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2. Government Medical College and Government General Hospital (Old RIMS)

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https://doi.org/10.21203/rs.3.rs-2676572/v1

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Background and Aim: Long COVID becomes an economic and public health challenge that affects the daily activities and quality of life of millions of COVID-19 survivors. Long COVID symptoms, particularly persistent fatigue, appear to be associated with a chronic state of inflammation. Based on the anti-inflammatory property of Tinospora cordifolia, CelWel has the potential to improve the symptoms of long COVID. The purpose of this study was to assess the efficacy and safety of CelWel in patients with long COVID.

Methods: This was a non-randomized, open-label pilot study with 15 COVID-19-infected male and female subjects who had long COVID symptoms. Subjects were given 0.4 mL of the CelWel supplement 4–6 times per day for 14 days. The severity of long COVID symptoms was assessed using the Fatigue Severity Scale Questionnaire (FSSQ) and the Yorkshire COVID-19 Rehabilitation Screening Test (C19-YRS) before and after treatment. In addition, plasma levels of proinflammatory cytokines and chemokines and the post-acute sequelae score of COVID-19 (PASC) were also assessed. Safety parameters such as adverse events, haematology, and serum biochemistry were also evaluated.

Results: Results showed that all COVID-19 survivors had higher FSSQ, C19-YRS, and PASC scores along with elevated plasma levels of proinflammatory cytokines and chemokines before treatment. CelWel supplementation for 14 days significantly reduced FSSQ and C19-YRS scores and plasma cytokine and chemokine levels. Furthermore, with CelWel treatment, PASC scores showed a decreasing trend in 11 subjects, while 4 subjects showed a reverse trend. All laboratory safety parameters were within the normal range, and no adverse events were reported during the study period.

Conclusion: These findings suggest that the CelWel supplement is a viable and safe option for reducing the severity of symptoms in patients with long COVID.

The SARS-CoV-2 coronavirus (COVID-19) has affected more than 750 million people around the world to date [1]. Acute manifestations of COVID-19 widely affect the pulmonary, cardiovascular, neurological, hematological, and gastrointestinal systems [2]. Its long-term impacts are not well known, but the large numbers of COVID-19 survivors represent post-COVID-19 sequelae [3]. The etiology of post-COVID symptoms is unknown; however, several factors have been proposed to be involved, including comorbidities, post-critical illness, and immune and inflammatory damage [4]. The most common signs and symptoms reported by COVID survivors include fatigue, cognitive decline, dyspnea, anxiety, weakness, shortness of breath, depression, palpitations, arthralgia, chest and muscle pain [5, 6], which impair their mobility, daily activities, and health-related quality of life (HR-QoL) [7, 8]. Fatigue is one of the most common and severe post-COVID symptoms among 52–58% of COVID-19 survivors [9], and the symptom has been reported to persist for more than a year after the onset of illness [10]. Fatigue is characterized by an ongoing experience of weakness, exhaustion, and increased difficulty doing physical (e.g., walking, climbing stairs, or lifting) or mental work [11]. In post-COVID syndrome, fatigue is frequently accompanied by muscle fatigue and fatiguability, which coincides with markers of inflammation and hypoperfusion [12].

Prolonged fatigue after COVID-19 shares clinical manifestations with other post-infectious fatigue syndromes as well as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) [13]. In both situations, there are higher levels of circulating proinflammatory cytokines (such as IL-1, IL-4, GM-CSF, IFN-γ, TNF-α, etc.) and CD8 + T cells, which are presumed to be involved in the pathophysiology of these illnesses. In such chronic inflammatory conditions, as well as possibly in prolonged COVID, inflammatory cytokines reduce basal ganglia function and dopamine while increasing neurotransmitter release in the brain, including serotonin, which causes persistent fatigue [14, 15]. In patients recovering from West Nile virus infections, pro-inflammatory (e.g., IL-2, IL-6) and antiviral (e.g., IFN-γ) cytokines were found to be elevated [16]. In contrast, the administration of IL-6 caused fatigue and sleep disturbances in healthy patients [17]. A similar mechanism could be at work in long-COVID fatigue. Considering the prominent role of inflammatory cytokines in longstanding COVID-19 symptoms, it was hypothesised that blocking proinflammatory cascades might alleviate longstanding COVID-19 symptoms, particularly fatigue.

