological post-COVID syndromes with varying causes, and it isn't yet known how long they last or who is affected. Those with more severe disease do seem to be at higher risk, but again, brain fog has also been reported in those with mild cases."

Dr. Radhakrishna says, "In a study of 100 nonhospitalized patients with COVID with persistent neurologic symptoms for at least six weeks, brain fog was reported in 81%, headache 68% and muscle aches 55%. Patients showed impairment in quality of life domains (cognitive and fatigue), attention and working memory compared with noninfected controls. There was no correlation between disease onset time and subjective recovery. I recall a health care provider who made mistakes while filling her disability form while recovering from COVID early in the pandemic."

"Shortness of breath may persist after COVID-19 pneumonia infection secondary to scarring or inflammatory response in the upper and lower respiratory system," says cardiologist Dr. Sam Kalioundji MD FACC / KALHEART and Dignity Health Northridge. "Although lung recovery takes time up to several months post COVID-19 infection breathing exercises and respiratory therapy can help with simple solutions as deep breathing exercises for several minutes a day or brisk walking."

"COVID-19 can also cause chest pain/heart problems in individuals secondary to inflammation of the heart muscle also none as pericarditis or myocarditis depending on the extent of the disease," says Dr. Kalioundji. "Ongoing chest pain can be a sign of ongoing heart inflammation which can lead to symptoms of palpitations or rapid heartbeat and shortness of breath. Anti-inflammatory medications such as nonsteroidal anti-inflammatory therapies for short period of time can sometimes improve symptoms and discomfort."

"While not uncommon to experience a headache during the acute phase of a COVID-19 infection, daily persistent headaches may last for several weeks and months. Often characterized as a dull achiness, tightness or throbbing sensation, patients may find it difficult to perform their activities of daily living as a result of this draining sensation," says Dr. Yadegar.

"Palpitations, chest pain, and tachycardia appear to be among the special subset of frequently occurring symptoms that are likely to be the most common hallmarks of Long COVID, including in children, along with fatigue, dyspnea, and joint soreness," says Dr. Ulm. "Up to a third of patients may experience such issues at 2 months and even 6 months afterward. As with exercise difficulties and their association with fatigue and dyspnea, myalgia (muscle pain), palpitations and tachycardia, and chest pain may likewise stem from a similar pathophysiological root. These are common 'flu-like' symptoms that appear to be especially frequent and more severe in acute COVID-19 patients, and studies thus far indicate that they may all result especially from the depth and intensity of the immune defensive response to an acute bout. Thus they are likely to be more severe and frequent in patients with more serious acute disease, and it is possible that, in contrast to issues like dyspnea and post-exertional malaise, they may actually be relatively more common in younger patients especially those with a hospital course, since they may mount a more vigorous immune response. However, such a possibility at this point remains conjecture, since we're still not far enough out from the acute cases — particularly for the nastier COVID variants like delta, mu, and R.1 — to answer these yet with much certainty, or to make prognostic predictions for affected individuals."

"Like many infectious illnesses, arthralgias and their associated fatigue are some of the slowest symptoms to resolve – and in the case of COVID-19, their resolution may move at a glacial pace. Presenting most commonly as joint, back or knee pain, patients may find it difficult to perform previously simple tasks, such as walking from room to room. With their pre-COVID infection energy levels not bouncing back quickly, these patients may suffer for an untold amount of time," says Dr. Yadegar.

Dr. Fauci has described "myalgia" as aches and pains, and these can appear anywhere on your body. One Long COVID patient thought he was having a heart attack and has severe chest pain but it turned out to be costochondritis, an inflammation of the rib cartilage.

"Paresthesia is not a common presentation in Long COVID-19. Generally felt in the arms, hands and legs and painless in nature, they are described as tingling, numbness, or skin crawling. These symptoms can be frequently alarming when they persist and can cause patients to become concerned about an ongoing stroke," says Dr. Yadegar.

"Also an uncommon symptom in Long COVID-19, abdominal pain can be associated with bloating, cramping, diarrhea, and loss of appetite. These manifestations can be difficult to distinguish from other conditions including gallstones, renal colic and fatty liver. Along with other Long COVID-19 symptoms, It is highly advisable to maintain ongoing medical attention in order to assess for any new conditions that may not be attributable to Long COVID-19," says Dr. Yadegar.

"While acute COVID-19 can result in sleep disturbances, Long COVID-19 may be associated with insomnia, difficulty falling asleep and frequent awakenings throughout the night. Often a symptom lasting for several weeks, it is uncommon for this symptom to last for several months. Nevertheless, sleep changes vary between individuals and result in different presentations amongst patients," says Dr. Yadegar.

"Low grade fevers that last for months after a patient has recovered from the acute illness, this remains one of the most frightening symptoms for patients. Generally episodic in nature, with some patients experiencing recurrence at specific times of the day, fevers remain an elusive and often alarming symptom for patients. It is essential for patients to monitor their fevers for any sudden increases that could signal a secondary infection," says Dr. Yadegar.

Lightheadedness is "less common, could be associated with change in posture, rapid heart rate or vertigo," says Dr. Radhakrishna. "This Long COVID symptom often comes in tandem with other symptoms that affect the cardiovascular system — particularly in patients with marked tachycardia, heart palpitations, or chest pain, or in some cases those with severe dyspnea especially upon exertion. It may also affect those with especially severe fatigue, again with exertion. Its frequency is thus tied in with that of those associated symptoms, and is likely to be more common among the elderly and those with comorbidities (especially those with a history of heart disease), and in those with a serious bout of acute COVID-19," says Dr. Ulm.

