Wednesday, May 5, 2021

COVID Long-Haulers: There is Hope

 by Dr. Iva Lloyd, ND


For too many individuals the long-term effects of COVID have been more distressing than the acute phase. Like all diseases and discussions about health, it is imperative to remember that health and disease are complex. It is appreciating the complexity and the context that each individual finds themselves in that helps to understand what is relevant for them and how best to deal with the situation. Here is an overview of what we know about long-haulers also referred to as post-acute-sequelae of COVID (PASC).

PASC Symptoms

Most people with PASC will experience a range of symptoms. The symptoms depend on a person's underlying susceptibilities and where the virus "sits" in their body.  The symptoms can include:

  • chronic fatigue 
  • low grade fever that may be consistent or intermittent
  • shortness of breath, especially on exertion with  or without a cough
  • compromised lung and/or heart function
  • joint and/or muscle pain or muscle atrophy
  • mental health concerns especially as it relates to worsening anxiety and/or depression
  • cognitive changes and brain fog
  • skin rashes
  • gastrointestinal upset
  • headaches and sense of dizziness or instability
  • decrease or change in smell and/or taste
  • changes in sleep
  • changes in menstrual cycle and flow

·       Risk of PASC

There does not seem to be a relationship between the severity of the initial infection and the risk of developing post-COVID symptoms. Research does tend to indicate that there may be an increased risk of developing PASC if a person had multiple symptoms (eg. >5) during the first week of illness. The symptoms associated with PASC tend to wax and wane, as well as shift, between physiological systems. The following outlines other risk factors.

  • Comorbidities that may increase risk:  Underlying conditions that may increase a person's risk of post-COVID symptoms include significant cardiovascular disease, unstable diabetes, chronic lung disease, lowered renal function, obesity, progressive asthma, and significant mental health problems.
  • Other characteristics that might increase an individual's risk: older age, female, blood type A, nutritional deficiencies, environmental factors (such as increased exposure to environmental pollutants, exposure to high levels EMF), chronic stress, lower socioeconomic status, and medications such as proton-pump inhibitors
  • High risk blood indicators:  There are some blood tests that may be correlated with an increased risk of PASC.  High D-Dimer, high ferritin, high LDH, progressive decrease in lymphocytes, high neutrophil/lymphocyte ratio.  Your naturopathic or medical doctor can assess these for you and determine if they are relevant indicators for you.
  • Nutrient deficiencies that may be worthwhile assessing: Vitamin A, Vitamin D, B12, Vitamin C, Vitamin K, Magnesium, Zinc, Omega 3 fatty acids, glutathione and melatonin.  Assessment of  gut health / microbiome.
  • Home care: moderate exercise, clean diet (anti-inflammatory, avoid food intolerances, sugar and limiting dampness forming foods (wheat, yeast, dairy), decrease stress, ensure adequate sleep and hydration.
There are four main manifestations of PASC - neurological, heart and lung, kidney and liver, and skin.  Likely, a person's underlying suspectibilitites will influence the symptoms that they experience.

Post CV-19 Neurological Syndrome

Brain / Neurological

1st degree

 

2nd degree

3rd degree

Symptoms

Loss of smell,

â cognition

â short-term memory

Brain fog, dysphagia, dysarthria, headache,

Trouble sleeping, depression, anxiety

â â cognition / memory

Confusion, delirium

Dizzy spells, lightheadedness,

Hair loss, HA

 

Cerebrovascular disease and/or changes in cognition and memory


Post CV-19 Heart / Lung Conditions

Heart / Blood vessels

1st degree

 

2nd degree

3rd degree

Symptoms

Impaired endothelial function

 

Fatigue, exercise intolerance, easy bruising, dry cough, body aches, sore throat

 

 

Dyspnea, extreme SOB and fatigue, áá exercise intolerance, bulging veins, Erratic HT beat, arrythmia, worsening dry cough,

tightness in chest, body aches, silent hypoxia, low affect, “lung burn”

Cerebrovascular disease


Post CV-19 Kidney / Liver Conditions

Kidney / Liver

1st degree

 

2nd degree

3rd degree

Symptoms

Fatigue, itchy skin, body aches

Ascites, itchy skin,

áá fatigue

 

Liver and / or Kidney dysfunctions

 

Post COVID-19 Skin Conditions

Skin Conditions

1st degree

 

2nd degree

3rd degree

Symptoms

Fever, persistent cough, fatigue, chills and sweats,

Urticaria

 

