Pathophysiology and mechanism of long COVID: a comprehensive review

Centre Administratif du Botanique, Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium.

Annals of medicine. 2022;54(1):1473-1487
PICO Summary


Patients with long COVID-19 (98 studies).


Systematic review to address the putative pathophysiology underlying the persisting symptoms of long COVID-19.



Of all the included studies, 54 addressed hypotheses concerning potential underlying mechanisms of long COVID-19 symptoms, while 44 studies comprised patient data. Evidence about the persistence of long COVID-19 symptoms was limited, and the underlying mechanisms remained ambiguous. Many hypotheses were put forth by articles reviewing the potential pathophysiology. Included articles reporting patient data were highly heterogeneous, as their patients had various COVID-19 severity levels and different time frame analysis.
BACKGROUND After almost 2 years of fighting against SARS-CoV-2 pandemic, the number of patients enduring persistent symptoms long after acute infection is a matter of concern. This set of symptoms was referred to as "long COVID", and it was defined more recently as "Post COVID-19 condition" by the World health Organization (WHO). Although studies have revealed that long COVID can manifest whatever the severity of inaugural illness, the underlying pathophysiology is still enigmatic. AIM: To conduct a comprehensive review to address the putative pathophysiology underlying the persisting symptoms of long COVID. METHOD We searched 11 bibliographic databases (Cochrane Library, JBI EBP Database, Medline, Embase, PsycInfo, CINHAL, Ovid Nursing Database, Journals@Ovid, SciLit, EuropePMC, and CoronaCentral). We selected studies that put forward hypotheses on the pathophysiology, as well as those that encompassed long COVID patients in their research investigation. RESULTS A total of 98 articles were included in the systematic review, 54 of which exclusively addressed hypotheses on pathophysiology, while 44 involved COVID patients. Studies that included patients displayed heterogeneity with respect to the severity of initial illness, timing of analysis, or presence of a control group. Although long COVID likely results from long-term organ damage due to acute-phase infection, specific mechanisms following the initial illness could contribute to the later symptoms possibly affecting many organs. As such, autonomic nervous system damage could account for many symptoms without clear evidence of organ damage. Immune dysregulation, auto-immunity, endothelial dysfunction, occult viral persistence, as well as coagulation activation are the main underlying pathophysiological mechanisms so far. CONCLUSION Evidence on why persistent symptoms occur is still limited, and available studies are heterogeneous. Apart from long-term organ damage, many hints suggest that specific mechanisms following acute illness could be involved in long COVID symptoms. KEY MESSAGESLong-COVID is a multisystem disease that develops regardless of the initial disease severity. Its clinical spectrum comprises a wide range of symptoms.The mechanisms underlying its pathophysiology are still unclear. Although organ damage from the acute infection phase likely accounts for symptoms, specific long-lasting inflammatory mechanisms have been proposed, as well.Existing studies involving Long-COVID patients are highly heterogeneous, as they include patients with various COVID-19 severity levels and different time frame analysis, as well.
Study details
Study Design : Systematic Review
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine