A new patient came to the office the other day. She is a forty year old woman with multiple vague complaints that began after her last bout of Covid-19 in 2023. Since that time she has experienced fatigue, decreased exercise tolerance and severe post-exertional exhaustion. She has been to multiple doctors and has been told that her symptoms are most likely due to anxiety and depression.
The conclusions are based on the fact that all of her laboratory values are normal and all of her X-rays and CAT scans are also normal. Therefore, there is nothing physically wrong with her so it has to be due to anxiety and depression.
The reality is nothing could be further from the truth. The problem is that the right questions weren’t asked. For one, no one asked her about her sleep. The patient stated that though she had no problems falling asleep, she had problems staying asleep with frequent interruptions to use the bathroom.
Fluid restriction urine osmolality showed that the patient could not concentrate her urine after twelve hours of fluid restriction. It was well below the 850 mOsm/kg that would be expected after having no fluids for twelve hours. In addition, the patient does complain of unquenchable thirst.
Diabetes insipidus has been associated with Covid-19 due to the virus causing neuroinflammation of the brain and inhibiting release of Antidiuretic Hormone (ADH) from the pituitary gland. Lack of ADH prevents reabsorption of water at the level of kidneys where ADH is meant to work.
The fatigue occurs because the intravascular volume is low and your heart has to pump faster in order to maintain an adequate blood pressure to ensure profusion of vital organs such as the brain. Many patients with underlying DI have low blood pressure with resting heart rate in the high 90’s or low 100’s. This is the equivalent to walking 24/7, which you can imagine will be exhausting.
It should be noted that because water is not being reabsorbed, the bladder will fill quickly. This is problematic at night because of disrupted sleep to go to the bathroom several times a night. Disrupted sleep will lead to fatigue.
The patient has been prescribed desmopressin at night and her bathroom visits at night have decreased. Over the next few weeks the dose will be titrated for optimal effectiveness.
Hopefully, with time, more clinicians will realize not to dismiss vague symptoms in the Post Covid-19 era and chalk it up to anxiety and depression.
