COVID-19 and rheumatic autoimmune systemic diseases: report of a large Italian patients series

Multi-omics analysis uncovered systemic lupus erythematosus and COVID-19 crosstalk

BACKGROUND

Studies have highlighted a possible crosstalk between the pathogeneses of COVID-19 and systemic lupus erythematosus (SLE); however, the interactive mechanisms remain unclear. We aimed to elucidate the impact of COVID-19 on SLE using clinical information and the underlying mechanisms of both diseases.

METHODS

RNA-seq datasets were used to identify shared hub gene signatures between COVID-19 and SLE, while genome-wide association study datasets were used to delineate the interaction mechanisms of the key signaling pathways. Finally, single-cell RNA-seq datasets were used to determine the primary target cells expressing the shared hub genes and key signaling pathways.

RESULTS

COVID-19 may affect patients with SLE through hematologic involvement and exacerbated inflammatory responses. We identified 14 shared hub genes between COVID-19 and SLE that were significantly associated with interferon (IFN)-I/II. We also screened and obtained four core transcription factors related to these hub genes, confirming the regulatory role of the IFN-I/II-mediated Janus kinase/signal transducers and activators of transcription (JAK-STAT) signaling pathway on these hub genes. Further, SLE and COVID-19 can interact via IFN-I/II and IFN-I/II receptors, promoting the levels of monokines, including interleukin (IL)-6/10, tumor necrosis factor-α, and IFN-γ, and elevating the incidence rate and risk of cytokine release syndrome. Therefore, in SLE and COVID-19, both hub genes and core TFs are enriched within monocytes/macrophages.

CONCLUSIONS

The interaction between SLE and COVID-19 promotes the activation of the IFN-I/II-triggered JAK-STAT signaling pathway in monocytes/macrophages. These findings provide a new direction and rationale for diagnosing and treating patients with SLE-COVID-19 comorbidity.

Impact of COVID-19 Pandemic on Patients With Rheumatic Diseases in Medina, Saudi Arabia: An Observational Cross-Sectional Study

INTRODUCTION

The Coronavirus disease of 2019 (COVID-19) pandemic undoubtedly ranks among the most health-impacting pandemics throughout medical history. Although the COVID-19 global public health emergency has ended, lessons need to be learned to be more ready to face similar pandemics in the future. Few studies in Saudi Arabia discuss the impact of the COVID-19 pandemic on autoimmune rheumatic disease (AIRD) patients. Thus, this study was conducted to elaborate on the effects of the COVID-19 pandemic on AIRD patients and rheumatology practices in Saudi Arabia.  Methods: This observational cross-sectional study was conducted among patients aged over 14 with AIRD using a pre-designed validated survey questionnaire. Data were collected from AIRD patients who were following up between November 2021 to April 2022 at the Rheumatology Clinic of King Fahad General Hospital in Madinah City, Saudi Arabia. This center was chosen as being the main hospital in the city following patients of AIRD.

RESULTS

A total of 324 patients were included in our study, with the majority (n=264, 81.5%) being females. The mean age was 44.42±14.4 years. Clinical data revealed that 115 (35.5%) of our patients experienced mild COVID-19 infection, 19 (5.9%) suffered from respiratory insufficiency, and seven (2.2%) required admission to the intensive care unit (ICU). Non-compliance to medication was recorded at 25.2%. There were 115 (35.5%) patients who had an AIRD flare that was significantly higher among those who were not adherent to the medications (p<0.001). Disease flare was also significantly seen among patients who were not on prednisone or were on low doses of prednisone (p<0.001). The majority (n=33, 97.1%) of the 34 infected patients who had an AIRD flare had their flare-up at the same time as their COVID-19 infection (p<0.001). COVID-19 vaccination rate was 87.7% (n=284). The most common reason for non-vaccination in 40 (12.3%) patients was the patients' concern about disease flare-ups by the vaccine or interference of the vaccine with their medication (n=16, 4.9%).

CONCLUSION

Our study showed a 35.5% (n=115) COVID-19 infection rate. The majority of our AIRD patients sustained minor infections that did not require hospitalization or ICU admission. The majority of the patients who underwent a severe COVID-19 infection course were not on prednisolone or were on low-dose prednisone. Due to COVID-19 restrictions and drug shortages, one in four patients (25.3%) stopped taking their medications and was significantly found to have a high prevalence of underlying AIRD flare. Despite the high vaccination rate, disease flare was the biggest concern for those who were not immunized. Although the COVID-19 pandemic has ended, doctors should be aware of risk factors associated with severe AIRD outcomes that should be balanced based on the infection severity, underlying disease flares, and patient-centered education about medication adherence and vaccination.

New-onset or relapse of uveitis after rapid spreading of COVID-19 infection in China and risk factor analysis for relapse

BACKGROUND

The aim of this study was to report the clinical profile of new-onset and relapse of uveitis following rapid spreading of coronavirus disease 2019 (COVID-19) infection due to change of anti-COVID-19 policies in China and investigate potential risk factors for inflammation relapse.

METHODS

In this retrospective case-control study, patients with new-onset or a history of uveitis between December 23, 2022, and February 28, 2023, were included to assess the influence of COVID-19 infection on uveitis. Detailed information on demographic data, clinical characteristics, treatment measures, treatment response, and ocular inflammatory status before and after COVID-19 infection was collected.

