Endocrine, Metabolic and Microbiome Influence on the Post-acute Sequelae SARS-CoV-2 (PASC)

The onset of the COVID-19 pandemic has led to a subset of patients that, once recovered from the acute infection, also experience an intractable and debilitating set of lingering symptoms termed post-acute sequelae SARS-CoV-2 infection (PASC). The most common symptoms include anxiety, shortness of breath, continued loss of the sense of smell and taste, loss of appetite with subsequent weight loss, sleep difficulties, severe fatigue, cognitive dysfunction (foggy brain) and increased frailty. These patients frequently present to the emergency room looking for symptom management because they are unable to perform normal activities of daily living and maintain job performance. Thus, it is critical to characterize the baseline endocrine, metabolic, inflammatory and microbiome alterations in the post-COVID syndrome patients to better identify and manage the symptoms to prevent potential long-term health consequences.

University of Texas Medical Branch (UTMB) has established a post-COVID clinic for management of these patients, but it is recognized that a more complete clinical picture of the underlying mechanisms driving these lingering symptoms is needed.

Persistent and long-lasting health problems are common in patients after COVID-19 infection. In a recent study of patients that had been hospitalized with COVID-19, two months after discharge, 87% reported at least one lingering symptom (joint pain, fatigue, breathing issues, etc), more than 50% reported more than three lingering issues, and over 40% reported a reduction in their of quality of life. Another study found that at 1-month after hospitalization for COVID-19, 74% reported persistent issues related to shortness of breath and a decrease in both physical and mental health. Preliminary data from the UTMB Post-COVID Recovery clinic agree with these two recent reports. In a recent study, 1 1/2 months after COVID-19 diagnosis, patients reported on average 10 of the 18 common symptoms (with 90% having chest pain, 87% dyspnea, 75% fatigue, and 90% with cognitive changes). While the previous studies examined patients that had severe COVID-19 infections, >50% of the patients were never hospitalized, yet have numerous persistent symptoms. This has serious implications for the ability of patients to return to work, downstream effects on mental health due to sometimes drastic lifestyle and work capacity changes, and the ability to engage in activities or hobbies enjoyed prior to COVID-19 illness.

Notably, the cluster of symptoms associated with PASC include profound fatigue and cognitive dysfunction, which are strikingly consistent with a syndrome that the investigators clinical research team has described in patients after traumatic brain injury (TBI) designated Brain Injury Associated Fatigue and Altered Cognition (BIAFAC). Over the last 12 months the investigators have reported the characteristics of BIAFAC syndrome. In particular, TBI patients with BIAFAC present with lingering and profoundly debilitating symptoms including severe fatigue, cognitive dysfunction (foggy brain), sleep disturbances, and the inability to perform activities of daily living that persist for years post-injury. Mechanistically the investigators have explored the role of the gut microbiome discovering altered communities in TBI patients in long-term care facilities compared with controls. The investigators also established that many TBI patients with BIAFAC also present with abnormal growth hormone (GH) secretion, and when treated with recombinant GH, a majority of patients have significant improvement of both fatigue and impaired cognition. While studies are underway to understand the details of the mechanism causing BIAFAC and why GH treatment alleviates symptoms in these patients, the investigators are intrigued that the symptom phenotype with PASC patients overlaps with many BIAFAC symptoms. It is possible that PASC may be addressed through similar treatment strategies including the potential for prebiotic/probiotic enhancement of microbiome health.

In the current pilot proposal, the investigators will characterize the baseline endocrine, metabolic, inflammatory and gut microbiome alterations in PASC patients and patients who recovered without lingering symptoms from COVID infection. These patients will be compared to the investigators extensive database of BIAFAC patients and normal controls. From this critical baseline data, the investigators will develop carefully defined clinical research trials that will test potential treatments for alleviating the syndrome. The investigators hypothesize that an imbalanced endocrine axis stemming from COVID-19 infection leads to metabolic, inflammatory and microbial dysregulation resulting in the onset of persistent post-COVID symptoms.

Specific Aims

Specific Aim 1: Characterize the baseline physiological measures of endocrine function, metabolism, inflammation, and composition of the gut and nasal microbiome of patients reporting symptoms of PASC.

Specific Aim 2: Assess baseline neuropsychological measures of fatigue, sleep, and cognition for patients reporting symptoms of PASC.

Specific Aim 3: Correlate physiological and neuropsychological measures of PASC and compare those measures to the investigators extensive database of BIAFAC patients and normal controls.

Specific Aim 4: Characterize the microbiome of patients with PASC and compare to: a)our database of healthy control subjects, b) our database of symptomatic BIAFAC patients, c) new collected samples of patients with a history of COVID who did not develop PASC.

COVID Non-Symptomatic controls (nPASC)

Inclusion criteria

• Male or female with a history of COVID with diagnosis confirmed by PCR test.
• Minimum of 6 months since diagnosis of COVID by PCR test.
• Ages 18 to 80 years.
• Participant is willing and able to give informed consent for participation in the study.

Exclusion criteria

• Current COVID infection.
• Unable to walk unassisted.
• Significant heart, liver, kidney, blood or respiratory disease as determined by Principal Investigator.
• Uncontrolled diabetes mellitus.
• Any history of a recently (12 months) diagnosed cancer other than a skin cancer (excluding melanoma).
• Current alcohol or drug abuse.
• History of psychosis.
• Pregnancy or become pregnant during the trial.
• Subjects who are being managed with narcotics will be excluded as the effects of central nervous system depressants may interfere with study test results.
• Other medical condition or medication administration deemed exclusionary by the study investigators.

COVID Symptomatic Subjects (PASC)

Inclusion criteria

• Male or female with a history of COVID with diagnosis confirmed by PCR test.
• Has been seen at UTMB Post COVID clinic.
• Minimum of 6 months since diagnosis of COVID by PCR test.
• Ages 18 to 80 years.
• Score of 3 or higher on any question 1-3 of the Brief Fatigue Inventory (BFI) questionnaire.
• Participant is willing and able to give informed consent for participation in the study.

Exclusion criteria

• Current COVID infection.
• Unable to walk unassisted.
• Significant heart, liver, kidney, blood or respiratory disease.
• Uncontrolled diabetes mellitus.
• Any history of a recently (12 months) diagnosed cancer other than a skin cancer (excluding melanoma).
• Current alcohol or drug abuse.
• History of psychosis.
• Pregnancy or become pregnant during the trial.
• Subjects who are being managed with narcotics will be excluded as the effects of central nervous system depressants may interfere with study test results.
• Other medical condition or medication administration deemed exclusionary by the study investigators.