Working Diagnosis:
Post COVID Lung Injury

Treatment:
Mild air trapping likely consequence of post COVID lung injury. The decline in lung function is stable and not progressing over time. Plan to reevaluate in six months. Patient was cleared to gradually return to running as tolerated.

Outcome:
Patient gradually returned to competitive running and completed her cross country season in the Fall 2021 with no further concerns. She was about eleven months out from her COVID infection. For the season, her average times and personal best for the 5,000m race were one minute slower when compare to her pre-COVID season.

Author's Comments:
This case illustrates a single sport athlete who did not take time off running despite active COVID infection. Return to play after COVID infection requires patient to quarantine for ten days with at least seven of the days without symptoms and patient is able to perform activities of daily living without cardiorespiratory symptoms. Return to sport should progress gradually over at least seven days but may take longer depending on the severity of illness. If the athlete has symptoms of myocarditis or continues to experience activity-limiting dyspnea post COVID infection, stop exercising immediately and conduct a cardiovascular and pulmonary workup which typically includes EKG, echocardiogram, troponin, and cardiology consultation with consideration of cardiac MRI. Athlete should refrain from exercise until evaluation is complete. Cardiac involvement post COVID infection appears to be low among athletes and recommendation is to use cardiac MRI and echocardiogram only when there is clinical suspicion and should not be used as primary screening tool.

Editor's Comments:
Air trapping is now know to be a complication seen in "long COVID" patients. Studies have also shown that severity of COVID symptoms did not affect the number of patients with post-COVID air trapping. From Cho et al. "The percentage of lung affected by air trapping was similar across COVID-19 severity groups (ambulatory, 25.4%; hospitalized, 34.6%; requiring intensive care, 27.3%; P =.10) and persisted in 8 of 9 participants imaged more than 200 days after diagnosis."

As we learn more about COVID and the long term complications we may alter our management. The current recommendations regarding activity for those with asymptomatic infection have changed and may continue to as the virus, treatment, prevention strategies are updated. In general any athlete with pulmonary symptoms due to a virus would not be recommended to participate.

References:
Cavigli L et al. "SARS-CoV-2 infection and return to play in junior competitive athletes: is systematic cardiac screening needed?" Br J Sports Med. 2022 Mar;56(5):264-270. doi: 10.1136/bjsports-2021-104764. Epub 2021 Nov 29

Daniels, Curt J et al. "Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes With Recent SARS-CoV-2 Infection: Results From the Big Ten COVID-19 Cardiac Registry." JAMA cardiology vol. 6,9 (2021): 1078-1087. doi:10.1001/jamacardio.2021.2065

Drezner JA, et al. "Cardiopulmonary Considerations for High School Student-Athletes During the COVID-19 Pandemic: Update to the NFHS-AMSSM Guidance Statement." Sports Health. 2022 Feb 21:19417381221077138. doi: 10.1177/19417381221077138. Epub ahead of print.

Elliott N, et al. Infographic. Graduated return to play guidance following COVID-19 infection. British Journal of Sports Medicine. 2020;54:1174-1175 doi:10.1136/bjsports-2020-102637

Giusto E, Asplund CA. Persistent COVID and a Return to Sport. Curr Sports Med Rep. 2022 Mar 1;21(3):100-104. doi: 10.1249/JSR.0000000000000943.

Lollgen H, et al. Infographic. Clinical recommendations for return to play during the COVID-19 pandemic. British Journal of Sports Medicine. 2021;55:344-345 doi:10.1136/bjsports-2020-102985

Petek BJ, et al. "Prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms following SARS-CoV-2 infection in 3597 collegiate athletes: a study from the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA)." Br J Sports Med. 2021 Nov 1:bjsports-2021-104644. doi: 10.1136/bjsports-2021-104644. Epub ahead of print.

Cho, Josalyn L., et al. "Quantitative chest CT assessment of small airways disease in post-acute SARS-CoV-2 infection." Radiology (2022): 212170.

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