RESULTS

This study included 349 patients with a history of uveitis. The uveitis relapse rate was higher (28.8%, n = 288) in those with COVID-19 infection than in patients without COVID-19 infection (14.8%, n = 61) (P = 0.024). Among the relapse cases, 50.8% experienced a relapse of anterior uveitis, while 49.2% had a relapse of uveitis involving the posterior segment. Multivariable regression analysis indicated a positive correlation between disease duration and uveitis relapse, while the last relapse exceeding one year before COVID-19 infection and the use of methotrexate during COVID-19 infection were negatively correlated with relapse of uveitis. Thirteen patients who developed new-onset uveitis following COVID-19 infection were included; among them, three (23.1%) had anterior uveitis and 10 (76.9%) had uveitis affecting the posterior segment. Regarding cases involving the posterior segment, four patients (30.8%) were diagnosed with Vogt-Koyanagi-Harada disease.

CONCLUSIONS

COVID-19 infection increases the rate of uveitis relapse. Long disease duration is a risk factor, while time since the last relapse more than 1 year and methotrexate use are protective factors against uveitis relapse.

Neem leaf glycoprotein binding to Dectin-1 receptors on dendritic cell induces type-1 immunity through CARD9 mediated intracellular signal to NFκB

BACKGROUND

A water-soluble ingredient of mature leaves of the tropical mahogany 'Neem' (Azadirachta indica), was identified as glycoprotein, thus being named as 'Neem Leaf Glycoprotein' (NLGP). This non-toxic leaf-component regressed cancerous murine tumors (melanoma, carcinoma, sarcoma) recurrently in different experimental circumstances by boosting prime antitumor immune attributes. Such antitumor immunomodulation, aid cytotoxic T cell (Tc)-based annihilation of tumor cells. This study focused on identifying and characterizing the signaling gateway that initiate this systemic immunomodulation. In search of this gateway, antigen-presenting cells (APCs) were explored, which activate and induce the cytotoxic thrust in Tc cells.

METHODS

Six glycoprotein-binding C-type lectins found on APCs, namely, MBR, Dectin-1, Dectin-2, DC-SIGN, DEC205 and DNGR-1 were screened on bone marrow-derived dendritic cells from C57BL/6 J mice. Fluorescence microscopy, RT-PCR, flow cytometry and ELISA revealed Dectin-1 as the NLGP-binding receptor, followed by verifications through RNAi. Following detection of β-Glucans in NLGP, their interactions with Dectin-1 were explored in silico. Roles of second messengers and transcription factors in the downstream signal were studied by co-immunoprecipitation, western blotting, and chromatin-immunoprecipitation. Intracellularization of FITC-coupled NLGP was observed by processing confocal micrographs of DCs.

RESULTS

Considering extents of hindrance in NLGP-driven transcription rates of the cytokines IL-10 and IL-12p35 by receptor-neutralization, Dectin-1 receptors on dendritic cells were found to bind NLGP through the ligand's peripheral β-Glucan chains. The resulting signal phosphorylates PKCδ, forming a trimolecular complex of CARD9, Bcl10 and MALT1, which in turn activates the canonical NFκB-pathway of transcription-regulation. Consequently, the NFκB-heterodimer p65:p50 enhances Il12a transcription and the p50:p50 homodimer represses Il10 transcription, bringing about a cytokine-based systemic-bias towards type-1 immune environment. Further, NLGP gets engulfed within dendritic cells, possibly through endocytic activities of Dectin-1.

CONCLUSION

NLGP's binding to Dectin-1 receptors on murine dendritic cells, followed by the intracellular signal, lead to NFκB-mediated contrasting regulation of cytokine-transcriptions, initiating a pro-inflammatory immunopolarization, which amplifies further by the responding immune cells including Tc cells, alongside their enhanced cytotoxicity. These insights into the initiation of mammalian systemic immunomodulation by NLGP at cellular and molecular levels, may help uncovering its mode of action as a novel immunomodulator against human cancers, following clinical trials.

Identifying diseases associated with Post-COVID syndrome through an integrated network biology approach

A growing body of research shows that COVID-19 is now recognized as a multi-organ disease with a wide range of manifestations that can have long-lasting repercussions, referred to as post-COVID-19 syndrome. It is unknown why the vast majority of COVID-19 patients develop post-COVID-19 syndrome, or why patients with pre-existing disorders are more likely to experience severe COVID-19. This study used an integrated network biology approach to obtain a comprehensive understanding of the relationship between COVID-19 and other disorders. The approach involved building a PPI network with COVID-19 genes and identifying highly interconnected regions. The molecular information contained within these subnetworks, as well as the pathway annotations, were used to reveal the link between COVID-19 and other disorders. Using Fisher's exact test and disease-specific gene information, significant COVID-19-disease associations were discovered. The study discovered diseases that affect multiple organs and organ systems, thus proving the theory of multiple organ damage caused by COVID-19. Cancers, neurological disorders, hepatic diseases, cardiac disorders, pulmonary diseases, and hypertensive diseases are just a few of the conditions linked to COVID-19. Pathway enrichment analysis of shared proteins revealed the shared molecular mechanism of COVID-19 and these diseases. The findings of the study shed new light on the major COVID-19-associated disease conditions and how their molecular mechanisms interact with COVID-19. The novelty of studying disease associations in the context of COVID-19 provides new insights into the management of rapidly evolving long-COVID and post-COVID syndromes, which have significant global implications.Communicated by Ramaswamy H. Sarma.

Impact of COVID-19 and vaccination campaign on 1,755 systemic sclerosis patients during first three years of pandemic. Possible risks for individuals with impaired immunoreactivity to vaccine, ongoing immunomodulating treatments, and disease-related lung involvement during the next pandemic phase

Introduction

The impact of COVID-19 pandemic represents a serious challenge for 'frail' patients' populations with inflammatory autoimmune systemic diseases such as systemic sclerosis (SSc). We investigated the prevalence and severity of COVID-19, as well the effects of COVID-19 vaccination campaign in a large series of SSc patients followed for the entire period (first 38 months) of pandemic.

