What is the treatment for post-COVID (Coronavirus Disease 2019) myalgia with normal C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR)?

Treatment for Post-COVID Myalgia with Normal CRP and ESR

For post-COVID myalgia with normal inflammatory markers, the recommended treatment includes graded exercise therapy, non-pharmacological approaches like breathing exercises, and symptomatic medication such as acetaminophen, while avoiding NSAIDs unless pericardial involvement is suspected. 1

Diagnostic Considerations

Post-COVID myalgia with normal CRP and ESR is consistent with the diagnosis of Post-Acute Sequelae of SARS-CoV-2 infection (PASC), commonly known as "long COVID." Normal inflammatory markers are frequently observed in post-COVID myalgia cases, as the persistent symptoms often occur without ongoing systemic inflammation 1.

Key diagnostic points:

• Myalgia is one of the most common musculoskeletal manifestations of long COVID 2
• Normal inflammatory markers (CRP and ESR) do not rule out post-COVID myalgia 1
• Prevalence of post-COVID myalgia ranges from 5.65% to 18.15% during the first year after infection 3
• Symptoms may fluctuate over time, with a typical pattern of decrease at 30 days, increase at 60 days, and second decrease after 180 days 3

Treatment Approach

Non-Pharmacological Interventions

1. Graded Exercise Therapy:

   • Begin with recumbent or semi-recumbent exercise (rowing, swimming, cycling) 1
   • Start with short duration (5-10 minutes/day) and gradually increase as tolerated 1
   • Transition to upright exercise as orthostatic intolerance improves 1

2. Traditional Chinese Medicine Exercises:

   • Baduanjin, Tai-chi, and 6-character breathing exercises 1
   • These have shown benefit for post-COVID rehabilitation 1

3. Breathing and Relaxation Techniques:

   • Breathing relaxation training and mindfulness training 1
   • Particularly helpful for associated anxiety and stress 1

4. Salt and Fluid Loading:

   • May provide symptomatic relief for associated tachycardia and orthostatic symptoms 1

Pharmacological Management

1. First-line medications:

   • Acetaminophen for pain relief
   • Avoid NSAIDs unless pericardial involvement is suspected, as they may increase inflammation and worsen outcomes 4

2. For associated orthostatic symptoms:

   • Beta-blockers (low dose)
   • Non-dihydropyridine calcium-channel blockers
   • Ivabradine
   • Fludrocortisone
   • Midodrine 1

3. For associated mood symptoms:

   • Consider psychological first aid and stress management 1
   • For severe anxiety/depression: medications with short half-life and low risk of drug-drug interactions at lowest possible dose and shortest duration 1

Monitoring and Follow-up

1. Regular assessment of symptom progression:

   • Track myalgia intensity and frequency
   • Monitor functional improvement with exercise therapy

2. Cardiac evaluation if needed:

   • If chest pain or palpitations develop, consider ECG, echocardiogram, and ambulatory rhythm monitoring 1

3. Follow-up schedule:

   • Initial follow-up at 4 weeks to assess treatment response
   • Subsequent visits every 1-3 months based on symptom severity

Pitfalls to Avoid

1. Overexertion: Pushing exercise too aggressively can worsen symptoms; gradual progression is key 1

2. NSAID use: Avoid NSAIDs as they may worsen inflammation in post-COVID states 4

3. Ignoring psychological aspects: Mental health support should be integrated into treatment 1

4. Misdiagnosis: Ensure other causes of myalgia are ruled out (fibromyalgia, polymyalgia rheumatica, etc.)

Post-COVID myalgia can significantly impact quality of life, but with appropriate management focusing on graded exercise, breathing techniques, and judicious use of medications, most patients will experience improvement over time 5.