It had all started innocuously enough — a cough and fever. After that, however, his illness took off. Within a week, he was on a breathing machine in the ICU because of a life-threatening lung infection from Covid-19.

His wife Heidi and two daughters painfully remember the next six days when Herbert was unconscious — wondering if and how they could be at his bedside during a strict no-visitor hospital policy, just to hold his hand in what might be his last days.

Herbert’s rapid worsening was even jarring for his medical team caring for him. “It was certainly unusual how quickly he went from a period of apparent stability to requiring ventilatory support,” said Dr. Neal Greenfield, a critical care physician who helped care for Michael at Northwestern Medicine Delnor Hospital in Geneva, Illinois.

But as quickly as Herbert got worse, he then recovered. His doctors reduced his sedation, and with his regained consciousness, Herbert video-called his family every day. Unable to speak with a breathing tube, he would sign, “I love you.”

He was taken off of his ventilator on his mother’s birthday — a week earlier than expected — and he gave his mom the best birthday gift a son could give.

“I was able to call her and just say, “Hi,” and then I was able to FaceTime my girls and wife, which was wonderful,” he said.

Herbert was released from the hospital a few days later. His cough and fever improved. On paper, he would be listed as recovered, but as we are learning, the aftermath of Covid-19 is not nearly as straightforward as once believed.

Tracking for a disease with little information

“Two months ago, recovery wasn’t on anyone’s mind. We were dealing with the crisis,” said Dr. Reynold Panettieri, vice chancellor of clinical and translational science and a pulmonary critical care physician at the Robert Wood Johnson Medical Center at Rutgers University in New Jersey.

While most patients with Covid-19 will fully recover, data from China suggest that some patients, especially those who had more severe infections, may face lasting — even permanent — damage to their bodies.

To better understand these effects, Panettieri is leading a six-month study of recovered Covid-19 patients. So far, his research group has enrolled more than 800 participants.

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“Now, we’ll start to see what the long-term consequences are,” Panettieri said. “And that is an issue that will really need to be addressed.”

Unlike most viral diseases, which may result in a nagging cough for weeks, Panettieri has observed that some patients recovering from Covid-19 have other serious symptoms that won’t go away.

“They had an illness for about two weeks, and three months later, they’re still not feeling ‘quite right,'” he said. “They were aggressive athletes or were exercising and…they still haven’t gotten back to that prowess that they were pre-illness.”

He said this could be related to a number of factors, including how the virus affects the lungs, heart and muscles.

For Michael Herbert, his doctors believe his lingering cough and shortness of breath are likely remnants of his serious bout of pneumonia. Despite leaving the hospital a month ago, Herbert still struggles to recover back to how he felt before getting sick.

Dangerous lung scarring reminiscent of SARS and MERS

While a longer recovery course might be expected for someone such as Herbert who faced a more severe illness, there’s also concern for more permanent lung damage, according to Dr. Ronald DePinho, professor and past president of MD Anderson Cancer Center and co-founder of Tvardi Therapeutics. DePinho is particularly worried that the immune response to Covid-19 may cause irreversible scarring known as pulmonary fibrosis.

Pulmonary fibrosis can be a “relentlessly progressive” disease of the lungs in which patients can become dependent on oxygen or even ultimately require lung transplants, he said. Again, this is after a patient is thought to have “recovered.”

Though it’s too early to know whether patients with the novel coronavirus will develop this sort of lung scarring, studies in other related coronaviruses, such as SARS and MERS, suggests certain Covid-19 patients may have lasting fibrosis. One study following 36 MERS patients found a third still had lung fibrosis on chest x-rays after a median follow-up of 43 days.

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And up to two-thirds of patients with SARS who were sick enough to require hospitalization also developed pulmonary fibrosis, according to DePinho. If the same pattern holds true for Covid-19, that could mean many thousands of people will have long-term lung scarring, he said.

The data from China thus far is still thin, but the early results follow the same pattern DePinho is describing. In a study of 63 Covid-19 patients from Wuhan, China, about 18% had “fibrous stripes” on CT scans. And in another study, it took more than 6 weeks for one patient’s chest CT to return to normal, even though his symptoms had already improved.

This might explain why some patients have significant drops in their lung function even after recovering from the novel coronavirus. Losses in lung function could be as high as 20 to 30 percent, the medical director of infectious diseases at Princess Margaret Hospital in Hong Kong told a media briefing in March.

