What is the management approach for a patient with postviral syndrome?

Management of Postviral Syndrome

For patients with postviral syndrome, implement a systematic, symptom-based approach prioritizing patient education, gradual recumbent exercise therapy, and multidisciplinary coordination, while ruling out serious complications through targeted investigations. 1

Initial Assessment and Patient Education

• Offer an initial consultation (video, phone, or in-person based on shared decision-making) for patients with symptoms persisting ≥4 weeks after acute viral illness 1
• Provide written information explaining that symptoms can change unpredictably, affecting people differently at different times, and may be singular, multiple, constant, transient, or fluctuating 1
• Listen with empathy and acknowledge the impact on daily activities, work, education, mobility, independence, and feelings of social isolation 1
• Assess physical, cognitive, psychological, and psychiatric symptoms along with functional abilities 1
• The most common symptoms are fatigue and breathlessness, though presentations are highly variable and wide-ranging 1

Essential Investigations to Rule Out Complications

Blood tests should include: 1

• Full blood count
• Kidney and liver function
• C-reactive protein
• Ferritin
• B-type natriuretic peptide
• Thyroid function

Additional testing based on symptoms: 1

• Chest radiography if continuing respiratory symptoms (though normal X-ray does not rule out lung disease)
• Exercise testing (1-minute sit-to-stand test) recording breathlessness, heart rate, and oxygen saturation
• Lying and standing blood pressure with heart rate recordings (3-minute active stand test, or 10 minutes if suspecting postural tachycardia syndrome)

Urgent referral is required for: 1

• Severe hypoxemia or oxygen desaturation on exercise
• Signs of severe lung disease
• Cardiac chest pain
• Multisystem inflammatory syndrome

Exercise Therapy Protocol

Start with recumbent or semi-recumbent exercise (rowing, swimming, cycling) rather than upright exercise, as upright activity can worsen fatigue and cause postexertional malaise. 1

Specific prescription: 1

• Begin with 5-10 minutes daily at an intensity allowing full-sentence speech
• Gradually increase duration by approximately 2 additional minutes per day each week
• Maintain submaximal, sustained intensity throughout exercise
• Transition to upright exercise only after orthostatic intolerance resolves
• This approach increases cardiac mass, blood volume, ventricular compliance, and functional capacity while avoiding setbacks

Critical pitfall: The UK's NICE guidelines caution against graded exercise therapy for patients with ME/CFS characteristics, but recumbent exercise at appropriate intensity remains beneficial 1

Symptom-Specific Management

For tachycardia and exercise intolerance: 1

• Apply interventions used for postural orthostatic tachycardia syndrome (POTS)
• Implement the recumbent exercise protocol described above
• Consider pharmacologic management of tachycardia if persistent

For dyspnea: 1

• Perform chest X-ray and/or non-contrast CT of lungs with pulmonary function testing
• Consider cardiopulmonary exercise testing (CPET) with flow-volume loops if initial workup unrevealing
• Obtain CT pulmonary angiogram or V/Q scan if pulmonary embolism suspected
• Pursue ischemia evaluation if obstructive coronary disease or microvascular dysfunction suspected

For chest pain: 1

• Perform stress imaging (echocardiography, SPECT, or CMR) especially if unable to exercise or ECG uninterpretable
• Consider PET myocardial perfusion imaging if microvascular dysfunction suspected
• Reserve invasive coronary angiography for abnormal noninvasive results or high suspicion for obstructive disease

Multidisciplinary Coordination

Patient-centered care models require coordination by teams including: 1

• Primary care clinicians
• Specialists (pulmonologists, cardiologists, neurologists, rheumatologists, psychiatrists, infectious disease experts)
• Social workers
• Psychologists
• Physical therapists

Support for Vulnerable Populations

• Provide extra time or additional support (interpreters, advocates) during consultations for underserved or vulnerable groups 1
• Raise awareness about long-term effects to improve access to assessment and care 1

Self-Management Strategies

• Educate on breathing control techniques: high side lying, forward lean sitting, pursed-lip breathing, square box breathing 1
• Teach appropriate walking pace regulation to reduce breathlessness and prevent oxygen desaturation 1
• Advise conservative resumption of daily activities at a safe, manageable pace with gradual increases based on symptoms 1

Key Caveats

• Not all symptoms will be related to the viral illness; investigations serve to identify serious complications, evaluate postviral symptoms, or detect new unrelated diagnoses 1
• Patients without symptoms in the initial weeks after infection can still develop postviral syndrome 1
• Those with extensive initial lung injury, mechanical ventilation, or serious cardiovascular complications may experience protracted sequelae from the initial insult rather than true postviral syndrome 1
• The pathophysiology remains poorly understood with heterogeneous underlying drivers, and the evidence base continues to evolve 1