AAPM&R：SARS-CoV-2感染後急性後遺症（PASC）：評価・治療新指針
米国物理医学リハビリテーション学会（AAPM&R）は、SARS-CoV-2感染後急性後遺症（PASC）としても知られるlong COVID患者の神経学的後遺症の評価と治療に関する新しい合意指針を発表
Physical Medicine & Rehabilitation誌のオンライン版で発表
最初の感染から1カ月以上症状が続いている患者を評価する必要がある
PASCを構成するものの定義は進化しているが、ガイダンスでは、文献によると、初感染から4週間を過ぎても症状が持続している場合と定義すべきで 最も一般的な神経症状は、頭痛、脱力感、筋肉痛、神経痛、振戦、末梢神経の問題、睡眠の問題、認知機能への影響である。
"進行性または不吉な「レッドフラッグ」神経症状を持つ患者を特定することが緊急のトリアージとなり、不可欠レッドフラッグの中には、突然または進行性の脱力感や突然または進行性の感覚変化があり、それらは急性の神経学的状態-long COVIDや他の病気によるもの-例えば脳卒中や脊髄の問題、ギランバレー症候群、ミオパシーなどを示す可能性がある
TABLE 1 PASC fatigue assessment recommendations
Statement
1 Patients should be assessed for fatigue patterns throughout their normal day to guide activity recommendations.
la Patients should be assessed for their responses to initiating and escalating activity on their fatigue.
1 b Patients should be evaluated for changes in daily functioning and activity levels.
1 c Patients' physical functioning and endurance should be assessed to inform activity and therapy recommendations. (Examples of tests that can be chosen based on an individual's activity tolerance: 30 s sit to stand; 2-min step (seated or standing); 6 min walk test; 10 m walk test).
2 Clinicians should assess for changes in activities of daily living, independent activities of daily living, school, work, and avocational (ie, hobbies)
3 A full patient history with review of preexisting conditions should be conducted
4 Patients should be evaluated for conditions that may exacerbate fatigue symptoms and warrant further testing and potential subspecialty referral (see Table 2).
Particular areas include:
• Sleep
• Mood, including anxiety, depression and PTSD. Note: Patients often report dissatisfaction with their care because of their persistent symptoms being attributed to psychological factors. It is important to note that mood disorders may be secondary to persistent medical issues or one of many factors leading to fatigue.
• Cardiopulmonary
• Autoimmune
• Endocrine
5 A medication review should be conducted to investigate medications that may be contributing to fatigue. Of note, antihistamine, anticholinergic, and antidepressant/anxiolytic medications can contribute to fatigue in patients with PASC.
6 The following basic lab workup should be considered in new patients or those without lab workup in the 3 months before visit including complete blood count with differential, chemistries including renal and hepatic function tests, thyroid stimulating hormone, c-reactive protein or erythrocyte sedimentation rate, and creatinine kinase.
Other laboratory tests may be considered based on the results of these tests or if there is specific concern for comorbid conditions as outlined in Table 2.
Abbreviations: PASC, postacute sequelae of SARS-CoV-2 infection; PTSD, posttraumatic stress disorder.
TABLE 3 National Aademy of Sciences proposed diagnostic criteria for ME/CFS
Proposed Diagnostic Criteria for ME/CFS
Diagnosis requires that the patient has the following three symptoms:
1. A substantial reduction or impairment in the ability to engage in preillness levels of occupational, education, social, or personal activities that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest,
2. Postexertional malaise and
3. Unrefreshing sleep
At least one of the following manifestations is also required:
1. Cognitive impairmenta or
2. Orthostatic intolerance
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Reproduced with permission. aFrequency and severity of symptoms should be assessed. The diagnosis of ME/CFS should be questioned if patients do not have these symptoms at least half of the time with moderate, substantial, or severe intensity.
Abbreviation: ME/CFS, myalgic encephalomyelitis/chronic fatigue syndrome.
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