Case Study Excerpt: Integrative Approaches to Long-COVID

Patient Information

Sarah is a 53-year-old woman living in Philadelphia with her husband and two daughters. She enjoys her career working as an advertising executive and has been with her current company for 18 years. She has always taken care of herself by running three miles at least five days a week and working out at her home gym in the morning before her kids wake up. Once a year she competes in a triathlon somewhere around the country and takes her family with her so they can enjoy a vacation together.

Race/Ethnicity: White

Problems: Persistent cough, Joint pain, Extreme fatigue, Foggy memory, Loss of taste/smell, Chronic migraines, Psoriasis

Social History: Drinks wine during the work week and 2-3 cocktails when out with friends on the weekends

Vital Signs:

• Height: 5’6”
• Weight: 122 pounds
• BMI: 19.69
• Blood pressure systolic: 113 mmHg
• Blood pressure diastolic: 75 mmHg
• HDL cholesterol: 127 mg/dL
• LDL cholesterol 82 mg/dL
• Non-fasting glucose 120 mg/dL

Medications: Occasional ibuprofen

Health Concerns:

• Persistent cough Joint pain, especially in the knees after regular runs 
• Ongoing extreme fatigue (sleeping more and unable to find motivation for everyday activities) 
• Difficulty with short-term memory 
• Chronic migraines 
• Psoriasis

Practitioner Perspective: Joel Evans, MD

For Joel, it's always important to establish trust with his patients. Joel knows that Sarah needs to feel that he understands what is going on with her and that he is confident that he can help her. Once that is established, it would be important for Joel to demonstrate that he recognizes her priorities and fears in recovering. He would want to know what the most important areas are for her to feel she’s getting better – is it functioning better at work? Is it exercising? Sleeping? Once he determines what is critical for her, he would explain what each supplement, intervention, or test he plans to conduct will do for her. In his experience, long COVID patients want to get better and they want to know how he will help them get there. Joel would do this by listening and allowing time for questions without any rush, so Sarah feels supported.

Testing

To gain a better understanding of what was happening, Joel would order a series of tests. He’d test for oxidative stress to see if there is mitochondrial dysfunction, he’d test for gut health, and order a comprehensive cytokine panel to clearly understand what’s happening with her immune system function. He may order a D-dimer test to see if she has increased vascular clotting. The cardiologist or primary care physician would likely order an EKG for the chest pain. The results of these tests would then influence Joel’s specific interventions. However, Joel would gauge the severity of Sarah’s symptoms, and likely start treating her before her test results came back within two to four weeks.  

Care Plan

Once the testing is ordered, Joel would now spend time recommending nutrients that will build up Sarah’s immune health, optimize gut function, reduce inflammation and oxidative stress, and improve mitochondrial function. The mitochondria, Joel said, are important to prevent viral infection, but are also destroyed by viral infections and since low energy is one of her issues, he would want to give her some supplements to increase her overall energy.  In addition, because of Sarah’s cognitive issues, Joel would want to give her something to address the endothelial dysfunction related to any microvascular disease and inflammation in the brain.

Supplements:

• For mitochondrial function: vitamin C, thiamine, riboflavin, choline, magnesium, CoQ10, folic acid, carnitine, and pyrroloquinoline quinone (PQQ).
• For immune health: Zinc, selenium, transfer factor, larch arabinogalactan, beta glucan, astragalus, green tea, and pomegranate.
• For cognition: choline, Lion’s mane mushroom, skullcap, ashwagandha, bacopa, American ginseng, and Huperzine-A

In addition, Joel would recommend curcumin for inflammation. Other supplements he would suggest are sulforaphane, resveratrol, and seaweed extract for the glycocalyx. Probiotics and glutamine for the gut, and prebiotics with bio-quercetin. He would also recommend melatonin to make sure Sarah is sleeping well. He would also encourage a healthy diet.

Though these would be Joel’s recommendations, what Sarah actually takes would depend on how severe her symptoms presented and what she would want to do. For instance, if her inflammation was really high, they would focus on Sarah taking anti-inflammatories. But while the results of the tests were still pending, he would treat her with a broad spectrum so all of the symptoms were addressed. Then, once the testing results came back, Joel would adjust his dosing.

Joel would want to see Sarah again in two weeks for a quick check in and then two weeks after that, and then schedule another appointment four weeks after that meeting. Sarah could also reach out to Joel with any questions via his practice’s electronic health record.

About the Expert

Joel Evans, MD, a board-certified OB/GYN and international lecturer, is the director of The Center for Functional Medicine in Stamford, Connecticut. He is also currently serving as chief of medical affairs at The Institute for Functional Medicine (IFM), and is the co-director of the IFM Resistance, Resilience, and Recovery: Patient Care in a Pandemic course on COVID-19. He now leads the IFM response to post-acute COVID-19 and has co-authored two recently published papers on the pandemic. Since its inception in 2011, he has continued to serve as the external lead of IFM’s Hormone Advanced Practice Module and is the chief medical officer of HealthPointe Solutions, which focuses on the use of artificial intelligence in healthcare.

Editor's Note: This text was originally published in the e-book, Integrative Approaches to Long COVID-19. To read more, click here.