I read the Viewpoint on long-COVID by Mariette with interest and consent.1 Mariette, skilled experimental and clinical immunologist, has come to the conclusion that patients presenting with long-COVID may suffer from a psychosomatic rather than some ill-defined immunological disorder. He finds them ‘fibromyalgia alike’. Premorbid chronic stress, patients’ perceptions and attribution (omnipresent vague symptoms are easily attributed to previous SARS-CoV-2 infection by patients as well as doctors) are phenomena that may indeed play a more important role in explaining long-COVID than, for instance, persistent viral infection or invoked autoimmunity.

In clinical rheumatology we know these phenomena quite well, when trying to distinguish among all newly referred patients those few with an inflammatory disease from the many that have widespread pain or degenerative joint disease. In my country, as in France, where the number of accessible rheumatologists is considerable and distances to the rheumatologists are short, we diagnose 5–10 patients with fibromyalgia for every new case of rheumatoid arthritis (RA). In countries with a shortage of rheumatologists, suspected patients with RA will have priority-access, and patients with suspected fibromyalgia will be put on a 1 year waiting list to no avail. The new patients with RA may look forward to excellent medication, nowadays a relatively good outlook. The many patients with fibromyalgia do not have such a perspective and may actually suffer more than those with RA. Rheumatologists are still relatively powerless in managing them properly, sometimes leading to therapeutic nihilism and even physician’s denial. In the pharmaceutical industry they would call this situation ‘huge unmet medical need’.

While Mariette and I largely agree on the resemblance of long-COVID to the spectrum of conditions to which fibromyalgia belongs, people like us will not only find Society against us, but also Politics urged by Society to establish large funds for fundamental research into long-COVID, as well as Science, attracted by these funds. l’Histoire ce répète is what Mariette would say, referring to our disappointingly poor yield of the research into the immunological causes of post-Lyme disease, chronic fatigue syndrome or chronic Q-fever syndrome, to mention a few, and long-COVID can likely be added to this list shortly.

However, naming a problem, how true it may be, does not suffice without thoughts about practical solutions, and also bears unforeseen challenges.

Appreciating long-COVID and fibromyalgia as ill-defined psychosomatic disorders with one ‘final common pathway’, ignitable by many different causes, such as common viruses, bears the danger of putting the rheumatologist in the forefront of the societal long-COVID problem. Patients with long-COVID will consult us (even) more often and ask for solutions that we cannot offer. Society may expect us, immuno-rheumatologists, to find pathophysiological explanations for a problem that we see as psychosomatic rather than immunological or infectious.

I would like to hear Mariette’s solutions for these challenges. Should we, rheumatologists, engage more with psychologists, chronic pain specialists and rehabilitation specialists and learn more of their skills? Mariette argues for more research into fibromyalgia-like post-COVID syndrome, but who should do this? Should our inflammation scientists, who have made their careers by unravelling the immuno-pathophysiology of our inflammatory diseases, switch gears and focus more on the pathophysiology of (hyper)sensitisation-syndromes and pain-syndromes? Perhaps!

I am sure that the fibromyalgia syndrome, whether or not finally being the same as long-COVID, represents an unmet need that deserves our full (scientific and clinical) attention, as much as our immunological diseases once successfully enjoyed.

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