CelWel is an oral supplement containing extracts of Tinospora cordifolia and Piper nigrum, as well as a very low concentration of thimerosal. T. cordifolia, one of the constituents of CelWel, has reportedly demonstrated anti-inflammatory activity by lowering pro-inflammatory cytokine levels (IL-1, TNF-α, IL-6, and IL-17), the frequency of IL-17-producing T cells, and the production of chemokines (RANTES) [18]. This study aimed to evaluate the efficacy and safety of the CelWel supplement in reducing long-term COVID symptoms, specifically fatigue, and levels of various inflammatory biomarkers.

2.1. Study Design, and Setting

This single-arm, non-randomized, open-label prospective study on the CelWel supplement was conducted from December 2022 to January 2023, by the Government Medical College and Government General Hospital in Srikakulam, Andhra Pradesh, India. The efficacy and safety of the CelWel supplement were evaluated as adjunctive therapy for a maximum of 14 days for COVID-19 survivors with persistent COVID-19 symptoms. The study was carried out in accordance with the Declaration of Helsinki, the Indian Council of Medical Research (ICMR) ethical guidelines for biomedical research, and ICH guidelines for good clinical practice (GCP). This study protocol was approved by the institutional medical ethical committee (Protocol no.: CW/C-19/1122, Version 1.0) and was prospectively registered with the Clinical Trials Registry-India (ID: CTRI/2022/12/048144) dated 15 December, 2022. All potential participants were voluntarily recruited, and informed consent was obtained prior to the initiation of any study-related procedures.

2.2. Participants

The electronic database of the Government Medical College and Government General Hospital, Srikakulam, Andhra Pradesh, was used to identify potential participants infected with SARS-CoV-2. Male and female patients over the age of 18 who had been diagnosed with COVID-19 by RT-PCR and had persistent mild to moderate post-COVID symptoms lasting 4 to 12 weeks since disease onset were recruited. Patients were excluded if they were asymptomatic, had severe systemic diseases, uncontrolled comorbid conditions, vascular disorders, cancers, were hospitalized or required oxygen support, or had received antiviral medication in the last 36 hours. Potential participants were screened for eligibility, and demographic data was collected at the outset.

2.3. Interventions

CelWel is an oral liquid supplement, and each 100 mL contains T. cordifolia extract (200 mg), P. nigrum extract (2.5 mg), and thimerosol (0.05 mg) as active ingredients. Subjects were instructed to take 0.4 mL of the CelWel supplement 4–6 times daily, 5 minutes before eating or drinking. After 14 days of treatment, the efficacy and safety were evaluated.

2.4. Primary Outcomes

The primary outcomes were improvements in chronic fatigue and other symptoms associated with long COVID patients as measured by fatigue severity scale questionnaires (FSSQ) [19] and a modified version of the COVID-19 Yorkshire Rehabilitation Screening (C19-YRS) checklist [20]. Fatigue severity was determined using self-administered FSSQ questionnaires (9 items). Each item was scored on a 7-point scale, with 1 representing strongly disagree and 7 representing strongly agree. Higher FSS scores for each item indicate more severe fatigue, and if an FSSQ score ≥ 4 indicates clinically significant fatigue [19]. The final score was the average of the 9 items. Prolonged COVID symptoms were assessed using a modified C19-YRS tool consisting of 18 items rated on an 11-point rating scale as 3 = mild symptom, 3–5 = moderate symptom, and 6–10 = severe symptom. The C19-YRS is well validated tool that correlates well with exercise tolerance, lower limb strength and mobility, anxiety, depression and HR-QoL [8]. The C19-YRS checklist analyzed symptoms related to body functions and structures (12 items), activity limitations (5 items), and personal factors (1 item). After 14 days of treatment, the FSSQ and C19-YRS scores were evaluated.

