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CHRONIC COVID-19: TREATMENT WITH IVERMECTIN AND ACETYLSALICYLIC ACID OF PERSISTENT SYMPTOMS OF ARTHALGIES IN SHOULDERS AND HIPS.

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CHRONIC COVID-19: TREATMENT WITH IVERMECTIN AND ACETYLSALICYLIC ACID OF PERSISTENT SYMPTOMS OF ARTHALGIES IN SHOULDERS AND HIPS.

Abstract

CHRONIC COVID: TREATMENT WITH IVERMECTIN AND ACETYLSALICYLIC ACID OF PERSISTENT SYMPTOMS OF ARTHALGIES IN SHOULDERS AND HIPS. Case Report in which symptoms reappear after 6 months after overcoming the acute stage of COVID-19. . SUMMARY. A Case Report is made of a patient who presents resolution of the persistent symptoms of arthralgia in the shoulders and hips after treatment with Ivermectin for 8 days and Acetylsalicylic Acid (ASA) for 10 days. The patient, a 56-year-old male, a doctor at a National Hospital in Lima, had suffered from Acute COVID-19 on April 30, 2020, which corresponds to 8 months and 6 days before starting the treatment described in the present report. In the acute episode of COVID-19, he presented similar arthralgias in the shoulders and hips, which subsided the day after starting treatment with Ivermectin. Once the acute stage, after 6 months of being asymptomatic, he again presented arthralgia in the shoulders and hips with characteristics similar to those presented in the acute episode of COVID-19. These arthralgias persist and do not improve, so after a little more than 2 months he consults for treatment for the supposed sequela of COVID-19. It is uncommon for symptoms associated with COVID-19 to reappear after 6 months of being asymptomatic. The case is evaluated and from the experience with other patients it is suggested that it is a persistent viral infection that remained latent and asymptomatic for 6 months and that there has been a reactivation of the infection with the presence of symptoms similar to those presented in the acute stage of COVID-19. The presence of SARS CoV-2 viral load after 20 days of the onset of COVID-19 symptoms has been demonstrated in several scientific publications. According to the patient's weight, the Treatment Protocol that was indicated was the “Therapeutic Test” for people who weigh more than 95 kilos and for moderate symptoms. The patient took 2 tablets of ASA 100 mg. after breakfast, lunch and dinner, for 10 days. As of the third day after he started taking ASA, he took ivermectin at a dose of 0.27 mg. per kilo of weight after lunch and dinner, for 8 days. The patient reported good tolerance, did not manifest gastric or intestinal discomfort or other possible relevant side effects due to the intake of the drugs. The response to treatment with Ivermectin would indicate that the cause that originated the arthralgias would correspond to the presence of viral load sensitive to Ivermectin. Resolution of the arthralgias in a few days supports the fact that it was a persistent SARS CoV-2 infection. Due to the experience of several treated cases that present a rapid clinical resolution, it is recommended that in the event of persistent or post-acute symptoms of COVID that appear after having overcome the acute stage, it should not be indicated as the first diagnostic possibility that is a sequela, because in practice we have observed that many cases that are diagnosed with sequelae of COVID respond to treatment with drugs to reduce viral load such as Ivermectin, plus antiplatelets, fibrinolytics and/or anticoagulants. It is concluded that, in the presence of persistent or post-acute symptoms of COVID-19, it is convenient that the diagnosis of a persistent viral infection be considered first, and that the corresponding treatment be indicated. Health professionals need to be trained in how to differentiate clinically between persistent COVID-19 symptoms and sequelae.
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CHRONIC COVID: TREATMENT WITH IVERMECTIN AND
ACETYLSALICYLIC ACID OF PERSISTENT SYMPTOMS OF
ARTHALGIES IN SHOULDERS AND HIPS. Case Report in which symptoms
reappear after 6 months after overcoming the acute stage of COVID-19.
Aguirre-Chang, Gustavo and Trujillo, Aurora. January 26, 2021.
