Nicole Press started feeling unwell in March 2020. At first, the stage manager, who splits her time between New York City and Pennsylvania, thought it might be allergies. But about a week in, she crashed hard.
“It felt like the worst flu I’ve ever had,” recalls Press, 37. She got tested for the coronavirus — SARS-CoV-2 — and her results came back positive. “At the time, I thought I was lucky,” she says. “I thought I’d be through with it and then be able to donate antibodies to others.”
But her COVID-19 symptoms dragged on and on and became debilitating: rashes, muscle aches, dizzy spells, fatigue, cough, shortness of breath, absence of taste and smell, vomiting, brain fog, body tingles, acid reflux, broken blood vessels, and hair loss.
“It hit two weeks, then three weeks, then a month,” says Press. “In hindsight, I would have done things differently [and gone to the doctor], but at the time, there were trucks full of bodies, healthcare workers were overwhelmed, and the message was ‘Stay home, don’t ask for help.’ So I just took vitamins and hoped for the best.”
Two months on, Press finally telephoned her doctor, who called her in for bloodwork. She tested positive for coronavirus antibodies, showed high levels of a generic inflammation marker, and was deficient in vitamin D. She also tested positive for mononucleosis (an illness caused by the Epstein-Barr virus), which she had previously contracted in high school. The rest of her labs looked normal.
She now understands that her condition is shared by many who have been infected with the novel coronavirus. It’s become known as COVID long-haulers phenomenon — as well as long COVID, post-acute COVID, or post-COVID syndrome — and it is receiving more attention as the number of sufferers with lingering symptoms rises worldwide.
A survey of Americans with mild COVID cases found that 35 percent hadn’t fully recovered two to three weeks after diagnosis. And English researchers estimated in the British Medical Journal that around 10 percent of people will experience symptoms lasting more than three weeks, while a smaller proportion will continue to feel unwell for months.
With more than 105 million confirmed COVID cases worldwide at press time, millions of people are or will be in the same boat — struggling to make sense of ongoing symptoms that their healthcare providers are often unable to help them address.
The absence of a clear biomarker makes chronic conditions like these challenging for many conventionally trained doctors, explains Elizabeth Boham, MD, MS, RD, a functional-medicine physician and medical director at the UltraWellness Center in Lenox, Mass.
“That’s what’s hard with all the postinfection inflammatory syndromes — long COVID, as well as chronic fatigue syndrome and chronic Lyme. There’s not one biomarker that says, ‘Oh, this is what it is.’ So physicians may discount it and say, ‘You’re recovered. You should be feeling better.’”
Yet increasing numbers of patients with chronic conditions, including growing numbers of COVID long-haulers, are looking for functional and integrative solutions, says Leo Galland, MD, a functional-medicine internist in New York City.
Long COVID shares several key characteristics with chronic fatigue syndrome (CFS) and chronic Lyme disease. These include problems with mitochondrial function (mitochondria are the energy-producing powerhouses inside our cells), fatigue, brain fog, and muscle pain.
The condition also has unique features, notes Galland. “In long COVID we see more organ systems involved. Chest pain, cough, and shortness of breath are common, as well as GI symptoms and abdominal pain. It’s also notable the degree to which they fluctuate. People can feel good one week and lousy the next, or even day to day.”
This certainly describes Press, who says her symptoms came in random waves. “Some days I pick up a glass of water and it feels like a glass. Other days it feels like a sandbag. I wake up in the morning and I don’t know how it’s going to be.”
While long COVID can present a larger and more varied constellation of symptoms than CFS or chronic Lyme, it seems to respond well to the same tools functional-medicine providers use to address those conditions.
“In the functional-medicine world, we look at the different functions that go on in the body,” explains Patrick Hanaway, MD, chief medical education officer at the Institute for Functional Medicine. “When we look at a post-infectious state where someone is having persistent symptoms across multiple organs, we ask, ‘What’s the functional imbalance that’s going on here?’”
Seeking the Root Causes of Symptoms
About three weeks into her COVID infection, Press started to lose feeling in her lips and struggled to breathe as a tingling numbness spread across her face. Her husband, Max, took her to the ER, where doctors dismissed her symptoms as a panic attack and sent her home.
In online support groups, many people describe similar experiences: lingering COVID symptoms are dismissed as a product of emotional or psychological distress.
“It’s real, but the doctors often say they don’t know what to do anymore,” says Press.
In June 2020, Press enrolled in a post-COVID patient-study group at New York City’s Mount Sinai Hospital. She was referred to an array of specialists, including a neurologist, rheumatologist, cardiologist, pulmonologist, rehab physician, dermatologist, and gastroenterologist.
While she was happy to be taken seriously, she didn’t sense they were connecting the dots among her wide-ranging symptoms. One doctor put her on an anti-inflammatory diet, but when she started having digestive issues, another instructed her to end it.
“I’m grateful for all of them, but I wish the doctors communicated with each other,” she says.
Complex conditions like this often challenge physicians who specialize in particular areas, but the root-cause approach of functional medicine can be especially well-suited to the task.
“Long COVID is a complex, multifactorial condition,” notes Hanaway. “We need to look at it not on an organ-system basis, but from a functional basis, to say, ‘What’s underneath here? What are the functions that interrelate those systems and how do we address that?’” (For more on what differentiates functional medicine, see “Functional Medicine: A Science Whose Time Has Come“; for functional-medicine recommendations for boosting immunity, see “5 Ways to Boost Your Immunity“.)
Some people are infected by the coronavirus and never get sick; others suffer damage to their immune system and ongoing inflammation. These effects can produce a broad range of symptoms, including cardiac inflammation and tachycardia (a heart rate of more than 100 beats per minute), fatigue, pain, brain fog, and breathing difficulties.
Two primary mechanisms may account for long-haul symptoms, says Galland: persistent immune imbalance and a disturbed gut microbiome.
“One thing that’s been documented in people who haven’t recovered from an acute infection is a consistent upregulation of white blood cells called monocytes and macrophages,” he says. “A lot of the symptoms have to do with that persistent immune imbalance and increased inflammation. It’s like a switch gets turned on that doesn’t get turned off.”
Galland traces this to the way COVID inactivates the ACE-2 enzyme. ACE-2 is the doorway the virus uses to enter our cells and is one of the body’s best tools for establishing balance and controlling inflammation.
“All the severe long-COVID symptoms can be traced back to the loss of ACE-2 activity, even in those who didn’t get really sick,” he explains. “Loss of ACE-2 can cause problems with energy metabolism and mitochondria, and result in cardiac problems, pneumonia, blood clots, kidney failure, strokes, seizures, brain fog, purple toes, excessive inflammation, and autoimmune disease.”
There is an abundance of ACE-2 receptors in the GI tract as well, and COVID commonly produces gut dysbiosis. This allows pro-inflammatory bacteria to thrive in the gut microbiome and contributes to other inflammatory symptoms, he says.
Dietary changes can be the first step to easing inflammation and oxidative stress, supporting ACE-2 activity, and improving mitochondrial function. “The treatment that I’m favoring involves supplements and a diet that is anti-inflammatory and flavonoid-rich, and helps to create a healthier gut microbiome,” he says. This functional-medicine approach allows him to address the range of symptoms at their root.
“We have experience using these tools with people with tick-borne and viral infections in the past and seeing improvements,” notes Hanaway. “Functional practitioners are using those same systems-biology tools to help return [long-haulers] to normal function.”
Strategies for Treating Long COVID