2.5. Secondary Outcomes

Secondary outcomes of this study included changes in plasma levels of inflammatory cytokines (IL-2 and IFN-γ) and chemokines (CCL4 (MIP-1β). IL-2, IFN-γ, and CCL4 (MIP-1β) levels in plasma were measured using multiplex bead-based flow cytometry (IncellKINE, IncellDx, Inc.) [21]. The assay was carried out in a 96-well microplate, and samples were analysed using a CytoFlex LX 3-laser flow cytometer (Beckman Coulter Life Sciences, USA) and Kaluza Analysis Software (Beckman-Coulter, Miami, FL). Changes in laboratory parameters, such as the complete blood count (CBC), ESR, renal function, and liver function parameters from baseline, were evaluated as part of the safety study.

2.6. Statistical analysis

A per-protocol (PP) population analysis was used to assess efficacy. Demographic data were presented as mean, percentage, and standard deviation (SD). Efficacy parameters, such as FSSQ and C19-YRS scores, were compared between baseline data and final follow-up data using the Wilcoxon signed-rank test. To compare the mean change in plasma IL-2, IFN-γ, and CCL4 (MIP-1β) levels from baseline to the final visit, the Wilcoxon signed-rank test was used. Unless otherwise stated, all hypotheses were tested at a significance level of 0.05. All statistical analysis was carried out using SSPS software version 10.0.

3.1. Demographic and Baseline Characteristics

A total of 15 participants were included in the study, of whom 9 (60%) were men and 6 (40%) were women. The subjects' average age was 47.0 ± 10.58 years. The mean height, weight, and BMI of the participants were 161 ± 8.16 cm, 61.60 ± 7.49 kg, and 23.71 ± 1.17 kg/m2, respectively.

3.2. Primary Outcomes

3.2.1. Assessment of Fatigue

The fatigue severity in COVID-19 survivors was assessed using the FSSQ on days 1 and 14. The results revealed that patients consistently had higher FSSQ scores (i.e., > 4) for each item as well as a higher mean FSSQ score at day 1. The FSSQ score of each item was significantly reduced after 14 days of CelWel treatment, and the changes were statistically significant (Table 1). The mean FSSQ score also decreased significantly (p < 0.001) from day 1 (43.30 ± 7.77) to day 14 (32.30 ± 5.35).

Table 1

FSSQ scores after 14 days of treatment with CelWel supplement.

Significance levels *p < 0.05, **p < 0.01 and ***p < 0.001.

3.2.2. Assessment of long COVID symptoms by C19-YRS Checklist

The severity of long COVID symptoms was assessed by the C19-YRS checklist at days 1 and 14. Among the Body Functions and Structures items, the intensity of the breathlessness on climbing stairs, fatigue, continence, cognition, anxiety, and depression at day 1 were the prominent symptoms compared to other symptoms, with C19-YRS reporting intensities of 5.43 ± 1.22, 6.08 ± 1.04, 6.0 ± 0.78, 5.17 ± 1.27, 6.00 ± 0.78, 5.40 ± 0.91 and 5.27 ± 1.10, respectively (Table 2). After 14 days of treatment, all these symptoms were present but significantly reduced. Improvements in fatigue, continence, cognition, anxiety, and depression symptoms were found to be statistically significant. Among the activities, a statistically significant improvement in mobility, personal care, usual activities, and social role were observed after 14 days of treatment compared to day 1. The global health perception was also statistically significantly reduced from 3.47 ± 1.51 (day 1) to 2.33 ± 1.50 (day 14).

Table 2

Intensity change in long COVID symptoms assessed by C19-YRS.

Significance levels *p < 0.05, **p < 0.01 and ***p < 0.001.