Pernio (persistent pain, discolouration of toes, cold)

Chilbains, urticaria

Morbilliform rash

Macular erythema

Vesicular eruptions

Papulosquamous eruptions

Retiform purpura

 Organ dysfunction

 Naturopathic Approach to Post-COVID Symptoms

Naturopathic doctors treat the whole person. They assess an individual's underlying susceptibilities and healing potential, their current health status, lifestyle, as well the impact prior diseases have had from a mental-emotional and physical perspective. Naturopathic approach to PASC would likely involve:

  • A detailed intake to fully understand an individual's susceptibilities, their current symptoms and how those symptoms have impacted their life.
  • A physical exam, as needed.
  • The requisitioning of blood work to verify the physical impact on the body. The specific laboratory tests would depend on each person's health history and PASC symptoms. 
  • Some symptoms will warrant the need for chest X-ray, scans or other testing.
The treatment of PASC needs to be individualized based on each person's unique constitution, susceptibilities and manifestation of symptoms. PASC is a new condition. There is very little research specific to this condition and naturopathic treatments. Based on uses of specific modalities Naturopathic doctors are likely to consider approaches that include one or more of the following:
  • Individualized dietary recommendations and other lifestyle recommendations to assist with healing.
  • Naturopathic modalities and therapies that might be indicated include:
    • Nutraceuticals such as N-Acetyl-Cysteine (NAC), Glutathione (nebulizer, oral), EGCG, Vitamin B12, Serropeptidase, Modified Citrus Pectin, Quercetin,     Lutein, Zexanthin, Astaxanthin, Vitamin A, C, D, E and Selenium and Zinc.

    • Herbal medicines to address the specific symptoms such as St. John’s Wort (Hypericum perforatum), Ginkgo (Ginkgo biloba), Bromelain, Turmeic (Curcuma longa), Cordyceps, Hawthorn (Crataegus monogyna), Astragalus (Astragalus membranous), Andrographis (Andrographis paniculate), Milk Thistle (Silybum marianum), Buplerum falciparum, Taraxacum officinalis (Dandelion), Nettle (Urtica dioica), Burdock (Arctium lappa)

    • Gemmotherapies such as Alnus glutinosa, Vaccinium vitis idea, Rosmarinus officinalis, Vinca minor, Lonicera nigra, Populus nigra, Prunus amygdalus, Corylus avelliana, Crataegus oxycacanta, Viscum album, Rosa canina, Gingko biloba, Juniperus communis, Ribes nigra, Fraxinus excelsior, Betula pubescens, Cedrus libani, Ulmus campestris

    • Homeopathic remedies and tissue salts.
    • Other naturopathic approaches as indicated such as acupuncture, hydrotherapy, Intravenous therapies, lifestyle counselling and others.
If you are someone you know is dealing with PASC, it might be worthwhile to work with a naturopathic doctor to discuss how they can support you on your journey back to health. To book an appointment with one of our naturopathic doctors, contact us at 905-940-2727 or email us at info@naturopathicfoundations.ca. 

References

Another article on COVID co-authored by Dr. Lloyd, ND:

 Lloyd I, Saunders P. Assessing for the co-morbidities and factors that may affect a patient's risk and response to COVID-19. CAND Vital Link. 2020;2:19-26.

The following is an overview of research on PASC.

 

Area of Study

References

Fatigue

 

 

·       Del Rio C, Collins LF, Malani P. Long-term Health Consequences of COVID-19. JAMA. 2020 Oct 5. doi: 10.1001/jama.2020.19719

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605.

·       Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network — United States, March–June 2020. MMWR Morb Mortal Wkly Rep 2020;69:993-998.

·       Tolba M, Abo Omirah M, Hussein A, Saeed H. Assessment and Characterization of Post-COVID-19 manifestations. Int J Clin Pract. 2020 Sep 29:e13746

·       https://evidence.nihr.ac.uk/themedreview/living-with-covid19/ (accessed Oct. 22, 2020)

·       https://www.thephysician.uk/editorial-after-the-pandemic (accessed Oct. 23, 2020)

·       Long COVID: let patients help define long-lasting COVID symptoms. Nature. 2020 Oct;586(7828):170

·       Townsend L, Dyer AH et al. Persistent fatigue following SARS-CoV2-infection is common and independent of severity of initial infection. medRxiv https://www.medrxiv.org/content/10.1101/2020.07.29.20164293v1 (accessed Oct. 23, 2020)

Dyspnea/ breathlessness

·       Del Rio C, Collins LF, Malani P. Long-term Health Consequences of COVID-19. JAMA. 2020 Oct 5. doi: 10.1001/jama.2020.19719

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605.