Patients and method

This prospective survey study included 1755 unselected SSc patients (186 M, 1,569F; mean age 58.7 ± 13.4SD years, mean disease duration 8.8 ± 7.3SD years) recruited in part by telephone survey at 37 referral centers from February 2020 to April 2023. The following parameters were carefully evaluated: i. demographic, clinical, serological, and therapeutical features; ii. prevalence and severity of COVID-19; and iii. safety, immunogenicity, and efficacy of COVID-19 vaccines.

Results

The prevalence of COVID-19 recorded during the whole pandemic was significantly higher compared to Italian general population (47.3 % vs 43.3 %, p < 0.000), as well the COVID-19-related mortality (1.91 % vs 0.72 %, p < 0.001). As regards the putative prognostic factors of worse outcome, COVID-19 positive patients with SSc-related interstitial lung involvement showed significantly higher percentage of COVID-19-related hospitalization compared to those without (5.85 % vs 1.73 %; p < 0.0001), as well as of mortality rate (2.01 % vs 0.4 %; p = 0.002). Over half of patients (56.3 %) received the first two plus one booster dose of vaccine; while a fourth dose was administered to 35.6 %, and only few of them (1.99 %) had five or more doses of vaccine. Of note, an impaired seroconversion was recorded in 25.6 % of individuals after the first 2 doses of vaccine, and in 8.4 % of patients also after the booster dose. Furthermore, the absence of T-cell immunoreactivity was observed in 3/7 patients tested by QuantiFERON® SARSCoV-2 Starter Set (Qiagen). The efficacy of vaccines, evaluated by comparing the COVID-19-related death rate recorded during pre- and post-vaccination pandemic periods, revealed a quite stable outcome in SSc patients (death rate from 2.54 % to 1.76 %; p = ns), despite the significant drop of mortality observed in the Italian general population (from 2.95 % to 0.29 %; p < 0.0001).

Conclusions

An increased COVID-19 prevalence and mortality rate was recorded in SSc patients; moreover, the efficacy of vaccines in term of improved outcomes was less evident in SSc compared to Italian general population. This discrepancy might be explained by concomitant adverse prognostic factors: increased rate of non-responders to vaccine in SSc series, low percentage of individuals with four or more doses of vaccine, ongoing immunomodulating treatments, disease-related interstitial lung disease, and/or reduced preventive measures in the second half of pandemic. A careful monitoring of response to COVID-19 vaccines together with adequate preventive/therapeutical strategies are highly recommendable in the near course of pandemic in this frail patients' population.

Thyroid Autoimmunity and SARS-CoV-2 Infection

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological culprit of COronaVIrus Disease 19 (COVID-19), can enter the cells via the angiotensin-converting enzyme 2 (ACE2) receptor, which has been found in several tissues including in endocrine organs, such as the ovaries, testes, pancreas, and thyroid. Several thyroid disorders have been associated with SARS-CoV-2 infection [subacute thyroiditis (SAT), thyrotoxicosis, and non-thyroidal illness syndrome (NTIS)] and, in part, they are believed to be secondary to the local virus replication within the gland cells. However, as documented for other viruses, SARS-CoV-2 seems to interfere with several aspects of the immune system, inducing the synthesis of autoantibodies and triggering latent or new onset autoimmune disease (AID), including autoimmune thyroid disease (AITD), such as Hashimoto Thyroiditis (HT) and Graves' disease (GD). Several mechanisms have been hypothesized to explain this induction of autoimmunity by SARS-CoV-2 infection: the immune system hyper-stimulation, the molecular mimicry between the self-antigens of the host and the virus, neutrophils extracellular traps, and finally, the virus induced transcriptional changes in the immune genes; nonetheless, more evidence is needed especially from large, long-term cohort studies involving COVID-19 patients, to establish or reject this pathogenetic relationship.

Protection of inactivated vaccine against SARS-CoV-2 infections in patients with comorbidities: a prospective cohort study

Protection against severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection of inactivated vaccines is not well characterized in people with comorbidities, who are at high risk of severe infection. We compared the risk of SARS-CoV-2 infection after complete vaccination with Sinopharm/BBIBP in people with comorbidities (e.g., autoimmune diseases, cardiovascular disease, chronic lung disease, and diabetes) with healthy individuals using a Cox-proportional hazard model. In July-September 2021, a total of 10 548 people (comorbidities, 2143; healthy, 8405) receiving the complete primary series of vaccination with Sinopharm/BBIBP in Bangkok, Thailand were prospectively followed for SARS-CoV-2 infection through text messaging and telephone interviewing for 6 months. A total of 295 infections from 284 participants were found. HRs (95% CI) of individuals with any comorbidities did not increase (unadjusted, 1.02 (0.77-1.36), P = 0.89; adjusted, 1.04 (0.78-1.38), P = 0.81). HRs significantly increased in the subgroup of autoimmune diseases (unadjusted, 2.64 (1.09-6.38), P = 0.032; adjusted, 4.45 (1.83-10.83), P = 0.001) but not in cardiovascular disease, chronic lung disease, or diabetes. The protection against SARS-CoV-2 infection of the Sinopharm vaccine was similar in participants with any comorbidities vs. healthy individuals. However, the protection appeared lower in the subgroup of autoimmune diseases, which may reflect suboptimal immune responses among these people.