3.3. Secondary Outcomes

3.3.1. Assessment of inflammatory cytokines and chemokines

Table 3 summarizes the plasma levels of IL-2, IFN-γ, and CCL4 (MIP-1β). Plasma levels of IL-2, IFN-γ, and CCL4 (MIP-1β) were measured on days 1 and 14. Table 3 shows that IL-2 levels increased slightly from 4.74 ± 2.45 (day 1) to 5.01 ± 2.90 (day 14), whereas IFN-γ and CCL4 (MIP-1β) levels decreased from 37.58 ± 86.27 to 18.23 ± 22.61 and 1527.07 ± 2185.50 to 1883.81 ± 3834.16, respectively. However, the changes were not statistically significant. We calculated the post-acute sequelae of COVID-19 (PASC) disease score based on the findings using the Patterson et al. [21] proposed formula: S1 = (IFN-γ + IL-2)/CCL4 (MIP-1β) with optimized threshold for S1 = 0.5. At day 1, all patients had a higher PASC score (> 0.5), and after 14 days of treatment, there was a trend in the reduction of PASC score among the 11 participants, but 4 patients showed a reversal of the trend in PASC score (Table 4).

Table 3

Plasma levels of cytokines/chemokines before and after treatment

Table 4

PASC Score among the participants before and after treatment

3.4. Safety

The safety parameters included CBC, ESR, and liver and kidney function parameters that were evaluated before and after 14 days of treatment. On day 14, analysis of safety parameters showed no significant differences compared to day 1, and all parameters were within the normal range (Supplementary Tables S1, and S2). There were no adverse or serious reactions reported during the treatment period.

Long-term COVID syndrome (the post-acute sequelae of SARS-CoV2 infection) is a growing public health problem. There is increasing evidence that a significant proportion of COVID-19 survivors develop a chronic and debilitating set of multisystem signs and symptoms [22]. It has a negative impact on society, the economy, and patients' quality of life, physical functioning, work participation, care dependency, and activities of daily living [23]. Long COVID has been associated with over 60 physical and psychological symptoms [24]. Profound fatigue is one of the most commonly reported symptoms in post-acute COVID-19 patients, with a prevalence of 52% within 3 weeks of hospital discharge [25]. The persistence of fatigue following an acute COVID infection is also associated with episodes of overwhelming exhaustion, depressive symptoms, poor sleep quality, memory impairment and low energy levels, all of which influence quality of life [26]. There is currently no specific pharmacotherapy available for the treatment of long COVID. Recently, efforts have been made to understand the cause, epidemiological burden, and potential biomarkers of long COVID [27].

This study aimed to evaluate the efficacy of the CelWel product in improving long COVID symptoms, particularly persistent fatigue in COVID-19 survivors. The findings revealed that all patients experienced clinically significant fatigue prior to CelWel treatment, as evidenced by a higher FSSQ score (≥ 4) for each question as well as an overall FSSQ score (> 40). After 14 days of treatment, CelWel significantly reduced FSSQ scores. The C19-YRS test was also used in this study to assess the effect of CelWel on post-COVID symptoms. Results showed that CelWel significantly improved some symptoms related to the body's functions and structures, including fatigue and limitations in activities. Therefore, CelWel was found to be an effective health supplement to ameliorate long COVID symptoms, including persistent fatigue in COVID-19 survivors. However, its exact mechanism for reducing persistent fatigue and other long COVID symptoms is unknown.

It has recently been suggested that an ongoing low-grade pro-inflammatory response may be linked to the development of post-COVID symptoms [28]. As mentioned in the introduction, long COVID and ME/CFS share some clinical manifestations. ME/CFS pathophysiology has been linked to immune function dysregulation, hyperinflammation, oxidative stress, and autoimmunity [29]. Furthermore, ME/CFS-associated post-infectious fatigue syndrome has been linked to other acute viral and bacterial infections such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), Epstein-Barr virus (EBV), human parvovirus (HPV)-B19, and Q fever [23, 30]. Moreover, neuroimmunological involvement is a crucial precondition for long-term fatigue [31, 32]. IFN-α and other cytokines of the innate immune response have been shown to promote behavioural changes in medically ill patients, including fatigue-related symptoms, by acting on the basal ganglia nuclei [33]. Evidence from studies with neuroimmunological disorders suggests strong connections between structural brain abnormalities and fatigue severity, such as changes in the basal ganglia [34, 35] and frontoparietal white matter [36] associated with fatigue in multiple sclerosis. New structural images of the brain in patients with post-COVID syndrome revealed abnormalities in the thalamus and basal ganglia, which are associated with post-COVID fatigue [26].

