Overview
Sequelae associated with atypical pneumonia or side effects of treatment medications
Chest tightness, shortness of breath, dyspnea after activity, hip pain, difficulty in walking, anxiety, depression, etc.
Sequelae are treated differently, including medication and surgery.
Symptoms may gradually improve or persist, affecting quality of life.
Definition
Sequelae of SARS are caused by the disease itself or by side effects of the medications used to treat it.
Atypical pneumonia, also known as Severe Acute Respiratory Syndrome (SARS), is an acute respiratory infection caused by SARS coronavirus infection.
Sequelae of SARS commonly include pulmonary dysfunction, ischemic osteonecrosis, and psychological trauma, and the persistence of symptoms has a major impact on patients’ lives.
Morbidity
Lung dysfunction
An early follow-up report of 258 SARS patients in Beijing Xiaotangshan Hospital 2 months after discharge suggested that 21% of patients had pulmonary diffusion dysfunction and 6% had restrictive ventilation impairment [1].
A follow-up of 94 recovered SARS patients 1 year after discharge suggested persistent pulmonary impairment in about 1/3 of them [2].
Ischemic osteonecrosis
A long-term follow-up summary of 71 SARS patients reported an incidence of ischemic osteonecrosis of about 34% [3].
Another study of 67 SARS patients found acute osteonecrosis in 42% of patients [4].
Psychological trauma
Data from 101 inpatients at Wong Tai Sin Hospital in Hong Kong showed that about 25% and 15% exhibited moderate to severe anxiety and depression respectively [1].
Etiology
Pathogenicity
Incomplete absorption of the pneumonia lesions in SARS leads to pulmonary fibroplasia and pulmonary fibrosis in the later stages, resulting in pulmonary dysfunction.
The use of high-dose glucocorticoids during the treatment of atypical pneumonia, the occurrence of intravascular fat embolism or thrombosis, coagulation dysfunction, and intraosseous hypertension can lead to ischemic necrosis of the femoral head [4].
Patients suffering from atypical pneumonia may develop psychological disorders such as post-traumatic stress syndrome or adverse emotions such as anxiety and depression due to physical and psychological suffering.
Triggers
Different triggers can lead to the occurrence and aggravation of SARS sequelae.
Patients with pulmonary fibrosis may have symptoms aggravated by fatigue, cold, upper respiratory tract infection and other factors.
Triggers of osteonecrosis also include alcohol consumption and trauma.
Psychological trauma can be re-triggered by re-encountering similar scenes or environments.
Symptoms
Main Symptoms
Lung dysfunction
Residual lesions in the lungs may progressively develop pulmonary fibrosis, shrinking lung volumes, and persistent chest tightness, shortness of breath, and dyspnea with activity even after discharge from the hospital.
Some of the symptoms may improve over time after discharge, and some patients have long-term lung lesions and associated symptoms.
Ischemic osteonecrosis
Seen in patients treated with high-dose glucocorticoids during SARS, the most common form is necrosis of the femoral head.
Necrosis of the femoral head is characterized by pain or soreness in the hip or thigh root, difficulty walking, painful claudication, and even forced walking on crutches.
Some patients also have osteoporosis and may suffer fractures [1-5].
Psychological disorders
Psychological disorders include depression, anxiety, and post-traumatic stress disorder, which are manifested as follows.
Low self-esteem, distress, anxiety, refusing to go out, or being afraid to go near people when going out for fear of re-infection or spreading to others.
Difficulty in adapting to society, belief that people around them do not accept them or that the world is a bad place, etc.
Most patients’ symptoms can be improved to some extent over time [5-6].
Other.
Some patients may have residual liver impairment, anemia, hyperglycemia, etc.
Consultation
Department of Medicine
Respiratory medicine
After being discharged from the hospital, patients with atypical pneumonia may consult the Department of Respiratory Medicine if they still have symptoms such as chest tightness, shortness of breath, and dyspnea after activity for a longer period of time.