·       https://evidence.nihr.ac.uk/themedreview/living-with-covid19/ (accessed Oct. 22, 2020)

·       Long COVID: let patients help define long-lasting COVID symptoms. Nature. 2020 Oct;586(7828):170

Cough

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605.

Chest pain/ heaviness

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605.

·       https://evidence.nihr.ac.uk/themedreview/living-with-covid19/ (accessed Oct. 22, 2020)

·       Long COVID: let patients help define long-lasting COVID symptoms. Nature. 2020 Oct;586(7828):170

Joint pain/ muscle pain

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605.

·       Long COVID: let patients help define long-lasting COVID symptoms. Nature. 2020 Oct;586(7828):170

Chemosensory disturbances

(persistent loss of sense of smell and taste)

·       Del Rio C, Collins LF, Malani P. Long-term Health Consequences of COVID-19. JAMA. 2020 Oct 5. doi: 10.1001/jama.2020.19719

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605

Cognitive blunting (“brain fog”)/ loss of concentration

·       Del Rio C, Collins LF, Malani P. Long-term Health Consequences of COVID-19. JAMA. 2020 Oct 5. doi: 10.1001/jama.2020.19719

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.     

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605

Emotional health and well-being:

·      

·       Del Rio C, Collins LF, Malani P. Long-term Health Consequences of COVID-19. JAMA. 2020 Oct 5. doi: 10.1001/jama.2020.19719

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.

·       https://evidence.nihr.ac.uk/themedreview/living-with-covid19/ (accessed Oct. 22, 2020)

·       Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: Systematic review of the current evidence. Brain Behav Immun. 2020 Oct;89:531-542.

·       Vittori A, Lerman J, Cascella M, Gomez-Morad AD, Marchetti G, Marinangeli F, Picardo SG. COVID-19 Pandemic Acute Respiratory Distress Syndrome Survivors: Pain After the Storm? Anesth Analg. 2020 Jul;131(1):117-119

·       Leung TYM, Chan AYL, Chan EW, Chan VKY, Chui CSL, Cowling BJ, Gao L, Ge MQ, Hung IFN, Ip MSM, Ip P, Lau KK, Lau CS, Lau LKW, Leung WK, Li X, Luo H, Man KKC, Ng VWS, Siu CW, Wan EYF, Wing YK, Wong CSM, Wong KHT, Wong ICK. Short- and potential long-term adverse health outcomes of COVID-19: a rapid review. Emerg Microbes Infect. 2020 Dec;9(1):2190-2199

 

Skin rashes:

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026

·       Skin rash should be considered a 4th key sign of COVID-19 https://covid.joinzoe.com/us-post/skin-rash-covid (accessed Oct. 23, 2020)

Other: 

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605

 Mitochrondia Support

·       Burtscher J, Cappellano G, Omori A, Koshiba T, Millet GP. Mitochondria: In the Cross Fire of SARS-CoV-2 and Immunity. iScience. 2020 Oct 23;23(10):101631

·       Saleh J, Peyssonnaux C, Singh KK, Edeas M. Mitochondria and microbiota dysfunction in COVID-19 pathogenesis. Mitochondrion. 2020 Sep;54:1-7.

·       Singh KK, Chaubey G, Chen JY, Suravajhala P. Decoding SARS-CoV-2 hijacking of host mitochondria in COVID-19 pathogenesis. Am J Physiol Cell Physiol. 2020 Aug 1;319(2):C258-C267.

·       Kloc M, Ghobrial RM, Kubiak JZ. The Role of Genetic Sex and Mitochondria in Response to COVID-19 Infection. Int Arch Allergy Immunol. 2020;181(8):629-634

·       Halpin SJ, McIvor C, Whyatt G, Adams A, Harvey O, McLean L, Walshaw C, Kemp S, Corrado J, Singh R, Collins T, O'Connor RJ, Sivan M. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation. J Med Virol. 2020 Jul 30. doi: 10.1002/jmv.26368.