With these similarities between long-term COVID and ME/CFS, as well as the neuroimmunological disorders associated with fatigue, it is plausible that SARS-CoV-2 infection may promote long-term COVID-19 symptoms, particularly fatigue, by inducing an inflammatory state and a dysregulated immune response. We measured plasma levels of IL-2, IFN-γ, and CCL4 (MIP-1β) to see if CelWel treatment affected patients' immunogenic profiles. CelWel had no effect on the proinflammatory cytokine IL-2, but it did downregulate IFN-γ and CCL4 (MIP-1β). In addition to that, after CelWel treatment, the PASC score decreased in 11 patients, indicating a reduction of the inflammatory state by preventing the production of proinflammatory cytokines in patients with prolonged COVID-19. However, four patients had the opposite trend in PASC score and would have required a large or very prolonged dose of CelWel to improve their PASC score. During the study period, no patients reported adverse events or abnormal clinical findings in laboratory parameters.

The limitations of the present study are the inability to measure other inflammatory cytokines, the non-randomized, small sample size, and the fact that the study was conducted in a single center. A future study should require comparing the effects of CelWel with placebos or standard NSAIDs on a large cohort for an extended period.

The results of this study indicate that the CelWel supplement has the potential to be an effective and safe treatment for prolonged COVID. CelWel may be able to overcome prolonged COVID symptoms by decreasing the inflammatory state of COVID survivors. However, the underlying mechanisms of action of CelWel need to be established through a large-scale trial.

ALT: alanine transaminase; AST: aspartate aminotransferase; BUN: blood urea nitrogen; C19-YRS: COVID-19 Yorkshire Rehabilitation Screening; CBC: complete blood count; CCL4: chemokine (C–C motif) ligand 4; COVID-19: coronavirus disease 19; EBV: Epstein Barr virus; ESR: erythrocyte sedimentation rate; FSSQ: fatigue severity scale questionnaires; GCP: good clinical practice; HPV: human parvovirus; HR-QoL: health-related quality of life; ICH: International Conference on Harmonization; ICMR: Indian Council of Medical Research; ME/CFS: myalgic encephalomyelitis/chronic fatigue syndrome; MERS: middle east respiratory syndrome; MIP-1β: macrophage inflammatory protein-1; PASC: post-acute sequelae of COVID-19; PTSD: posttraumatic stress disorder; RANTES: regulated upon activation, normal T cell expressed and presumably secreted; RBS: random blood sugar; RT-PCR: reverse transcription polymerase chain reaction; SARS: severe acute respiratory syndrome; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2

Author Contributions: Dr.Alben Sigamani,studydesign and manuscript editing; Dr. K. Sunil Naik,clinical investigation and manuscript editing; Sangeetha Sampath Kumar, manuscript preparation and literature support.

Data Availability: The corresponding author can provide derived data to support the findings of this study upon request.

Conflict of Interest: No conflict of interest associated with this study.

Acknowledgements: We would like to acknowledge the management of the Government Medical College and Government General Hospital (Old RIMS), Srikakulam, for their assistance for this study. We would also like to thank the nursing staff, and support staff of the Hospital for their assistance throughout this study.

1. World Health Organization. COVID-19 Dashboard, 2022. Available at: https://covid19.who.int/.

2. Zheng KI, Feng G, Liu WY, Targher G, Byrne CD, Zheng MH. Extrapulmonary complications of COVID-19: A multisystem disease? J Med Virol. 2021; 93:323–35.

