PMC:7289100 / 30099-38201 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7289100","sourcedb":"PMC","sourceid":"7289100","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7289100","text":"8 Preexisting autoimmune rheumatic diseases and COVID-19 infection\nSince the breakout of the Covid-19 in late 2019 in China, many unresolved issues regarding both dealing with the fate of the preexisting autoimmune rheumatic diseases in patients who are affected by the virus including those under immunosuppressive and biologic therapy, as well as the impact of these therapies on the severity of the viral disease itself. Early reports in the course of the pandemia suggested that based on the data recovered from other and previous viral infections, there would be an increased probability for patients with rheumatic diseases to acquire the Covid-19 disease or are they prone to an increased severity of the infection if they do acquire it. On the contrary, however, early on, there was some evidence regarding the potential benefit of some of the drugs which have been used in the therapy of rheumatic disease [83,84].\nPatients with SLE had posed a serious concern during the Covid-19 pandemia. This group of patients is well known to bear an increased risk of severe infections, due to both their immune system and the related organ damage as well as due to the therapies used including immunosuppressive drugs. In a report of 19 SLE patients from France who were clinically quiescent on a long-term treatment with Hydroxychloroquine (HCQ) and were infected by the Covid-19 virus, the authors were able to conclude that the clinical course of these lupus patients did not show any signs of the disease exacerbation, except for a single case of tenosynovitis [85]. A preliminary analysis of patients included in the COVID-19 Global Rheumatology Alliance registry, showed that 17% of 110 patients with rheumatic diseases who have been diagnosed with COVID-19 as of April the 1st, 2020- were patients with lupus [86]. Thus the frequency of patients with lupus who have been diagnosed with COVID-19 was over-represented, at about twice as compared to rheumatoid arthritis which is a much commoner rheumatic disease among the adult population. In a recent small report from northern Italy of SLE patients with either swab confirmed Covid-19 infection (n = 4) or a clinical diagnosis, based on 3 out of 4 symptoms of the viral infection (n = 8), the authors stated that the disease course was generally mild and self-resolving although one of the four patients who was on haemodialysis due to end-stage renal disease, needed intensive care for the development of acute respiratory distress syndrome [87]. Based on the clinical information published to date from the new and previous outbreaks caused by the coronaviruses, there is no overwhelming evidence that patients with rheumatic disease are at an increased risk compared with other comorbidities [[88], [89], [90]]. In a rather larger prospective report from New York, the authors reviewed a group of 86 patients with immune-mediated inflammatory disease including 59 cases of inflammatory arthritides (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, psoriasis and inflammatory bowel disease) with confirmed Covid-19, and 27 additional patients with suspected Covid-19 [91]. Two-thirds of the patients were on biologics or other immunomodulatory drugs. Hospitalized patients, as compared to those who were only followed on an out-patient basis, had more classical Covid-19 comorbidities. Conventional DMARDs were used more frequently in the hospitalized group of patients, whereas biologics were more often used in the ambulatory group of patients. The authors suggest that based on their findings the baseline use of biologics was not associated with worse Covid-19 outcomes. In another small report from China five patients with rheumatic disease and Covid-19 are described [92]. Four had rheumatoid arthritis and one with systemic sclerosis. All 5 patients had chest CT showing patchy ground glass opacities in the lungs. All 5 patients were treated with antiviral agents, antibiotics and the immunomodulatory agents for their rheumatic disease. Two of the 5 patients remained in stable condition in the course of the hospitalization, 2 progressed to severe Covid-19 and one was critically ill, though all patients recovered and were discharged from hospital. Similarly, a report by Monti et al. [93] suggested that patients with rheumatoid arthritis treated with biological DMARDs or targeted synthetic DMARDs did not seem to be at increased risk of life-threatening complications from Covid-19 compared with the general population. Another recent study from Italy supports the approach of encouraging connective tissue disease patients to maintain the ongoing rheumatologic therapy as well as adhere to the measures of infection prevention, thus avoiding relapse of the rheumatic disease without increasing the risk of Covid-19 [94]. Their study population included 123 adult patients (110 females) with systemic lupus erythematosus (n = 61), systemic sclerosis (n = 43), undifferentiated connective tissue disease (n = 9) and Sjogren syndrome (n = 10). About 60% of the patients were treated with conventional DMARDs, with a similar percentage of patients taking corticosteroids as well. Twenty five of the 110 patients received biologics. Only one rather young female patient with systemic sclerosis was found to be positive for Covid-19 and developed a critical course with interstitial pneumonia leading to her death despite intubation and an attempt with tocilizumab. A further 14 patients reported mild respiratory symptoms compatible with a viral infection but did not have access to a swab test and showed a rapid recovery of their symptoms. The authors concluded that only 5 out of their 123 patients had discontinued their current rheumatological therapy, with none of the rest 115 patients experiencing flare-ups of their disease. Similarly, Conticini et al recently reported of a large cohort of 859 patients from Italy affected by different rheumatic diseases, which were treated by biological DMARDs or by targeted synthetic DMARDs [95]. Only 2 patients who were both on biologics (rituximab or tocilizumab), were diagnosed with COVID-19, one of which even with bilateral diffuse interstitial pneumonia. Both patients had a complete recovery without interruption of the biological treatment. Similar favorable outcome has been reported for few cases with large-vessel vasculitis and granulomatosis with polyangiitis associated with Covid-19 infection [96,97]. Thus it seems that baseline use of biologics is not associated with worse Covid-19 outcomes. The situation might be different with patients suffering from systemic sclerosis, where the typical interstitial lung disease (ILD) could share some CT features with Covid-19 associated pneumonia [[98], [99], [100]]. Currently the impact of pre-existing systemic sclerosis associated with pulmonary and cardiac involvement, on the course of Covid-19 is yet unknown. Such a single case with scleroderma associated ILD and polyarthritis, who had been previously treated with anti-interleukin-6 receptor blocker (Tocilizumab) with a favorable response, was recently reported [101]. In the course of this therapy, 4 weeks after the last tocilizumab infusion, she reported a contact with Covid-19 and was found to be positive for the virus by a nasopharyngeal swab. Her condition remained stable during the course of the acute disease and following a negative swab and cure, she had received the next scheduled tocilizumab injection. It should be noted that early reports from China during the outbreak of the SARS-Cov2 were able to demonstrate increased levels of IL-6 and CRP, suggesting that this subgroup of patients may develop the Covid19 related cytokine storm. Randomized trials using anti-IL-6 receptor monoclonal antibody are currently ongoing. Recently many countries and organizations have set up registries incorporating patients with pre-existing rheumatic and autoimmune diseases who had encountered a Covid-19 infection. The largest international registries include The Global Rheumatology Alliance of Covid-19 and the Eular Covid-19 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