Clinico-epidemiological profile and outcome of infected health care workers during the three consecutive waves of COVID-19 pandemic: a longitudinal cohort study

Background

Health care workers are considered as high-risk population, who deal with many unknown, undiagnosed, and subclinical infectious diseases in their daily life. Currently, the COVID-19 pandemic posed as an add-on burden for these frontline workers in all aspects. Although, many adverse physical and mental effects of pandemic among health care workers (HCWs) were discussed worldwide, a long-term study for delayed complications needed to be explored.

Aim

The study evaluates and compares three waves of the pandemic in various aspects such as the incidence, prevalence, severity, risk factors, and variations in the pattern of COVID-19 infection, impact of vaccination, and post-infection complications among the HCWs.

Methodology

A longitudinal observational study was carried out over a period of 2 years and another 6 months for follow-up. The study included all HCWs who tested positive in any one wave of COVID-19 pandemic with any one of the confirmed COVID-19 test. Each COVID-19-affected HCW was followed up through telephone calls and direct interviews conducted at the study site. Admission details and other background details of the study population were collected from the hospital records.

Results

A total of 968 HCWs were COVID-19 positive in any of the three waves, and highest incidence (53.00%) was caused by the Omicron variant. High severity and hospitalization was observed in the first wave (no vaccination) and fully immunized personnel were found to be out of danger of being hospitalized during all succeeding waves (chi-square value: 87.04, p < 0.05). Predictors such as female gender, occupational exposure, and comorbid status were identified as possible risk factors for infection. A total of 70 HCWs reported with 104 complications, of which chronic diseases such as new onset of diabetes (n = 3), cardiovascular events (n = 8), worsening of preexisting comorbidities (n = 8), etc. were found out.

Conclusions

This study proves the benefit of being immunized rather than the risk of being infected. This study documents that immunization impacted complication and hospitalization rates of COVID-19 infection. This evidence may help in tackling vaccine hesitancy across the nations.

Prevalence & Impact of COVID-19 in Systemic Sclerosis Patients and Assessment of the Demographic & Clinical Features in Cases Associated with Worse Prognosis: Results of a Single Centre Registry

Background

Our knowledge of the COVID-19 infection impact on systemic sclerosis (SSc) is scarce. This study aimed to assess the prevalence of COVID-19 infection and to determine the predictive factors of worse outcomes and death in SSc patients.

Methods

In this cohort study all patients who attended our clinic between 20th February 2020 and 20th May 2021 were followed, and those with a history of COVID-19 infection completed the questionnaire. Results of para-clinical tests were extracted from the SSc database. The outcomes were classified as: alive vs. deceased and, mild vs. worse outcomes. Descriptive statistics and binary logistic regression models were applied.

Results

Of the total 192 SSc patients studied, COVID-19 affected 12.5%; 6% experienced mild disease, 7% were hospitalized and 3% died. The worse outcome was associated with: older age [95%CI: 1.00-1.08], smoking [95%CI: 2.632-33.094], diabetes [95%CI: 1.462-29.654], digital pitting scars (DPS) [95%CI: 1.589-21.409], diffusing capacity of the lungs for carbon monoxide [DLCO<70 [95%CI: 1.078-11.496], left ventricular ejection fraction (LVEF)<50% [95%CI: 1.080-38.651], systolic pulmonary artery pressure (sPAP)>40 mmHg [95%CI: 1.332-17.434], pericardial effusion (PE) [95%CI: 1.778-39.206], and tendon friction rub [95%CI: 1.091-9.387]. Death was associated with male gender [95%CI: 1.54-88.04], hypertension [95%CI: 1.093-2.155], digital ulcers (DU) [95%CI: 0.976-18.34], low forced vital capacity (FVC) [95%CI: 0.03-0.81], and joint flexion contracture (JFC) [95%CI: 1.226-84.402].

Conclusion

Risk factors for the worse outcome in COVID-19 infected SSc patients included, older age, smoking, diabetes, DPS, DLCO<70, LVEF<50%, sPAP>40 mmHg, PE, and TFR. Death was associated with the male gender, hypertension, DU, low FVC, and JFC.

COVID-19 infection with complicated fulminant myocarditis: a case report

Herein, we report the case of a young female patient who suffered from myositis and heart failure due to fulminant myocarditis induced by the 2019 coronavirus disease (COVID-19). After receiving intra-aortic balloon pump (IABP) and immunomodulatory treatment, her vital signs gradually stabilized and the IABP was removed. Cardiac and muscle magnetic resonance imaging confirmed extensive myocardial and skeletal muscle edema. Though it is not uncommon for COVID-19 infection to be complicated by myocarditis and myositis, such serious muscle injury warrants clinical vigilance.

Clinical course and prognostic factors of COVID-19 infection in patients with chronic inflammatory-rheumatic disease: A retrospective, case-control study

OBJECTIVES

This study aims to investigate the prognosis of novel coronavirus disease-2019 (COVID-19) infection in patients with the chronic inflammatory-rheumatic disease and evaluate the effects of immunosuppressive drugs on the prognosis, clinical characteristics, laboratory findings and hospitalization periods of the rheumatic patients with COVID-19 infection.

PATIENTS AND METHODS

Between April 2020 and March 2021, a total of 101 patients (30 males, 71 females; mean age: 48±14.4 years; range, 46 to 48 years) with the rheumatic diseases diagnosed with COVID-19 infection were included. A total of 102 age- and sex-matched patients (35 males, 67 females; mean age: 44±14.4 years; range, 28 to 44 years) who were diagnosed with COVID-19 infection and had no history of rheumatic disease in the same period were included as the control group. Data including demographic characteristics of the patients, presence of any symptoms of COVID-19 disease, laboratory data at the time of diagnosis, and treatments administered were collected.