3. Sykes DL, Holdsworth L, Jawad N, Gunasekera P, Morice AH, Crooks MG. Post-COVID-19 symptom burden: What is long-COVID and how should we manage it?. Lung. 2021; 199:113–9.

4. Verveen A, Wynberg E, van Willigen HDG, Boyd A, de Jong MD, de Bree G, Davidovich U, Lok A, Moll van Charante EP, Knoop H, Prins M, Nieuwkerk P; RECoVERED Study Group. Severe Fatigue in the First Year Following SARS-CoV-2 Infection: A Prospective Cohort Study. Open Forum Infect Dis. 2022; 9:ofac127.

5.Daugherty SE, Guo Y, Heath K, Dasmariñas MC, Jubilo KG, Samranvedhya J, Lipsitch M, Cohen K. Risk of clinical sequelae after the acute phase of SARS-CoV‐2 infection: retrospective cohort study. BMJ. 2021; 373:n1098.

6. Hansen KS, Mogensen TH, Agergaard J, Schiottz-Christensen B, Ostergaard L, Vibholm LK, Leth S. High-dose coenzyme Q10 therapy versus placebo in patients with post COVID-19 condition: a randomized, phase 2, crossover trial. Lancet Reg Health Eur. 2023; 24:100539.

7. Kunoor A, Surendran D, Hari H, Viswan V, Harikrishnan K, Mehta AA. Impact of early pulmonary rehabilitation in postacute COVID Disease: A single-center experience from India - A quasi-experimental study. Indian J Public Health. 2022; 66:S51-5.

8. Straudi S, Manfredini F, Baroni A, Milani G, Fregna G, Schincaglia N, Androni R, Occhi A, Sivan M, Lamberti N. Construct Validity and Responsiveness of the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) in a Cohort of Italian Hospitalized COVID-19 Patients. Int J Environ Res Public Health. 2022; 19:6696.

9.Fernández-de-Las-Peñas C, Palacios-Ceña D, Gómez-Mayordomo V, Palacios-Ceña M, Rodríguez-Jiménez J, de-la-Llave-Rincón AI, Velasco-Arribas M, Fuensalida-Novo S, Ambite-Quesada S, Guijarro C, Cuadrado ML, Florencio LL, Arias-Navalón JA, Ortega-Santiago R, Elvira-Martínez CM, Molina-Trigueros LJ, Torres-Macho J, Sebastián-Viana T, Canto-Diez MG, Cigarán-Méndez M, Hernández-Barrera V, Arendt-Nielsen L. Fatigue and Dyspnoea as Main Persistent Post-COVID-19 Symptoms in Previously Hospitalized Patients: Related Functional Limitations and Disability. Respiration. 2022; 101:132 – 41.

10. Yong SJ. Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treaents. Infect Dis (Lond). 2021; 53:737–54.

11. Calvo-Paniagua J, Díaz-Arribas MJ, Valera-Calero JA, Gallardo-Vidal MI, Fernández-de-Las-Peñas C, López-de-Uralde-Villanueva I, Del Corral T, Plaza-Manzano G. A tele-health primary care rehabilitation program improves self-perceived exertion in COVID-19 survivors experiencing Post-COVID fatigue and dyspnea: A quasi-experimental study. PLoS One. 2022; 17:e0271802.

12. Kedor C, Freitag H, Meyer-Arndt L, Wittke K, Hanitsch LG, Zoller T, Steinbeis F, Haffke M, Rudolf G, Heidecker B, Bobbert T, Spranger J, Volk HD, Skurk C, Konietschke F, Paul F, Behrends U, Bellmann-Strobl J, Scheibenbogen C. A prospective observational study of post-COVID-19 chronic fatigue syndrome following the first pandemic wave in Germany and biomarkers associated with symptom severity. Nat Commun. 2022; 13:5104.

13.Komaroff AL, Lipkin WI. Insights from myalgic encephalomyelitis/chronic fatigue syndrome may help unravel the pathogenesis of postacute COVID-19 syndrome. Trends Mol Med. 2021; 27:895–906.

