To the Editor—The coronavirus disease 2019 (COVID-19) pandemic has been major sanitary crisis of recent times. Its pathogenesis is complex and systemic manifestations are the most varied. ^{Reference Machhi, Herskovitz and Senan1} In addition to serious cases of hospitalization, persistent symptoms have been observed in patients that impact on rehabilitation and quality of life. ^{Reference Nalbandian, Sehgal and Gupta2} This clinical condition is recognized as a postacute COVID-19 syndrome that affects different severe acute respiratory coronavirus virus 2 (SARS-CoV-2)–positive patients. ^{Reference Nalbandian, Sehgal and Gupta2,Reference Yong3}

By acting directly with the oral cavity and subsequent exposure to aerosol and saliva, dentists are at risk for infection by novel coronavirus and, consequently, can also develop sequelae. ^{Reference Santana, Pinho, de Albuquerque and Souza4} Thus, we report a case series of post-acute COVID-19 syndrome in maxillofacial surgeons of a Brazilian public center and highlight the need for clinical follow-up of these professionals.

Between April and June 2020, 20 maxillofacial surgeons in Sergipe, Brazil, worked during the first wave of COVID-19 performing high complexity surgeries and, unfortunately, most of them were infected (15 of 20, 75%). In addition, 4 individuals tested positive for SARS-CoV-2 in subsequent months (2–5 months) (Table 1). The mean age of participants was of 46.1 years (SD ±5.2) and 15 cases (75%) were SARS-CoV-2 positive. Of these 15 cases, 11 (73.3%) showed persistent symptoms during 12 months of follow-up.

Table 1. Clinical Profile of Oral Surgery Group Infected During First COVID-19 Pandemic Wave in Brazilian Public Center Medical and Potential Sequels and Symptoms in Subsequent Months

Note. M, male; F, female.

^a Results provided by RT-qPCR analysis for SARS-CoV-2.

These postacute symptoms ranged from mild to moderate, including fever, muscle disorders, chemosensory alterations, respiratory and intestinal complications, and intestinal alterations. These persistent symptoms directly affected the performance of their usual activities as professionals and, consequently, caused a decline in quality of life. These clinical findings coincided with the characteristics of postacute COVID-19 syndrome. Moreover, the continuation of these symptoms beyond 6 months were reported by 9 of the 11 maxillofacial surgeons diagnosed with postacute COVID-19 syndrome. Some professionals experienced significant worsening of symptoms and development of comorbidities, such as hypertension and glycemic disorders.

Postacute COVID-19 syndrome, or long COVID, is defined as persistence of symptoms or appearance of sequelae beyond 3 or 4 weeks from the onset of disease. ^{Reference Nalbandian, Sehgal and Gupta2} In general, the most commonly reported symptoms are fatigue, sleep difficulties, and anxiety and/or depression. ^{Reference Nalbandian, Sehgal and Gupta2,Reference Augustin, Schommers and Stecher5} The pathophysiologic mechanisms of syndrome are unclear, although damage provoked by host inflammatory response and immunological deficits may predispose a COVID-19 patient to a greater chance of sequelae. ^{Reference Williamson, Walker and Bhaskaran6}

To our knowledge, this is the first study to report a case series of sequelae of COVID-19 in maxillofacial surgeons presenting postacute COVID-19 syndrome followed for 12 months. Commonly, studies have reported the prevalence of postacute COVID-19 syndrome in patients followed for 6 months; fatigue and dyspnea affected a larger number of these patients. ^{Reference Nalbandian, Sehgal and Gupta2,Reference Augustin, Schommers and Stecher5} Also, the presence of comorbidities have been reported as determining factors of increased severity of disease, ^{Reference Yong3,Reference Williamson, Walker and Bhaskaran6} which was not observed in our study.

Researchers have focused on the analysis of the sequelae of COVID-19 in hospitalized patients once they are expected to have longer convalescence. ^{Reference Augustin, Schommers and Stecher5} The professionals evaluated in our study did not need hospitalization; thus, regardless of the severity of the disease, the sequelae may be significant and can impact quality of life. Interestingly, Augustin et al (2021) ^{Reference Augustin, Schommers and Stecher5} demonstrated that long-term symptoms of postacute COVID-19 syndrome are not exclusive to more severely ill patients or those with a long period of hospitalization, despite the expectation of longer convalescence for hospitalized patients. In their study, 930 (97.1%) of 958 COVID-19 patients who were not hospitalized developed symptoms as shortness of breath, fatigue, joint pain, anosmia, and/or ageusia.

Other important alterations found in the literature are thromboembolic disorders, renal failure, pulmonary fibrosis, Hashimoto thyroiditis, gastrointestinal and hepatobiliary sequelae, psoriasis, and Guillain-Barré syndrome. ^{Reference Nalbandian, Sehgal and Gupta2,Reference Caress, Castoro, Simmons, Scelsa, Lewis, Ahlawat and Narayanaswami7} The association between COVID-19 and development of these pathologies is still poorly understood, but some hypotheses have been postulated. Regarding anosmia, it is thought that SARS-CoV-2 may damage the olfactory neuroepithelium by linkage to the ACE2 receptor and that fatigue could result from endothelial dysfunction in brain capillaries as consequence of the inflammatory process. ^{Reference Hoffmann, Kleine-Weber and Schroeder8,Reference Nauen, Hooper, Stewart and Solomon9}

In conclusion, our results reinforce the need for long follow-up of healthcare workers affected by novel coronavirus, mainly, those working on the front lines and in environments with a high flow of infected patients, including individuals not hospitalized. In addition, most of these symptoms may be underdiagnosed and directly affect quality of life; thus, a multidisciplinary approach is needed, as well as monitoring of symptoms after the initial period of illness.