ABSTRACT
A Case Report is made of a patient who presents resolution of the persistent symptoms of
arthralgia in the shoulders and hips after treatment with Ivermectin for 8 days and
Acetylsalicylic Acid (ASA) for 10 days.
The patient, a 56-year-old male, a doctor at a National Hospital in Lima, had suffered from
Acute COVID-19 on April 30, 2020, which corresponds to 8 months and 6 days before
starting the treatment described in the present report.
In the acute episode of COVID-19, he presented similar arthralgias in the shoulders and
hips, which subsided the day after starting treatment with Ivermectin.
Once the acute stage, after 6 months of being asymptomatic, he again presented arthralgia
in the shoulders and hips with characteristics similar to those presented in the acute
episode of COVID-19. These arthralgias persist and do not improve, so after a little more
than 2 months he consults for treatment for the supposed sequelae of COVID-19.
It is uncommon for symptoms associated with COVID-19 to reappear after 6 months of
being asymptomatic. The case is evaluated and from the experience with other patients it is
suggested that it is a persistent viral infection that remained latent and asymptomatic for 6
months and that there has been a reactivation of the infection with the presence of
symptoms similar to those presented in the acute stage of COVID-19.
The presence of SARS CoV-2 viral load after 20 days of the onset of COVID-19 symptoms
has been demonstrated in several scientific publications.
According to the patient's weight, the Treatment Protocol that was indicated was the
“Therapeutic Test” for people who weigh more than 95 kilos and for moderate symptoms.
The patient took 2 tablets of ASA 100 mg. after breakfast, lunch and dinner, for 10 days. As
of the third day after he started taking ASA, he took ivermectin at a dose of 0.27 mg. per
kilo of weight after lunch and dinner, for 8 days.
The patient reported good tolerance, did not manifest gastric or intestinal discomfort or
other possible relevant side effects due to the intake of the drugs.
The response to treatment with Ivermectin would indicate that the cause that originated the
arthralgias would correspond to the presence of viral load sensitive to Ivermectin.
Resolution of the arthralgias in a few days supports the fact that it was a persistent SARS
CoV-2 infection.
Due to the experience of several treated cases that present a rapid clinical resolution, it is
recommended that in the event of persistent or post-acute symptoms of COVID-19 that
appear after having overcome the acute stage, it should not be indicated as the first
diagnostic possibility that is a sequela, because in practice we have observed that many
cases that are diagnosed with sequelae of COVID respond to treatment with drugs to
reduce viral load such as Ivermectin, plus antiplatelets, anticoagulants and /or fibrinolytics .
It is concluded that, in the presence of persistent or post-acute symptoms of COVID-19, it is
convenient that the diagnosis of a persistent viral infection be considered first, and that the
corresponding treatment be indicated.
Health professionals need to be trained in how to differentiate clinically between persistent
COVID-19 symptoms and sequelae.
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
Shoulders and Hips. Aguirre-Chang, G. Trujillo A. January 2021.
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Key Words: Arthralgias, COVID-19, Persistent Symptoms, Ivermectin, Acetylsalicylic Acid.
INTRODUCTION
Background.
In published studies, a prevalence of 10 to 45% (1 to 4) of persistent symptoms is
reported among people who became ill with COVID-19.
In Peru, with our collaborating doctors, we have observed that with the use of
Ivermectin, the percentage of people who present persistent or post-acute symptoms
after the acute stage of COVID-19 has passed, is only 2 to 4% of the total cases
treaties (5).
Arthalgia in COVID-19.
Arthralgia of the large joints is a rare musculoskeletal manifestation in COVID-19. In a
descriptive cohort study, its prevalence was 2% among patients infected with COVID-
19 (5). On clinical examination, it is noted that no swelling, joint effusion, or evidence of
synovial inflammation has been identified.
It is pointed out that arthralgia would be due to a direct damage of the virus at the level
of the synovial tissue, since the ACE-2 receptors are present at this level. And it is
mentioned that additionally there could also be deposits of immune complexes within
the joints (5).