RESULTS

The rate of hospitalization was higher in 38 (37%) patients without rheumatic diseases than in 31 (31%) patients with rheumatic diseases (p=0.324). The rate of lung infiltration on radiographic examination was higher in patients without rheumatic diseases (40% vs. 49%) (p=0.177). COVID-19 infection symptoms such as anosmia 45 (45%), ageusia 51 (50%), shortness of breath 45(45%), nausea 29 (29%), vomiting 16 (16%), diarrhea 25 (25%) and myalgia-arthralgia 81 (80%) were higher in patients with rheumatic diseases. In terms of laboratory values, lymphocyte count (p=0.031) was statistically higher in patients without rheumatic diseases. Hydroxychloroquine (35%), oseltamivir 10 (10%), antibiotics 27 (26%), acetylsalicylic acid 52 (51%), and supplementary oxygen 25 (25%) treatments which used to cure COVID 19 infection were administered more in patients without rheumatic diseases. The number of treatments administered was higher in patients without rheumatic diseases (p<0.001).

CONCLUSION

Patients with the chronic inflammatory-rheumatic disease have more symptoms due to COVID-19 infection, but the disease course is not poor and hospitalization rates are lower.

COVID-19 and Mixed Cryoglobulinemia Syndrome: Long-Term Survey Study on the Prevalence and Outcome, Vaccine Safety, and Immunogenicity

PURPOSE

Mixed cryoglobulinemia syndrome (MCs) is a rare immunoproliferative systemic disorder with cutaneous and multiple organ involvement. Our multicenter survey study aimed to investigate the prevalence and outcome of COVID-19 and the safety and immunogenicity of COVID-19 vaccines in a large MCs series.

METHODS

The survey included 430 unselected MCs patients (130 M, 300 F; mean age 70 ± 10.96 years) consecutively collected at 11 Italian referral centers. Disease classification, clinico-serological assessment, COVID-19 tests, and vaccination immunogenicity were carried out according to current methodologies.

RESULTS

A significantly higher prevalence of COVID-19 was found in MCs patients compared to Italian general population (11.9% vs 8.0%, p < 0.005), and the use of immunomodulators was associated to a higher risk to get infected (p = 0.0166). Moreover, higher mortality rate was recorded in MCs with COVID-19 compared to those without (p < 0.01). Patients' older age (≥ 60 years) correlated with worse COVID-19 outcomes. The 87% of patients underwent vaccination and 50% a booster dose. Of note, vaccine-related disease flares/worsening were significantly less frequent than those associated to COVID-19 (p = 0.0012). Impaired vaccination immunogenicity was observed in MCs patients compared to controls either after the first vaccination (p = 0.0039) and also after the booster dose (p = 0.05). Finally, some immunomodulators, namely, rituximab and glucocorticoids, hampered the vaccine-induced immunogenicity (p = 0.029).

CONCLUSIONS

The present survey revealed an increased prevalence and morbidity of COVID-19 in MCs patients, as well an impaired immunogenicity even after booster vaccination with high rate of no response. Therefore, MCs can be included among frail populations at high risk of infection and severe COVID-19 manifestations, suggesting the need of a close monitoring and specific preventive/therapeutical measures during the ongoing pandemic.

Evaluation of COVID-19 clinical features and outcomes in individuals with rheumatic disease

features and course of coronavirus disease 2019 (COVID-19) in individuals with rheumatic disease. Materials and Methods: This retrospective study was carried out at the Erciyes University rheumatology outpatient clinic from July 1 to August 1, 2021. The demographic and clinical data and summarized COVID-19 history, clinical course of COVID-19, fatigue, and pain levels of patients with rheumatic disease were obtained from our institutional electronic registration database and patient files. Results: Recruited participants were 106 individuals (83% female, %17 male) with rheumatic disease who had been confirmed by laboratory tests to have COVID-19 and recovered from the COVID-19 infection. Their mean age and body mass index (BMI) were 48.69±11.5 years and 29.89±6.76 kg/m2, respectively. Additionally, 21 (19.8%) had been hospitalized, and five (4.7%) had been admitted to the intensive care unit. The most common rheumatic diseases were axial spondyloarthritis (40; 37.7%) and rheumatoid arthritis (26 cases; 24.5%). Patients who received conventional synthetic disease-modifying drugs (csDMARDs) reportedly experienced more pain, fatigue, and headaches than those in the biologic agent and non-steroidal anti-inflammatory drug (NSAID) groups. Conclusion: Our study results reveal similar symptoms and hospitalization rates among patients with rheumatic disease who recovered from COVID-19 and received either csDMARDs, biologic agents, or NSAIDs. However, patients in the csDMARD group reported more pain, fatigue, and headache compared to the other groups.

Potential effects of hydroxysafflor yellow A on reducing pulmonary inflammation and fibrosis due to SARS-COV2

Cytokine storm is a condition that is characterized by a massive production of proinflammatory cytokines. Failure in balancing the up-regulation and down-regulation causes excessive production of proinflammatory cytokines in the fight against SARS-CoV2 virus infection, leading to lung damage and acute respiratory distress syndrome; in addition, high levels of IL-6 can activate the clotting pathways and vascular endothelial cells, which can inhibit blood circulation and heart muscle function and cause pulmonary, kidney, and liver fibrosis. Hydroxysafflor Yellow A (HSYA) is a compound that has been shown to reduce tissue lung damage through Toll-Like Receptor (TLR) 4, inhibits phosphorylation of the NF-κB pathway, and plays a role in balancing the up-regulation and down-regulation of inflammatory cytokines. This review of literature discusses the ability of HSYA to reduce inflammation that causes pulmonary cell and tissue damage. HSYA can inhibit the activation of the NF-κB signaling pathway and suppress the binding of the TGF-β1 promoter. This molecular mechanism can reduce lung damage by attenuating the inflammatory response by inhibiting the TLR 4-dependent pathways that can improve the condition of mice affected by pulmonary fibrosis, including inflammation that leads to vascular tissue repair. The molecular mechanism of HSYA can inhibit inflammatory mechanisms in lung injury, vascular tissue damage, and liver and kidney fibrosis. Therefore, this literature review can be used as a reference for in vivo research and clinical trials for further research on the ability to heal patients with cytokine storm that causes cardiovascular tissue damage and lung injury in patients infected with SARS-CoV-19.