14. Jennifer C. Felger AHM. Cytokine Effects on the Basal Ganglia and Dopamine Function: The Subcortical Source of Inflammatory Malaise. Front Neuroendocrinol. 2012; 33:315.

15. Cordeiro LMS, Rabelo PCR, Moraes MM, Teixeira-Coelho F, Coimbra CC, Wanner SP, Soares DD. Physical exercise-induced fatigue: the role of serotonergic and dopaminergic systems. Braz J Med Biol Res. 2017; 50:e6432.

16. Islam MF, Cotler J, Jason LA. Post-viral fatigue and COVID-19: lessons from past epidemics. Fatigue: Biomed. Health Behav. 2020; 8:61–9.

17.Späth-Schwalbe E, Hansen K, Schmidt F, Schrezenmeier H, Marshall L, Burger K, Fehm HL, Born J. Acute effects of recombinant human interleukin-6 on endocrine and central nervous sleep functions in healthy men. J Clin Endocrinol Metab. 1998; 83:1573–9.

18. Sannegowda KM, Venkatesha SH, Moudgil KD. Tinospora cordifolia inhibits autoimmune arthritis by regulating key immune mediators of inflammation and bone damage. Int J Immunopathol Pharmacol. 2015; 28:521–31.

19. Valko PO, Bassetti CL, Bloch KE, Held U, Baumann CR. Validation of the fatigue severity scale in a Swiss cohort. Sleep. 2008; 31:1601–7.

20. Sivan M, Halpin S, Gee J. Assessing long-term rehabilitation needs in COVID-19 survivors using a telephone screening tool (C19-YRS tool). Adv Clin Neurosci Rehabil. 2020; 19:14–7.

21. Patterson BK, Guevara-Coto J, Yogendra R, Francisco EB, Long E, Pise A, Rodrigues H, Parikh P, Mora J, Mora-Rodríguez RA. Immune-Based Prediction of COVID-19 Severity and Chronicity Decoded Using Machine Learning. Front Immunol. 2021; 12:700782.

22. Global Burden of Disease Long COVID Collaborators. Estimated global proportions of individuals with persistent fatigue, cognitive, and respiratory symptom clusters following symptomatic COVID-19 in 2020 and 2021. JAMA. 2022; 328:1604–15.

23. Van Herck M, Goërtz YMJ, Houben-Wilke S, Machado FVC, Meys R, Delbressine JM, Vaes AW, Burtin C, Posthuma R, Franssen FME, Hajian B, Vijlbrief H, Spies Y, van't Hul AJ, Janssen DJA, Spruit MA. Severe Fatigue in Long COVID: Web-Based Quantitative Follow-up Study in Members of Online Long COVID Support Groups. J Med Internet Res. 2021; 23:e30274.

24. Michelen M, Manoharan L, Elkheir N, Cheng V, Dagens A, Hastie C, O'Hara M, Suett J, Dahmash D, Bugaeva P, Rigby I, Munblit D, Harriss E, Burls A, Foote C, Scott J, Carson G, Olliaro P, Sigfrid L, Stavropoulou C. Characterising long COVID: a living systematic review. BMJ Glob Health. 2021; 6:e005427.

25. Lopez-Leon S, Wegman-Ostrosky T, Perelman C, Sepulveda R, Rebolledo PA, Cuapio A, Villapol S. More than 50 long-term effects of COVID-19: a systematic review and meta-analysis. Sci Rep. 2021; 11:16144.

26. Heine J, Schwichtenberg K, Hartung TJ, Rekers S, Chien C, Boesl F, Rust R, Hohenfeld C, Bungenberg J, Costa AS, Scheibenbogen C, Bellmann-Strobl J, Paul F, Franke C, Reetz K, Finke C. Structural brain changes in patients with post-COVID fatigue: a prospective observational study. eClinicalMedicine 2023; 58:101874.