Orthopedics
Patients with atypical pneumonia may consult the Department of Orthopedics if they have symptoms such as pain or soreness in the hip or thigh root, or difficulty in walking after being discharged from the hospital.
Psychiatry
Patients with atypical pneumonia who have been discharged from the hospital with symptoms such as anxiety, depression, or difficulty adapting to society can consult the Department of Psychiatry.
Preparation for medical treatment
Consultation: Registration, Preparation of documents, Frequently asked questions
Tips for medical treatment
A general physical examination, chest CT, hip MRI, etc. may be required during the visit, so loose clothing should be worn.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms and special manifestations.
Is there chest tightness, shortness of breath, difficulty breathing after activity, etc.?
Is there hip pain, difficulty walking, etc.?
Are there feelings of anxiety, depression, low self-esteem, fear, etc.?
List of medical history
When was the diagnosis of SARS made?
What medications were used during the treatment of atypical pneumonia, and was there any heavy use of glucocorticoids?
Checklist
Test results in the last six months, which can be brought to the doctor’s office
Laboratory tests: blood routine, blood biochemistry, etc.
Imaging tests: chest CT, hip magnetic resonance imaging, etc.
Medication list
Medication in the last 3 months, if there is a box or package, you can bring it to the doctor
Calcium supplement and bone preservation drugs: calcium carbonate, alendronate, etc.
Pain medication: ibuprofen, celecoxib, etc.
Diagnosis
Diagnosis is based on
Medical History
The patient has the following medical history.
Previous history of atypical pneumonia.
Use of high-dose glucocorticoids during the development of atypical pneumonia.
Clinical manifestations
Symptoms
Symptoms of pulmonary dysfunction, such as chest tightness, shortness of breath, and dyspnea with activity may be present.
Symptoms of ischemic osteonecrosis may be present, such as pain in the hip or thigh root and difficulty walking.
Symptoms related to psychological trauma, such as anxiety, depression, low self-esteem and fear.
Physical signs
Patients with pulmonary fibrosis may hear end-inspiratory bursting sounds in both lower lungs.
Patients with femoral head necrosis have limited hip joint movement, with the most obvious limitation of internal rotation, flexion and external rotation.
Laboratory Tests
Blood tests
Patients with SARS may have a mild decrease in hemoglobin or may not have any abnormalities.
Blood biochemistry
Patients with sequelae of SARS may have mild residual liver and renal impairment, with elevated liver enzymes, urea, etc., or may not have any abnormalities.
Imaging
Pulmonary fibrosis
Patchy, nodular lesions, gridding, honeycomb-like changes, etc. may be seen on chest CT or HRCT in patients with residual lung lesions.
Femoral head necrosis
Hip X-ray may show narrowing of the joint space, flattening of the femoral head, and increased density of subchondral bone in the joint.
Hip MRI mostly shows abnormal signal in the anterior and superior part of the femoral head, with a low signal in the form of a band in T1WI, and a low signal or two parallel signal shadows of internal high and external low in T2WI [7].
Other
Pulmonary function tests
Pulmonary function tests are performed in patients with pulmonary fibrosis, which may indicate pulmonary diffusion or ventilation dysfunction [8].
Lung biopsy
Lung biopsy is the gold standard for the diagnosis of pulmonary fibrosis, with large numbers of collagen fibers and fibroblasts visible in the lesions.
Differential diagnosis
Pulmonary fibrosis in sequelae of SARS should be differentiated from other pulmonary fibrosis, such as idiopathic pulmonary fibrosis, nonspecific interstitial pneumonia, and desquamative interstitial pneumonia.
Femoral head necrosis in SARS sequelae should be differentiated from other causes of femoral head necrosis, such as excessive alcohol consumption, chronic liver disease, femoral neck fracture and other causes.
Psychological disorders in SARS should be differentiated from personality disorders and schizophrenia [6-8].
Treatment
Treatment aim: improve symptoms, improve quality of life, prolong survival.