COVID-19 in Patients with Rheumatic Disease Using Immunomodulatory Drugs: Imaging Findings and Predictors of Hospitalization

Introduction

SARS-CoV-2 causes more severe symptoms in most chronic diseases, and rheumatic disease is no exception. This study aims to investigate whether there is an association between the use of immunomodulatory medications, including conventional disease-modifying agents (csDMARDs), glucocorticoids, and biologic DMARDs, and outcomes such as hospitalization and lung involvement in patients with rheumatic disease with COVID-19.

Methods

We performed a cross-sectional study on 177 COVID-19 cases with rheumatologic diseases using immunomodulatory drugs as their regular treatment. All patients were evaluated regarding their initial chest computed tomography (CT) scan, COVID-19 symptoms, and comorbidities. We ran predictive models to find variables associated with chest CT-scan involvement and hospitalization status.

Results

CT findings showed lung involvement in 87 patients with chest CT-scan severity score (C-ss) of less than 8 in 59 (33%) and more than 8 in 28 (16%) of our patients. Of all patients, 76 (43%) were hospitalized. Hospitalized patients were significantly older and had more comorbidities (P = 0.02). On multivariate analysis, older age [odds ratio (OR) 1.90, 95% confidence interval (CI) 1.31-3.08] and comorbidity (OR 2.75, 95% CI 1.06-3.66) were significantly associated with higher odds of hospitalization (P = 0.03). On multivariate analysis, older age (OR 1.15, 95% CI 0.94-2.01), pulmonary diseases (OR 2.05, 95% CI 1.18-3.32), and treatment with csDMARDs (OR 1.88, 95% CI 0.37-1.93) were associated with higher C-ss (P = 0.039).

Conclusions

This study found that advanced age and comorbidities, similar to the general population, are risk factors for hospitalization in patients with COVID-19 with rheumatic disorders. Administration of csDMARDs, older age, and pulmonary disorders were linked to increased risk of COVID-19 pneumonia in these individuals.

SARS-CoV-2 induces "cytokine storm" hyperinflammatory responses in RA patients through pyroptosis

Background

The coronavirus disease (COVID-19) is a pandemic disease that threatens worldwide public health, and rheumatoid arthritis (RA) is the most common autoimmune disease. COVID-19 and RA are each strong risk factors for the other, but their molecular mechanisms are unclear. This study aims to investigate the biomarkers between COVID-19 and RA from the mechanism of pyroptosis and find effective disease-targeting drugs.

Methods

We obtained the common gene shared by COVID-19, RA (GSE55235), and pyroptosis using bioinformatics analysis and then did the principal component analysis(PCA). The Co-genes were evaluated by Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and ClueGO for functional enrichment, the protein-protein interaction (PPI) network was built by STRING, and the k-means machine learning algorithm was employed for cluster analysis. Modular analysis utilizing Cytoscape to identify hub genes, functional enrichment analysis with Metascape and GeneMANIA, and NetworkAnalyst for gene-drug prediction. Network pharmacology analysis was performed to identify target drug-related genes intersecting with COVID-19, RA, and pyroptosis to acquire Co-hub genes and construct transcription factor (TF)-hub genes and miRNA-hub genes networks by NetworkAnalyst. The Co-hub genes were validated using GSE55457 and GSE93272 to acquire the Key gene, and their efficacy was assessed using receiver operating curves (ROC); SPEED2 was then used to determine the upstream pathway. Immune cell infiltration was analyzed using CIBERSORT and validated by the HPA database. Molecular docking, molecular dynamics simulation, and molecular mechanics-generalized born surface area (MM-GBSA) were used to explore and validate drug-gene relationships through computer-aided drug design.

Results

COVID-19, RA, and pyroptosis-related genes were enriched in pyroptosis and pro-inflammatory pathways(the NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome complex, death-inducing signaling complex, regulation of interleukin production), natural immune pathways (Network map of SARS-CoV-2 signaling pathway, activation of NLRP3 inflammasome by SARS-CoV-2) and COVID-19-and RA-related cytokine storm pathways (IL, nuclear factor-kappa B (NF-κB), TNF signaling pathway and regulation of cytokine-mediated signaling). Of these, CASP1 is the most involved pathway and is closely related to minocycline. YY1, hsa-mir-429, and hsa-mir-34a-5p play an important role in the expression of CASP1. Monocytes are high-caspase-1-expressing sentinel cells. Minocycline can generate a highly stable state for biochemical activity by docking closely with the active region of caspase-1.

Conclusions

Caspase-1 is a common biomarker for COVID-19, RA, and pyroptosis, and it may be an important mediator of the excessive inflammatory response induced by SARS-CoV-2 in RA patients through pyroptosis. Minocycline may counteract cytokine storm inflammation in patients with COVID-19 combined with RA by inhibiting caspase-1 expression.

A case series of dermatomyositis following SARS-CoV-2 vaccination

BACKGROUND/OBJECTIVE

The most significant adverse events following SARS-CoV-2 vaccination are myocarditis and pericarditis. Myositis and dermatomyositis have been reported following SARS-CoV-2 infection, but vaccine-induced dermatomyositis (DM) has not been reported. Our case series aimed to characterize new onset dermatomyositis or disease-related flares following SARS-CoV-2 vaccination.