·       European Respiratory Journal 2020; 56: Suppl. 64, 4143. https://erj.ersjournals.com/content/56/suppl_64/4143.abstract (accessed Niv 6, 2020)

·       Ojo AS, Balogun SA, Williams OT, Ojo OS. Pulmonary Fibrosis in COVID-19 Survivors: Predictive Factors and Risk Reduction Strategies. Pulm Med. 2020 Aug 10;2020:6175964

·       Li G, Hu R, Gu X. A close-up on COVID-19 and cardiovascular diseases. Nutr Metab Cardiovasc Dis. 2020 Jun 25;30(7):1057-1060

·       Boukhris M, Hillani A, Moroni F, Annabi MS, Addad F, Ribeiro MH, Mansour S, Zhao X, Ybarra LF, Abbate A, Vilca LM, Azzalini L. Cardiovascular Implications of the COVID-19 Pandemic: A Global Perspective. Can J Cardiol. 2020 Jul;36(7):1068-1080 

Specific organ dysfunction (heart):

·       

 

·       Del Rio C, Collins LF, Malani P. Long-term Health Consequences of COVID-19. JAMA. 2020 Oct 5. doi: 10.1001/jama.2020.19719

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026

·       Tolba M, Abo Omirah M, Hussein A, Saeed H. Assessment and Characterization of Post-COVID-19 manifestations. Int J Clin Pract. 2020 Sep 29:e13746

·       Leung TYM, Chan AYL, Chan EW, Chan VKY, Chui CSL, Cowling BJ, Gao L, Ge MQ, Hung IFN, Ip MSM, Ip P, Lau KK, Lau CS, Lau LKW, Leung WK, Li X, Luo H, Man KKC, Ng VWS, Siu CW, Wan EYF, Wing YK, Wong CSM, Wong KHT, Wong ICK. Short- and potential long-term adverse health outcomes of COVID-19: a rapid review. Emerg Microbes Infect. 2020 Dec;9(1):2190-2199

·       https://evidence.nihr.ac.uk/themedreview/living-with-covid19/ (accessed Oct. 22, 2020)

·       https://www.thephysician.uk/editorial-after-the-pandemic (accessed Oct. 23, 2020)

·       Long COVID and inflammation: a cardiologists point of view https://www.medscape.com/viewarticle/935488#vp_2 (accessed Oct 23, 2020)

·       Note: the reduction in heart pumping after recovering from COVID-19 may be more common in men according to preliminary results from the COVERSCAN study https://www.itv.com/news/2020-08-12/long-covid-what-is-it-what-are-the-symptoms-and-what-help-is-there-for-sufferers (accessed OCT 23, 2020)

Specific organ dysfunction (lung):

·       

·       Del Rio C, Collins LF, Malani P. Long-term Health Consequences of COVID-19. JAMA. 2020 Oct 5. doi: 10.1001/jama.2020.19719

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026

·       Tolba M, Abo Omirah M, Hussein A, Saeed H. Assessment and Characterization of Post-COVID-19 manifestations. Int J Clin Pract. 2020 Sep 29:e13746

·       Leung TYM, Chan AYL, Chan EW, Chan VKY, Chui CSL, Cowling BJ, Gao L, Ge MQ, Hung IFN, Ip MSM, Ip P, Lau KK, Lau CS, Lau LKW, Leung WK, Li X, Luo H, Man KKC, Ng VWS, Siu CW, Wan EYF, Wing YK, Wong CSM, Wong KHT, Wong ICK. Short- and potential long-term adverse health outcomes of COVID-19: a rapid review. Emerg Microbes Infect. 2020 Dec;9(1):2190-2199

·       https://evidence.nihr.ac.uk/themedreview/living-with-covid19/ (accessed Oct. 22, 2020)

·       https://www.thephysician.uk/editorial-after-the-pandemic (accessed Oct. 23, 2020)

Specific organ dysfunction (brain):

·      

·       Del Rio C, Collins LF, Malani P. Long-term Health Consequences of COVID-19. JAMA. 2020 Oct 5. doi: 10.1001/jama.2020.19719

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605

·       Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ. 2020 Aug 11;370:m3026.

Specific organ dysfunction (kidney):

 

 

·       https://www.thephysician.uk/editorial-after-the-pandemic (accessed Oct. 23, 2020)

·       Tolba M, Abo Omirah M, Hussein A, Saeed H. Assessment and Characterization of Post-COVID-19 manifestations. Int J Clin Pract. 2020 Sep 29:e13746

·       Prelimary results from the COVERSCAN study in Oxford https://www.itv.com/news/2020-09-29/long-covid-long-term-effects-of-coronavirus-include-damage-to-heart-liver-kidneys-oxford-study-reveals (accessed Oct. 23, 2020)

Other Research

 

·       Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 P ost-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11;324(6):603-605.