Because it is a not very frequent symptom, because it presents almost as the only
symptom in the present case and because it occurs after 6 months of remaining
asymptomatic, it is reported as a clinical case and separately from the other cases we
have under study.
CASE REPORT
56-year-old male patient, of a medical profession, who works in a National Hospital in
the city of Lima in Peru, weighs 110 kilos, it has the pre-existing diagnoses of Arterial
Hypertension, Obesity and Bronchial Asthma.
Acute Stage of COVID-19:
Symptoms of COVID-19 started on April 30, 2020, the diagnosis of SARS CoV-2
infection was confirmed by: molecular laboratory test (PCR).
He began treatment for COVID-19 with Ivermectin from the third day of onset of
symptoms, at a dose of 0.20 mg. per kilo of weight during the first 2 days, and from the
third to the ninth day I take daily doses of 0.27 mg. per kilo of weight (i take 1 bottle of 5
ml. containing 30 mg of Ivermectin per day).
The symptoms that he presented from the first days were general malaise, weakness,
headache with retro ocular pain, fever, night sweats, sleep disturbance with difficulty in
falling asleep (insomnia). On the second day from the onset of symptoms,, arthralgia
was added in both shoulders and hips (both coxofemoral joints), which subsided the
day after taking the first dose of Ivermectin. He also presented hyporexia, myalgias, dry
cough and skin hypersensitivity, for which he refers that he could not tolerate lying on
the folds and wrinkles of the bed sheets. He did not present dyspnea or decrease in
Oxygen Saturation.
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
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In total, he took Ivermectin for 9 days, from May 2 to 10, 2020, with the resolution of
almost all his symptoms the day he finished the treatment. He only had a weakness or
asthenia that lasted 9 days more.
In addition to the Ivermectin she took Azithromycin 500 mg. for 5 days.
He states that with the treatment a previous lesion that he had, a flat wart type located
in the middle third of the right forearm, of 0.2 cm, disappeared.
In their control tests, at least up to 5 months after acute infection, IgG remained
positive.
Reappearance of Symptoms in the Chronic Stage of COVID-19.
After 6 months of being asymptomatic, he again presented arthralgias in the shoulders
and hips of similar characteristics to those presented in the acute stage of COVID-19.
These arthralgias persist and do not improve, so after a little more than 2 months he
consulted us for treatment for the supposed sequelae of COVID-19.
He refers that arthralgias generate functional limitation due to pain, making it difficult,
for example, to take off and put on his shirt. There is no evidence of swelling in the
joints. When it hurts a lot, he refers to taking two 500 mg Paracetamol (Acetaminophen)
pills, this is done more often at night to fall asleep.
The join pain is greater in the shoulders and especially in the right. It also presents a
decrease in muscle mass in the right triceps, muscle pain, tremor and fasciculations.
In addition to the aforementioned arthralgias, the patient reported that he had a slight
decrease in long-term memory, with difficulty at times in finding the right words while
talking with some patients he attended, as part of his work as a doctor.
Analysis and Presumptive Diagnosis of the Case.
We then have the case of a patient who has suffered from Acute COVID-19 8 months
and 5 days before the date of consultation. With the treatment with Ivermectin, he
achieved the resolution of his acute symptoms, and after 6 months of remaining
asymptomatic, arthralgias similar to those he presented in the acute stage of COVID-19
reappear.
The case is analyzed, it does not correspond to give the diagnosis of sequelae since it
was 6 months that it remained without arthralgias, that is, there was a resolution of the
symptoms, and after 6 months there is a reactivation, that is not a sequela.
Based on the experience with other treated patients, the presumptive diagnosis of a
persistent viral infection that remained latent and asymptomatic or silent for 6 months
and presents a reactivation of the infection with the presence of arthralgias similar to
those that presented in the acute stage of COVID -19.
Use of the “Therapeutic Test” for guidance to Etiology and Diagnosis.
The available molecular tests use nasal discharge and oropharynx samples, therefore
they are not useful for the diagnosis of infections other than the respiratory tract (6).