MATERIALS AND METHODS

A total of 53 patients from our institution with a new or pre-existing diagnosis of DM were recruited and consented. Phone interviews were conducted to obtain vaccination status and symptoms following vaccination. Electronic medical records were reviewed to extract age, sex, autoantibody profiles, comorbidities, immunomodulatory therapies, creatine kinase (CK) values, and SARS-CoV-2 vaccination dates from the provincial vaccination registry. For patients who reported disease flares, records were reviewed for the onset and nature of symptoms, extent of organ involvement and changes in immunomodulation.

RESULTS

On average, patients received 2.62 vaccine doses (range 1-3 doses). A total of 3 of 51 patients (5.88%) experienced dermatomyositis symptoms following vaccination. Two patients were newly diagnosed with dermatomyositis, one requiring hospitalization. Reported symptom onset following vaccination ranged from 1 to 30 days. Of note, all of these patients had normal CK values, even though there was muscle biopsy-confirmed myositis in one patient. Eight patients in the cohort (15.1%) had asymptomatic CK elevation (<1.5 X ULN).

CONCLUSION

New onset dermatomyositis or flare up of pre-existing dermatomyositis may be a rare complication in SARS-CoV-2 vaccination although no studies can support a true correlation. Several pathophysiologic mechanisms are proposed.

Dermatomyositis Flare After a COVID-19 Infection Successfully Treated with Rituximab: A Case Report and Literature Review

INTRODUCTION

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there has been a sudden surge in the incidence of several immune-mediated diseases, including dermatomyositis. The reported cases of COVID-19-related dermatomyositis are heterogeneous in their clinical presentation and implemented therapies.

CASE STUDY

We report a 23-year-old female patient diagnosed with a 3-year history of dermatomyositis. She has been well-controlled on maintenance therapy. However, 6 weeks after a mild COVID-19 infection, she developed a dermatomyositis flare. She improved only after aggressive treatment with pulse steroids, intravenous immunoglobulin, and rituximab.

CONCLUSION

Exacerbation of dermatomyositis can be encountered following a COVID-19 infection, even if the infection is mild. Aggressive therapy should be considered in such cases. The prognosis, however, is generally favorable.

Ivermectin role in COVID-19 treatment (IRICT): single-center, adaptive, randomized, double-blind, placebo-controlled, clinical trial

BACKGROUND

To investigate the efficacy and safety of ivermectin compared to hydroxychloroquine and placebo in hospitalized moderate to severe COVID-19 patients.

RESEARCH DESIGN AND METHODS

The study was an adaptive, randomized, double-blinded, controlled, single-center trial. The study was a series of 3-arm comparisons between two different investigational therapeutic agents (ivermectin and hydroxychloroquine) and a placebo. There was interim monitoring to allow early stopping for futility, efficacy, or safety.

RESULTS

Ivermectin decreased survival time from 29 to 18.3 days (HR, 9.8, 95%CI, 3.7-26.2), while it did not shorten the recovery time (HR, 1.02, 95%CI, 0.69-1.5). Subgroup analysis showed an association between ivermectin-related mortality and baseline oxygen saturation level. Moreover, stratified groups showed higher risk among patients on high flow O2. Hydroxychloroquine delayed recovery from 10.1 to 12.5 days (HR, 0.62, 95%CI, 0.4-0.95) and non-significantly decreased survival time from 29 to 26.8 days (HR, 1.47, 95%CI, 0.73-2.9). However, 3 months mortality rates were increased with hydroxychloroquine (RR, 2.05, 95%CI, 1.33-3.16). Neither ivermectin nor hydroxychloroquine increased adverse events and demonstrated safety profile compared to placebo.

CONCLUSIONS

The study recommends against using either ivermectin or hydroxychloroquine for treatment of COVID-19 in hospitalized patients with any degree of severity. Clinical trial registration: www.clinicaltrials.gov identifier is: NCT04746365.

Prevalence of Myositis-Specific Autoantibodies and Myositis-Associated Autoantibodies in COVID-19 Patients: A Pilot Study and Literature Review

Coronavirus disease 2019 (COVID-19) infection has been linked to numerous autoimmune manifestations. Neither the mechanism nor the etiology of this association has been fully explored or elucidated. Prior studies have detected myositis in patients with proven COVID-19 infection, suggesting a relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the development of myositis. Studies have reported elevated levels of autoimmune antibodies, including myositis-specific autoantibodies (MSAs) and myositis-associated autoantibodies (MAAs), in patients with COVID-19 infection, however the prevalence is not well documented. Our objective was to assess the prevalence of MSAs and MAAs in COVID-19 patients compared with unaffected subjects. Serum samples from 74 unvaccinated, polymerase chain reaction (PCR)-positive COVID-19 infected patients were compared with serum samples from 41 healthy, unaffected individuals. All serum samples were tested for MSA and MAA reactivity. Within the COVID-19-positive group, six (8.1%) patients exhibited MSA/MAA positivity, compared with only one (2.4%) individual from the control group. Although a higher prevalence of MSA/MAA positivity was observed within the COVID-19 infected group, the difference did not reach statistical significance (p=0.223). The autoantibodies detected in this study have a unique association with dermatomyositis and other inflammatory myopathies, and may play a role in COVID-19-associated myopathy. This article was previously presented as an abstract at Jacobs School of Medicine and Biomedical Sciences Research Day on June 3rd, 2022. 