Therapeutic principle: there is no specific drug in the clinic at present, and symptomatic and supportive treatment is the mainstay, with surgical treatment if necessary.
General treatment
Patients with pulmonary fibrosis can have appropriate pulmonary rehabilitation training, including abdominal breathing, balloon blowing training, etc., which should be carried out under the guidance of professional rehabilitator; patients with low blood oxygen can have long-term oxygen therapy.
Patients with necrosis of femoral head should avoid weight bearing as much as possible, and they can walk with crutches, sciatic braces and walking aids, and in serious cases, they should be bedridden or wheelchair-bound. If the hip pain is severe, bed rest and lower limb traction can often relieve the symptoms.
Psychological disorders require psychoeducation, reconstruction of concepts and other treatments.
Traditional Chinese medicine treatment
Chinese medicinal preparations that nourish the lungs and kidneys, detoxify and resolve phlegm can help relieve symptoms in patients with pulmonary fibrosis.
Low-frequency electrotherapy and acupuncture can relieve pain caused by femoral head necrosis, which usually takes a longer time.
Patients with psychological disorders can be supplemented with treatment such as Gui Shen Tang and An Shen Ding Zhi Wan.
Medication
There is no specific drug to reverse pulmonary fibrosis. Pirfenidone or N-acetylcysteine can be used to stop the deterioration of lung function.
Femoral head necrosis can be treated with non-steroidal anti-inflammatory drugs (e.g., aspirin) for pain relief, and anticoagulants (e.g., heparin), vasodilators (e.g., iloprost), and bisphosphonates (e.g., alendronate) may also be effective in improving necrosis.
Psychological disorders may be treated with drugs such as 5-hydroxytryptamine reuptake inhibitors in the acute phase [6-9].
Surgical treatment
Lung transplantation can be performed if necessary for pulmonary fibrosis.
Patients with femoral head necrosis can undergo artificial joint replacement if necessary [8].
Prognosis
Cure
It has been reported that pulmonary dysfunction and ischemic osteonecrosis can recover somewhat over time, and after reaching a plateau stage of sustained stability and no further deterioration, symptoms may persist, and a small number of patients may experience spontaneous healing or severe deterioration [3-4,10].
Psychological trauma is mostly recoverable with active intervention.
Harmfulness
Patients with pulmonary dysfunction may show chest tightness and shortness of breath after activity, and femoral head necrosis may lead to difficulty in walking, which will have a greater impact on learning and life and work.
Patients with psychological disorders have difficulty in adapting to society in the short term, and in severe cases, they may have self-harm or suicidal tendency.
Daily
Daily Management
Pulmonary dysfunction
For those with cardiorespiratory tolerance, chronic aerobic exercise, such as deep breathing and walking, can be carried out in a gradual manner.
For those with severe pulmonary fibrosis, chronic low-flow oxygen inhalation can be used at home.
Osteonecrosis
Adequate supplementation of protein and calcium is needed to control body weight, meanwhile, smoking and alcohol should be abstained, and low-fat and low-sugar diet should be taken.
People with osteonecrosis of the femoral head should pay attention to keep warm, avoid cold stimulation, at home can use hot compresses, massage and other methods of physical therapy to reduce pain.
Osteonecrosis patients should avoid weight-bearing during exercise, and improve the function of bone joints with appropriate activities, meanwhile, increase the muscle strength to prevent muscle atrophy.
Psychological trauma
Patients need to rebuild a good state of mind, enhance self-confidence, and actively integrate into society.
Appropriate physical exercise should be carried out to increase the body’s tolerance ability, sharpen the will and improve the psychological state.
Family members should give encouragement and care to the patient, avoid tension and anxiety, and maintain a relaxed family environment.
Prevention
Doctors should choose carefully when using hormone therapy and pay attention to controlling the timing and dosage of hormone use [11].
In the process of atypical pneumonia treatment, we should educate the patients to deepen their understanding of the disease and improve their psychological tolerance.