The presence of a small viral load in the tissues of the shoulder and hip joints cannot be
diagnosed using samples from the nose and oropharynx.
It should also be considered that it is an intracellular infection, so in the post-acute and
chronic stages the virus is not present in the secretions or at this level the viral load
would be too low to be detected with the current molecular tests, which they only
sample of secretions from above and outside the tissues of the nose and oropharynx. A
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
Shoulders and Hips. Aguirre-Chang, G. Trujillo A. January 2021.
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negative molecular test only indicates that there is insufficient viral load in the
secretions from the nose and oropharynx (6).
In the absence to date, of tests to diagnose viral load of a location other than the
respiratory tract and at the tissue or cell level, what we are using is the "Therapeutic
Test" with Ivermectin and Acetyl Salicylic Acid - ASA (7).
The “Therapeutic Tests” have been used for several decades, for example, Levodopa is
used in Parkinson's Disease, Dystonia and other movement disorders (8), Proton Pump
Inhibitors (PPIs) are used for Gastroesophageal Reflux (9), and in smear-negative
Tuberculosis (10) the Therapeutic Test is also used, among other pathologies.
If after performing this Test, the patient presents a significant clinical improvement i n
the few days that the test lasts, the test is interpreted as Positive for a persistent viral
infection, this explains the therapeutic response to Ivermectin, whose main effect in a
person with COVID-19 is to reduce the load SARS CoV-2 virus.
We have applied this “Therapeutic Test” in dozens of patients, and the persistent
symptoms that best respond to the test are anosmia (11), nasal congestion, tachycardia
or palpitations, pain in the chest, pain in the middle of the back (12), night sweats, fever
or low-grade fever, dyspnea or shortness of breath, bronchospasm. We have had
cases with arthralgias as one more of the symptoms that the patient presents, and
these cases have responded favorably to the "Therapeutic Test", but we had not
previously treated a patient who after 6 months presented arthralgias of large joints as
the main symptom and practically as the only symptom.
Treatment Protocol
Based on the experience of our team, regarding the treatment of persistent symptoms
of COVID-19 (11,12), the Protocol of the “Therapeutic Test” was indicated, which is
based on treatment with Ivermectin and ASA (7), the latter is included with the aim of
reducing platelet hyperactivity, the hypercoagulable state and the favorable
microenvironment that would be established in the body and that we propose becomes
a factor for the persistence of the SARS CoV-2 infection (13,14).
As the patient's weight was 110 kilos, the Treatment Protocol that was indicated was
the “Therapeutic Test” for people who weigh more than 95 kilos and for moderate
symptoms (7).
Although his vital functions were within normal ranges, it was considered that they were
moderate symptoms because the pain generated a functional limitation to be able to
carry out several of his activities of daily life.
The protocol to be followed starts only with ASA and from the 3rd day Ivermectin is
added. The detail of the Treatment Protocol is shown in Table 1.
In addition to the IVM and ASA, in the "Therapeutic Test" it is indicated to take Sodium
Bicarbonate at the rate of half a teaspoon in a glass of water at 11 am and 10.30 pm for
5 days, and then only at night. As an alternative, you have Famotidine, at a dose of 40
mg. every 8 hours for 7 days (7).
To avoid less absorption of the drug Ivermectin, the patients had to avoid consuming
the fruits and juice of: orange, grapefruit, mandarin and acid lemon, during the
treatment period.
To avoid an increase in gastric acid, it is indicated that they should avoid consuming
coffee, sodas, drinks with caffeine or taurine ("energy drinks"), in addition to alcohol and
chili.
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
Shoulders and Hips. Aguirre-Chang, G. Trujillo A. January 2021.
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Table 1.
THERAPEUTIC TEST" FOR PATIENTS WITH PERSISTENT SYMPTOMS OF COVID-19.
PROTOCOL FOR PEOPLE WHO WEIGHT MORE THAN 95 KILOS AND HAVE MODERATE
SYMPTOMS
MEDICINE
DOSE FOR PEOPLE OVER 95 KG. AND MODERATE SYMPTOMS
ACETYLSALICYLIC
ACID (ASA)
600 to 650 mg. a day, divided into 2 or 3 doses a day, after meals, for
7 days.