27. Koc HC, Xiao J, Liu W, Li Y, Chen G. Long COVID and its Management. Int J Biol Sci. 2022; 18:4768–80.

28. Afrin LB, Weinstock LB, Molderings GJ. Covid-19 hyperinflammation and post-Covid-19 illness may be rooted in mast cell activation syndrome. Int J Infect Dis. 2020; 100:327–32.

29. Rivera MC, Mastronardi C, Silva-Aldana CT, Arcos-Burgos M, Lidbury BA. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Comprehensive Review. Diagnostics. 2019; 9:91.

30. Ortega-Hernandez OD, Shoenfeld Y. Infection, vaccination, and autoantibodies in chronic fatigue syndrome, cause or coincidence? Ann N Y Acad Sci. 2009; 1173:600–9.

31. Frontera JA, Yang D, Lewis A, Patel P, Medicherla C, Arena V, Fang T, Andino A, Snyder T, Madhavan M, Gratch D, Fuchs B, Dessy A, Canizares M, Jauregui R, Thomas B, Bauman K, Olivera A, Bhagat D, Sonson M, Park G, Stainman R, Sunwoo B, Talmasov D, Tamimi M, Zhu Y, Rosenthal J, Dygert L, Ristic M, Ishii H, Valdes E, Omari M, Gurin L, Huang J, Czeisler BM, Kahn DE, Zhou T, Lin J, Lord AS, Melmed K, Meropol S, Troxel AB, Petkova E, Wisniewski T, Balcer L, Morrison C, Yaghi S, Galetta S. A prospective study of long-term outcomes among hospitalized COVID-19 patients with and without neurological complications. J Neurol Sci. 2021; 426:117486.

32. Hartung TJ, Neumann C, Bahmer T, Chaplinskaya-Sobol I, Endres M, Geritz J, Haeusler KG, Heuschmann PU, Hildesheim H, Hinz A, Hopff S, Horn A, Krawczak M, Krist L, Kudelka J, Lieb W, Maetzler C, Mehnert-Theuerkauf A, Montellano FA, Morbach C, Schmidt S, Schreiber S, Steigerwald F, Störk S, Maetzler W, Finke C. Fatigue and cognitive impairment after COVID-19. eClinicalMedicine. 2022; 53:101651.

33. Capuron L, Pagnoni G, Demetrashvili MF, Lawson DH, Fornwalt FB, Woolwine B, Berns GS, Nemeroff CB, Miller AH. Basal Ganglia Hypermetabolism and Symptoms of Fatigue during Interferon-α Therapy. Neuropsychopharmacol. 2007; 32: 2384–2392.

34. Jaeger S, Paul F, Scheel M, Brandt A, Heine J, Pach D, Witt CM, Bellmann-Strobl J, Finke C. Multiple sclerosis–related fatigue: altered resting-state functional connectivity of the ventral striatum and dorsolateral prefrontal cortex. Mult Scler J. 2019; 25:554–564.

35. Fleischer V, Ciolac D, Gonzalez-Escamilla G, Grothe M, Strauss S, Molina Galindo LS, Radetz A, Salmen A, Lukas C, Klotz L, Meuth SG, Bayas A, Paul F, Hartung HP, Heesen C, Stangel M, Wildemann B, Then Bergh F, Tackenberg B, Kümpfel T, Zettl UK, Knop M, Tumani H, Wiendl H, Gold R, Bittner S, Zipp F, Groppa S, Muthuraman M; German Competence Network Multiple Sclerosis (KKNMS). Subcortical volumes as early predictors of fatigue in multiple sclerosis. Ann Neurol. 2022; 91:192–202.

36. Yarraguntla K, Bao F, Lichtman-Mikol S, Razmjou S, Santiago-Martinez C, Seraji-Bozorgzad N, Sriwastava S, Bernitsas E. Characterizing Fatigue-Related White Matter Changes in MS: A Proton Magnetic Resonance Spectroscopy Study. Brain Sci. 2019 May 27;9(5):122.

supplementaryMaterials.docx

Table S1: CBC parameters and ESR before and after treatment Table S2: Serum biochemical parameters before and after treatment