More on Covid-19 and the lungs

There is another factor that may be driving long-term issues with the lungs, unrelated to scarring or fibrosis. We are learning those with Covid-19 also can form blood clots at an abnormally high rate. In rare situations, a clot that has formed in the deep veins of the legs may travel to the lungs — known as a pulmonary embolism. This is what happened to Warnell Vega, a healthy 33-year-old I interviewed with Covid-19 who survived a life-threatening pulmonary embolism and is now home in recovery.

Michael Herbert with his daughters after being in the hospital with Covid-19.

As is often the case, Vega developed a pulmonary embolism with little or no warning. He only had a mild cough when he passed out in his bathroom. He woke up in an ICU at Mount Sinai hospital. He was subsequently diagnosed with Covid-19, after which a scan revealed a pulmonary embolism. His doctors told me that Vega became critically ill and developed signs of pulmonary hypertension, which happens 2-4% of the time in patients with a PE (pulmonary embolism). So far Vega told me he feels close to normal, but recent clinical studies have shown that close to half of patients who suffered a pulmonary embolism will still experience exercise limitations at one year.

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Given his history of a blood clot and pulmonary embolism, Vega is at risk of developing a blood clot again, and may need to be on blood thinners for some time as he continues to recover.

Blood thinners in general might improve outcomes for hospitalized patients with Covid-19, according to a report published Wednesday in the Journal of the American College of Cardiology. The team at Mount Sinai conducting the study found 29% of patients on ventilators who were provided blood thinners died, compared to 63% of patients on ventilators who were not given blood thinners. The improvement in mortality rates with blood thinners might demonstrate how dangerous blood clots from Covid-19 are.

The heart

Another significant risk factor for a successful recovery is the impact of this virus on the heart. The virus’ impact on the lungs may eventually lead to less oxygenated blood reaching the heart. Ot the virus may attack the heart itself, leading to myocarditis — inflammation of the heart muscle. Both can lead to chronic heart damage, even in the previously healthy.

“There have been a number of reported cardiac complications associated with the Covid virus and they’re so varied,” said Dr. Joseph Brennan, the director of the coronary intensive care unit at Yale University School of Medicine.

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He said there are a couple ways to look at how Covid-19 could cause long-term effects on the heart. One way is the direct impact of the virus on the heart, and the other is how clotting from Covid could lead to heart attacks.

“We are all aware that heart attacks may have long-term consequences because of a potential and permanent decline in heart function,” he said. “Those that have had…heart attacks associated with the Covid virus will more than likely have long-term consequences.”

A study published in the medical journal JAMA Cardiology found 19.7% of hospitalized Covid-19 patients suffered from some type of cardiac injury. Such patients might not be able to exercise as much, feel breathless or feel like their heart is beating faster than usual for an indefinite period of time. In general, a faster heart rate will likely be a common side effect in the long run for Covid-19 patients, especially if patients have underlying lung issues from Covid-19, he said.

Though Michael Herbert did not have heart-related complications from Covid-19, he did suffer from diabetes, high blood pressure and obesity — conditions that affect heart health and put him at risk for a more severe infection, according to the US Centers for Disease Control and Prevention.

The brain

Another important organ at risk for damage from blood clots? The brain. Large clots would more likely cause obvious symptoms, but smaller ones may lead to a type of dementia known as vascular dementia. Both can cause permanent damage that might not present itself until years down the line.

“We know that if someone has a stroke, it approximately doubles their risk of getting dementia later in life,” said Dr. Marion Buckwalter, associate professor of neurology and neurosurgery at Stanford University. “[Our research group] discovered that people who had a more vigorous immune response by day two after stroke were more likely to have cognitive decline in the first year after stroke.”

Michael Herbert feels lucky that he hasn’t experienced these types of symptoms during his recovery, especially given how severe his infection was.

Michael Herbert with the staff who treated him.

“I’m feeling good,” Michael said. “My strength has come back. It’s not perfect, but I feel better.”

Though his progress has been incremental, he remains encouraged that each day has been a step in the right direction. He remembers how weak he felt trying to move from his ICU bed to a wheelchair. Now, he is working towards walking two miles a day without stopping.

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The entire ordeal has been a huge wake up call for him — he now takes his health much more seriously, and he is grateful that his doctors have provided him a second chance.

“I mean, I have bonus time here in life,” he said. “I was supposed to be dead, and I didn’t die. I’m not going to waste any days I have left.”

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