IVERMECTIN (IVM)
From the 3rd day after starting ASA, take IVM 0.2 to 0.3 mg. per kilo of
weight after lunch and dinner, for 5 days.
If after taking 5 days of Ivermectin and 7 days ASA, the% improvement in symptoms is 40%
or more, treatment should be continued until total improvement in symptoms is achieved or,
until no longer present improvement with treatment.
It was also indicated that during the treatment period follow the Diet included in the
published Therapeutic Test (7), which consists on the one hand in consuming a
greater amount of food rich in Lysine, Tryptophan, Glycine, Glutamine, Cysteine,
Vitamin D and Niacin (see Table 2).
Table 2
FOODS WITH HIGH CONTENT OF LYSINE, AND ALSO OF TRYPTOPHAN, GLYCIN,
GLUTAMINE, CYSTEINE, VITAMIN D AND NIACIN.
turkey, chicken, egg, beef (not canned, fresh);
cheese, but up to 75 grams a day (and not cured or semi-cured, or goat),
yogurt, but up to 150 ml a day;
mango, apricot, medlar, cherry, pear, fig, carambola;
potato, quinoa, amaranth (kiwicha);
turnip, beet and aguacate (avocado) but not more than 1 a day.
And on the other hand, it is indicated that on the contrary, patients should avoid during
treatment, foods that are considered acute pro-inflammatory, such as those that are
rich in content of the amino acid arginine and histamine (see Table 3).
Regarding the follow-up of the improvement in symptoms, the first day that the
treatment is going to start, all the symptoms are given a percentage of 100% (A score
of 10 out of 10 can also be used).
From the 2nd day, every 2 days, before going to bed, the patient should write down the
percentage that he considers has improved or that the symptoms have been reduced.
After taking 5 days of Ivermectin, on the 8th day from the start of the treatment protocol,
the response to treatment should be evaluated by means of the percentage
improvement in symptoms on that date. It is indicated that, if in the evaluation, the
improvement is 40% or more, the treatment should be continued until the total
improvement of the symptoms is achieved or until no longer present or perceive clinical
improvement with treatment.
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
Shoulders and Hips. Aguirre-Chang, G. Trujillo A. January 2021.
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Table 3
ACUTE WITH HIGH CONTENT OF ARGININE AND HISTAMINE
coffee, soda, drinks with caffeine or with lactate, black tea;
alcohol of all kinds (cocktails, beer, wine, etc);
walnut of all kinds, hazelnut, pecan, almonds, peanut, chestnuts, pistachios;
orange, tangerine, grapefruit, lemon, banana, coconut, blackberries, cashew or marañon, kiwi,
cocoa, cocoa chocolate;
sesame seeds, oats, rice (especially whole grain), wheat, whole wheat bread, peas, green bean,
chickpeas, barley, flaxseed (or flax seeds), seeds of: pumpkin, chia, poppy and sunflower;
tomato, spinach, eggplant, rutabaga or kohlrabi, cabbage, cucumber;
chili, curry, chucrut, monosodium glutamate, tomato sauce, vinegars, soy sauce (shoyu),
mayonnaise, mustard;
sausages, cold cuts, canned meat (food preserves);
fish and shellfish (especially canned or smoked fish);
sweets, pastries, colorants; eat low sugar and salt.
RESULTS
The patient took the following medications and at the doses mentioned belown:
- IVERMECTIN: in 0.6% dropper bottle (presentation available in the country). The
patient took 2 doses a day, after lunch and dinner. Each of the 2 doses I take was 1
bottle containing 30 mg. of Ivermectin, that is, he took 60 mg per day, which is
equivalent to a dose of 0.54 mg. per kilo of weight per day (60 mg./ 110 kg.), which
he took for 8 days in a row. The patient stated that he saw the practical ease of
taking the entire bottle (30 mg.) in each dose, instead of counting drop by drop.