"In the realm of Long COVID, this symptom is more-or-less a corollary of the common fatigue and dyspnea seen for long-haulers — resulting largely from weakness and exhaustion — though it can also be exacerbated more directly by the myalgia and joint pain that manifest in many chronic COVID sufferers. It's seen across the spectrum of patients who've had a bout with acute COVID-19, though likely more common and severe in those who'd battled through serious cases, in the elderly, and in those with multiple comorbidities, who may have diminished functional capacity to begin with," says Dr. Ulm.

"Headache, joint and chest pain can last for several weeks to months," says Dr. Radhakrishna.

"COVID-19 rashes are usually itchy and this may lead to poor sleep. Some people with rashes also experience sensitivity to ultraviolet (UV) light, getting red patches on their face after being outside for a short period of time," says the Zoe Report. You could have a 'prickly heat' or chickenpox-type rash or a hive-type rash.

"Some individuals develop chronic fatigue with headaches and dizziness and feelings of brain fog," says Dr. Kalioundji. "Researchers continue to evaluate the cause of this and therapies for improvement. COVID survivors are sometimes left with mental health issues such as lingering depression and anxiety due to long periods of isolation, illness or death in family or friends and financial stress."

"Anosmia (loss of smell) and dysgeusia (significant alteration in taste perception) have become among the most recognizable hallmarks of COVID-19, helping to distinguish it symptomatically from the flu and other severe viral infections with overlap in clinical presentation. Alongside other neurological symptoms like brain fog, they haven't been examined as thoroughly in retrospective and case studies as fatigue and dyspnea, and the few reports thus far vary widely in their estimated frequency for long-haulers, from 10% up to around 40% of affected patients with chronic COVID-19. It's as yet unclear if they indicate more persistent long-haul COVID than constitutional symptoms like fatigue, but they seem to be widely present in a broad range of Long COVID sufferers even for those who haven't been hospitalized, and have been observed in children, which may be a hallmark of an excessive immune response as much as viral infiltration into the central nervous system," says Dr. Ulm.

"Nearly 1/5 of patients with COVID have exhibited menstrual volume and cycle changes. Women have reported symptoms variable – lighter, irregular and missed periods and less frequently heavier periods. Most of these women returned to normal menstrual cycle in 1-2 months after COVID infection," says Dr. Radhakrishna.

"A common Long COVID-19 presentation that is seen mostly in young to middle- aged otherwise healthy women is persistent shortness of breath, palpitations, and dizziness, a condition known as POTS (Postural Orthostatic Tachycardia Syndrome). Similar to the various immune system complications observed in acute COVID-19, POTS presentations can slightly vary between patients. Unfortunately, many of these symptoms mimic generalized anxiety, and patients, particularly females, suffering from these symptoms are tasked with self-advocacy to elucidate the true etiology behind their condition," says Dr. Yadegar.

Anyone who gets COVID can get Long COVID. They are getting it as you read this: Young, old, fit, unhealthy, whether you have a severe case of COVID or a mild case—there is no exact pattern. "Although there is no particular detail on who is affected and how long they are affected there are different theories and why this occurs. This may be secondary to a small viral load lingering in the body versus an overt immune reaction to the infection that persists," says Dr. Kalioundji. "This has been unexplained thus far by any identifiable pathophysiological process," said Dr. Fauci of these symptoms. One study Fauci mentioned showed that "anywhere from 10 to more than 35% who might have at least one symptom between three and six months following the diagnosis of COVID-19." Kids can get it also, albeit at a smaller percentage than adults. 

There is no "cure" for Long COVID. "We are doing studies now that have key questions and gaps. We need to know more about the epidemiology, the phenotype or presentation of a person, the spectrum, hopefully understanding the pathophysiological mechanisms, which would then lead to the possibility of intervention," said Dr. Fauci. "Also risk factors and finding out interesting questions, whether infection triggers changes in the body that increased the risk of other conditions, such as cardiovascular disease and neurological disease. What we've been doing right now is putting forth a program which are referred to as RECOVER for researching COVID to enhance recovery. It's an initiative that seeks to understand, prevent then treat the long-term effects. And it is a medic cohort study. And hopefully over the coming months to a year, we will give us more information made public as to this very perplexing symptom complex."

"The best way to avoid Long COVID-19 symptoms is to avoid the initial infection," says Dr. Kalioundji. Get vaccinated! "Recommendation to seek medical expertise or advice with lingering symptoms is advised. Proven therapies have been physical therapy and activity in a gradual slow return to work life balance with healthy habits including diet and sleep."

Says Dr. Radhakrishna: "Much is not known about COVID infection. What can we do after COVID? Recovery time after viral infection is dependent on several factors – underlying medical condition, severity of infection, complications. Most symptoms are likely to improve but sometimes have a protracted course. The timeline for recovery is variable. Call your physician after the quarantine period to discuss symptoms and mitigation measures. Therapy is usually supportive and supplemental such as use of supplemental oxygen, cough suppressants, graded exercise regimen…Although data is limited, vaccination does not appear to worsen symptoms in long haulers and in some cases improvement in symptoms have been noted. Bottom line: AVOID COVID, get vaccinated; AVOID crowded areas and wear masks. If you get COVID, seek advice for management of your symptoms. Be patient with yourself, the recovery process is not always smooth, bouncing back to health may take some time. Rest, nutrition, and graded activity helps."

If you feel you have these symptoms, contact your doctor. And again, get vaccinated. Vaccinated people "were about half as likely as an unvaccinated person who then got infected to report Long COVID symptoms, which is again, interestingly, another reason why it is so important to get vaccinated," said Dr. Fauci. And to protect your life and the lives of others, don't visit any of these 35 Places You're Most Likely to Catch COVID.

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