·         Tenforde MW, Kim SS, Lindsell CJ, et al. Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network — United States, March–June 2020. MMWR Morb Mortal Wkly Rep 2020;69:993-998. 

·         Zhou H, Lu S, Chen J, Wei N, Wang D, Lyu H, Shi C, Hu S. The landscape of cognitive function in recovered COVID-19 patients. J Psychiatr Res. 2020 Oct;129:98-102

·         Hascup ER, Hascup KN. Does SARS-CoV-2 infection cause chronic neurological complications? Geroscience. 2020 Aug;42(4):1083-1087.

·         Troyer EA, Kohn JN, Hong S. Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms. Brain Behav Immun. 2020 Jul;87:34-39.

·         Steardo L Jr, Steardo L, Verkhratsky A. Psychiatric face of COVID-19. Transl Psychiatry. 2020 Jul 30;10(1):261.

·         Alam SB, Willows S, Kulka M, Sandhu JK. Severe acute respiratory syndrome coronavirus 2 may be an underappreciated pathogen of the central nervous system. Eur J Neurol. 2020 Jul 15:10.1111/ene.14442.

·         Heneka MT, Golenbock D, Latz E, Morgan D, Brown R. Immediate and long-term consequences of COVID-19 infections for the development of neurological disease. Alzheimers Res Ther. 2020 Jun 4;12(1):69.

·         Salimi S, Hamlyn JM. COVID-19 and Crosstalk With the Hallmarks of Aging. J Gerontol A Biol Sci Med Sci. 2020 Sep 16;75(9):e34-.

·         Disser NP, De Micheli AJ, Schonk MM, Konnaris MA, Piacentini AN, Edon DL, Toresdahl BG, Rodeo SA, Casey EK, Mendias CL. Musculoskeletal Consequences of COVID-19. J Bone Joint Surg Am. 2020 Jul 15;102(14):1197-1204.

·         Azim D, Nasim S, Kumar S, Hussain A, Patel S. Neurological Consequences of 2019-nCoV Infection: A Comprehensive Literature Review. Cureus. 2020 Jun 24;12(6):e8790.

·         Kaniusas E, Szeles JC, Kampusch S, Alfageme-Lopez N, Yucuma-Conde D, Li X, Mayol J, Neumayer C, Papa M, Panetsos F. Non-invasive Auricular Vagus Nerve Stimulation as a Potential Treatment for Covid19-Originated Acute Respiratory Distress Syndrome. Front Physiol. 2020 Jul 28;11:890.

·         Kempuraj D, Selvakumar GP, Ahmed ME, Raikwar SP, Thangavel R, Khan A, Zaheer SA, Iyer SS, Burton C, James D, Zaheer A. COVID-19, Mast Cells, Cytokine Storm, Psychological Stress, and Neuroinflammation. Neuroscientist. 2020 Oct-Dec;26(5-6):402-414.

·         Conti P, Caraffa A, Tetè G, Gallenga CE, Ross R, Kritas SK, Frydas I, Younes A, Di Emidio P, Ronconi G. Mast cells activated by SARS-CoV-2 release histamine which increases IL-1 levels causing cytokine storm and inflammatory reaction in COVID-19. J Biol Regul Homeost Agents. 2020 Sep-Oct,;34(5):1629-1632.

·         Shaik Y, caraffa A, Ronconi G, Lessiani G, Conti P. Impact of polyphenols on mast cells with special emphasis on the effect of quercetin and luteolin. Cent Eur J. Immunol. 2018;43(4):476-481)

·         Akour A. Probiotics and COVID-19: is there any link? Lett Appl Microbiol. 2020 Sep;71(3):229-234.

·         Saleh J, Peyssonnaux C, Singh KK, Edeas M. Mitochondria and microbiota dysfunction in COVID-19 pathogenesis. Mitochondrion. 2020 Sep;54:1-7.

·         Dhar D, Mohanty A. Gut microbiota and Covid-19- possible link and implications. Virus Res. 2020 Aug;285:198018.

·         Baghbani T, Nikzad H, Azadbakht J, Izadpanah F, Haddad Kashani H. Dual and mutual interaction between microbiota and viral infections: a possible treat for COVID-19. Microb Cell Fact. 2020 Nov 26;19(1):217.

·         Baumann A, Gönnenwein S, Bischoff SC, Sherman H, Chapnik N, Froy O, Lorentz A. The circadian clock is functional in eosinophils and mast cells. Immunology. 2013 Dec;140(4):465-74


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