- ACETYLSALICYLIC ACID (ASA): 100 mg tablets. I take 2 tablets (200 mg.) after
breakfast, lunch and dinner, which is equivalent to a daily dose of 600 mg, which I
took for 10 days.
- RANITIDINE: 300 mg tablets, took 1 tablet at 10 o'clock at night, until the day the
treatment was finished. At this point, it is clarified that the indication by Protocol
was to take Famotidine 40 mg. every 12 hours, but this drug is not currently
available in the country. Another alternative was Cimetidine. But the patient opted
for Ranitidine. Regarding Sodium Bicarbonate (baking soda), the patient indicated
that he only took it for the last 2 days of treatment.
At the end of the treatment, the patient reported good tolerance, did not manifest gastric
or intestinal discomfort or other possible relevant side effects due to the intake of the
drugs.
He only presented a lesion similar to a scab, located on the skin of the left leg, rounded,
1 cm. in diameter, superficial, not painful and without signs of inflammation.
Regarding the follow-up of the improvement in symptoms, a table was made with the
improvement percentages every 2 days (see Table 4).
The patient stated that from the first day of treatment he began to feel improvement
with decreased pain due to arthralgias. By the second day, he presented a 20%
improvement in pain in the hips, 15% in the left shoulder, and 5% in the right shoulder.
By the fourth day after starting the treatment, already having 2 days of treatment with
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
Shoulders and Hips. Aguirre-Chang, G. Trujillo A. January 2021.
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Ivermectin, the improvement was significant, it was reduced to 50% in the hips, 35% in
the left shoulder and 25% in the right shoulder.
Table 4
PERCENTAGE OF REDUCTION OF ARTHALGIES OF THE SHOULDERS AND HIPS
shoulder
Date
01/08/21
01/10/21
01/12/21
01/14/21
01/16/21
ASA day
4th day
6th day
8th day
10th day
No lon-
ger takes
Ivermectin taking day
2nd day Iv
4th day Iv
6th day Iv
8th day Iv
Symptom: Pain
% pain reduction
On right shoulder
25%
45%
65%
96%
97%
On left shoulder
35%
55%
75%
100%
100%
Right/left Coxofemoral
50%
65%
80%
100%
100%
On the sixth day the improvement in the hips was 65% and on the eighth day it was
80%; the improvement in the left shoulder was 55% on the sixth day and 75% on the
eighth day; and the improvement in the right shoulder was 45% and 65% respectively.
According to the established protocol, as the percentage of improvement in symptoms
was greater than 40% on the eighth day of the Test, the indication was to continue with
the treatment until the total improvement of the symptoms was achieved or, until no
longer present or perceive improvement with treatment.
By the 10th day, 10 days of treatment with ASA and 8 days with Ivermectin was
completed. That day, the patient stated that he was able to move around riding his
bicycle, without presenting pain in the hip joints, which he could not do for several
weeks, for which he indicated that the improvement achieved in hip arthralgias was
100%. This is then a 100% improvement in hip arthralgias. It indicates that the left
shoulder no longer presents pain (100% reduction in arthralgia). He has only slight pain
left in his right shoulder, equivalent to a 96% improvement at that level.
In the evaluation 2 days after the last day of treatment, the patient reported that the
total improvement (100%) was maintained for the joints of the hips and the left
shoulder, while for the arthralgia of the right shoulder the improvement was 97%.
The following week after completing the treatment, the patient went to see a specialist
in traumatology, who told him that the pain in his right shoulder was due to
supraclavicular tendonitis, and for the pain he indicated that he undergo rehabilitation
therapies.
Regarding the slight decrease in memory and the difficulty in finding some words while
talking, the patient stated that this was 100% resolved and that he was already mentally
as before he got sick. This result is also important
After 8 days of having completed the treatment with Ivermectin for 8 consecutive days,
the patient took 3 more doses of Ivermectin, at a rate of 0.27 mg. per kilo of weight per
day (30 mg per day for 110 kg of weight) for 3 days.
This was taken by the patient as a reinforcement of the treatment received, and also as
prophylaxis because the patient was going to travel to another city with community
transmission, so he was going to be exposed to places with a high risk of exposure,
such as land terminals of transportation from the city of origin and destination, and on
round trips.
A medical check-up was carried out 12 days after the end of the treatment, the patient
stated that he remained without pain in the joints of the hips and left shoulder, and only
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
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presented mild pain in the right shoulder, which was of the same intensity as at the end
of the treatment 12 days before.
DISCUSSION.
A Case Report is made of a patient who presents resolution of persistent symptoms of
arthralgia in shoulders and hips after treatment with Ivermectin for 8 days and Acetyl
Salicylic Acid (ASA) for 10 days. After 6 months of being asymptomatic, he again
presented arthralgia in the shoulders and hips with characteristics similar to those
presented in the acute episode of COVID-19. These arthralgias persist and do not
improve, so after just over 2 months (8 months from the start of the symptoms of Acute
COVID), he consults us for treatment for the supposed sequelae of COVID-19.
It is rare for symptoms associated with COVID-19 to reappear after 6 months of being
asymptomatic. The case is evaluated and from the experience with other patients
(11,12) it is suggested that it is a persistent viral infection that remained latent and
asymptomatic for 6 months and that there has been a reactivation of the viral infection.
There are several scientific publications that indicate the presence of a SARS CoV-2
viral load after 20 days of illness (16 to 33).
Association between the use of Ivermectin and the lower frequency of Persistent
Symptoms.
The marked percentage difference observed in the prevalence of persistent COVID-19
symptoms (10 to 45% vs 2 to 4%) described in the publications made and described at
the beginning of this document, would be due to our indication of a effective drug to
reduce viral load, such as Ivermectin, whose use according to what we have observed,
reduces the probability of the development of a persistent infection by the SARS CoV-2
virus, which in turn gives rise to persistent symptoms.
The association between the higher use of Ivermectin, and the significantly lower
frequency of persistent symptoms, supports the claim that there is a persistent viral
infection (30), and viral load and replication are reduced with the use of Ivermectin.
It is clarified that the lowest frequency of persistent or post-acute symptoms of COVID
occurs when the full treatment with Ivermectin is complied with, that is, when it is given
for several days and until at least 1 day after all the symptoms are resolved. which is
equivalent to between 3 to 20 days of daily treatment and continued with Ivermectin,
the number of days of treatment varies according to the severity of the case.
Incomplete treatments, of only 2 days, or with doses less than 0.2 mg. per kilo of
weight, on the contrary, we have observed in our environment that they are associated
with a higher frequency of persistent or post-acute symptoms of COVID.
In the case reported, according to what was stated by the patient, in the treatment of
the acute stage of COVID-19 that he suffered, when taking the ninth and last dose of
Ivermectin, he still presented the symptom of weakness ot asthenia and this persisted
for 9 more days. The persistence of this symptom indicates that the patient
discontinued treatment even though he had symptoms, and it is understood that he still
had a viral load, which we assume was quantitatively low. The fact of not having
continued taking Ivermectin, while symptoms persisted, that would have allowed a
small amount of viral load to remain in the body, which has remained latent or silent,
until, due to an increase in viral load or a decrease in host immunity, symptoms
reappear, which we consider to be a reactivation of the latent viral infection (34).
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
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The patient in the acute stage received 9 consecutive days of Ivermectin, at a dose of
0.20 mg. per kilo of weight the first 2 days, and 0.27 mg. per kilo from day 3 to 9,
despite which, symptoms have reappeared months later. For many patients and
physicians today, the 9-day treatment with Ivermectin, with a dose of 0.27 per kilogram
of weight most days, would seem sufficient, even more so if treatment was started early
and there was no reduction in the oxygen saturation or lung involvement. But as we see
in this case, symptoms reappeared months later.
Currently, in moderate and severe cases of COVID-19 we are indicating that they take
Ivermectin up to 3 days after all the symptoms are resolved (35), this is to be more sure
that the viral load is eliminated and prevent them from developing an infection viral
persistent.
Symptoms that appear in the Post-Acute and Chronic Stage
We must mention that, in our experience, patients treated with Ivermectin, frequently
what they present are not symptoms that begin in the acute stage and persist
continuously for weeks, but rather they are symptoms that appear after an
asymptomatic period after having overcome the acute stage of COVID-19 with
treatment with Ivermectin.
Often these are symptoms that already presented in the acute stage of the COVID-19
disease, as in the present case reported, but new symptoms may also occur that did
not appear in the acute stage of the disease, such as the symptoms associated with an
impairment of the cognitive level and people's memory, or tachycardia and pain in the
middle of the back.
Regarding the name, more than persistent symptoms, in these cases they would be
clinically described as symptoms that appear or reappear, either in the sub-acute or
post-acute stage that goes from 4 to 12 weeks counting from the date of onset of
symptoms, or in the chronic stage of infection by SARS CoV-2 that goes from 12
weeks. In the present case, the arthralgias that the patient presents correspond to
symptoms that reappear in the chronic stage of the disease, so it would be a Chronic
COVID (15).
Appearance of Post-Acute Symptoms corresponding to a Reactivation of a Latent
Persistent Viral Infection
If symptoms of COVID appear after a few days or weeks after being discharged from
the acute disease, it would correspond to a persistent viral infection, which is latent,
dormant or silent, and at a certain time, it gives symptoms again, which we consider to
be a reactivation of the latent viral infection.
Under this approach, in the case reported, it was decided to give treatment with a drug
to reduce viral load, which is Ivermectin, adding an antiplatelet aimed at reducing
platelet hyperactivity and hypercoagulability, which is ASA or Aspirin.
Treatment of the Reappearance of Symptoms from Persistent Viral Infection.
The present case would then be a Reactivation of a persistent viral infection, which was
latent, silent or sub-clinical.
According to the patient's weight, the Treatment Protocol indicated was the
"Therapeutic Test" for people who weigh more than 95 kilos and for moderate
symptoms (7). The patient took 200 mg. of AAS after breakfast, lunch and dinner, for 10
days. As of the third day after he started taking ASA, he took ivermectin at a dose of
0.27 mg. per kilo of weight after lunch and dinner, for 8 days (0.54 mg per kilo of
Chronic COVID: Treatment with Ivermectin and Acetylsalicylic Acid of Persistent Symptoms of Arthralgia in
Shoulders and Hips. Aguirre-Chang, G. Trujillo A. January 2021.
10
weight, per day). Also, I take Ranitidine. It is clarified that the indication was to take
Famotidine, but this drug was not available in the country.
The patient reported good tolerance, did not manifest gastric or intestinal discomfort or
other possible relevant side effects due to the intake of the drugs.
The response to treatment with Ivermectin would indicate that the cause that originated
the arthralgias would correspond to the presence of viral load sensitive to Ivermectin.
The resolution of the arthralgias in a few days supports the fact that it was a persistent
SARS CoV-2 infection (12,34).
Persistent Infections are the most common cause of Persistent Symptoms, not
the Sequelae.
Based on the experience of several treated cases that present a rapid clinical resolution
(11,12), it is recommended that in the event of persistent or post-acute symptoms of
COVID that appear after having overcome the acute stage of the disease, it should not
be indicated as the first Diagnostic possibility that it is a sequela, because in practice
we have shown that many cases that are diagnosed with COVID sequelae respond to
treatment with drugs to reduce viral load such as Ivermectin plus antiplatelets,
anticoagulants and/or fibrinolytics.
Conclusions
It is concluded that, in the presence of persistent or post-acute symptoms of COVID-19,
it is convenient that the diagnosis of a persistent viral infection by SARS CoV-2 be
considered first, and that the corresponding treatment be indicated.
Health professionals need to be trained in how to differentiate clinically between
persistent COVID-19 symptoms and sequelae.
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