Thyroid autoimmunity and SARS-CoV-2 infection: Report of a large Italian series

Since the beginning of the pandemic, numerous risk factors have been associated with SARS-CoV-2 infection and COVID-19 outcomes, such as older age, male sex, and the presence of comorbidities, such as hypertension, obesity, and diabetes. Preliminary data also suggest epidemiological association between SARS-CoV-2 infection and systemic autoimmune disease. For this reason, we investigated if patients affected by autoimmune thyroid disorders (AITD) are at risk of developing SARS-CoV-2 infection or COVID-19 disease.

From April to September 2020, we have conducted a telephone survey that included 515 consecutive unselected patients with known thyroid disorders, of which 350 were affected by AITD. All 11 definitive diagnosis of COVID-19 (def-sympt-COVID-19) belonged to the AITD group, while the rest 14 cases highly suspected for COVID-19 (suspect-sympt-COVID-19) were equally detected in both group (7 in AITD and 7 in not-AITD). The overall prevalence of symptomatic COVID-19 (def-sympt-COVID-19 + suspect-sympt-COVID-19), recorded in the 350 AITD population was statistically significant higher compared to that reported in the Italian and Tuscan general population at the same time period of the present survey (18/350 = 5.14% vs 516/100000 = 0.51% [p < 0.001; OR = 10.45, 95% CI 6.45–16.92] and vs 394/100000 = 0.39% [p < 0.001; OR = 13.70, 95% CI 8.44–22.25], respectively).

Therefore, our results suggest a higher prevalence of SARS-CoV-2 infection and COVID-19 disease in patients with AITD.

Identification and Characterization of Epithelial Cell-Derived Dense Bodies Produced upon Cytomegalovirus Infection

Dense bodies (DB) are complex, noninfectious particles produced during CMVinfection containing envelope and tegument proteins that may be ideal candidates as vaccines. Although DB were previously described in fibroblasts, no evidence of DB formation has been shown after propagating CMV in epithelial cells. In the present study, both fibroblast MRC-5 and epithelial ARPE-19 cells were used to study DB production during CMV infection. We demonstrate the formation of epithelial cell-derived DB, mostly located as cytoplasmic inclusions in the perinuclear area of the infected cell. DB were gradient-purified, and the nature of the viral particles was confirmed using CMV-specific immunelabeling. Epithelial cell-derived DB had higher density and more homogeneous size (200-300 nm) compared to fibroblast-derived DB (100-600 nm).In agreement with previous results characterizing DB from CMV-infected fibroblasts, the pp65 tegument protein was predominant in the epithelial cell-derived DB. Our results also suggest that epithelial cells had more CMV capsids in the cytoplasm and had spherical bodies compatible with nucleus condensation (pyknosis) in cells undergoing apoptosis that were not detected in MRC-5 infected cells at the tested time post-infection. Our results demonstrate the formation of DB in CMV-infected ARPE-19 epithelial cells that may be suitable candidate to develop a multiprotein vaccine with antigenic properties similar to that of the virions while not including the viral genome.

Systemic sclerosis in the time of COVID-19

The COVID-19 pandemic represents one of the biggest challenges of the 21st century. In addition to the general effect on society and health-care systems, patients with systemic sclerosis and their physicians face specific challenges related to the chronic nature of their disease, the involvement of multiple organs, and the use of immunosuppressive treatments. Data from registries and single centre cohorts indicate that the risk of contracting SARS-CoV-2 does not seem to increase substantially in people with systemic sclerosis; conversely, severe COVID-19 outcomes are seen more frequently in these patients than in the general population. Vaccination against SARS-CoV-2 is therefore highly recommended for patients with systemic sclerosis; however, no specific recommendations are available regarding the different vaccine platforms. Both patients and physicians should be aware that the effectiveness of vaccines might be reduced in patients taking immunosuppressive therapy, because antibody responses might be blunted, specifically in patients treated with rituximab and mycophenolate mofetil.

Bioinformatics analysis of potential common pathogenic mechanisms for COVID-19 infection and primary Sjogren’s syndrome

Background

Accumulating evidence has revealed that the prevalence of Coronavirus 2019 (COVID-19) was significantly higher in patients with primary Sjogren’s syndrome (pSS) compared to the general population. However, the mechanism remains incompletely elucidated. This study aimed to further investigate the molecular mechanisms underlying the development of this complication.

Methods

The gene expression profiles of COVID-19 (GSE157103) and pSS (GSE40611) were downloaded from the Gene Expression Omnibus (GEO) database. After identifying the common differentially expressed genes (DEGs) for pSS and COVID-19, functional annotation, protein-protein interaction (PPI) network, module construction and hub gene identification were performed. Finally, we constructed transcription factor (TF)-gene regulatory network and TF-miRNA regulatory network for hub genes.

Results

A total of 40 common DEGs were selected for subsequent analyses. Functional analyses showed that cellular components and metabolic pathways collectively participated in the development and progression of pSS and COVID-19. Finally, 12 significant hub genes were identified using the cytoHubba plugin, including CMPK2, TYMS, RRM2, HERC5, IFI44L, IFI44, IFIT2, IFIT1, IFIT3, MX1, CDCA2 and TOP2A, which had preferable values as diagnostic markers for COVID-19 and pSS.

Conclusions

Our study reveals common pathogenesis of pSS and COVID-19. These common pathways and pivotal genes may provide new ideas for further mechanistic studies.

Absent or suboptimal response to booster dose of COVID-19 vaccine in patients with autoimmune systemic diseases

Autoimmune systemic diseases (ASD) show impaired immunogenicity to COVID-19 vaccines. Our prospective observational multicenter study aimed at evaluating the seroconversion elicited by COVID-19 vaccine over the entire vaccination cycle including the booster dose.

Among 478 unselected ASD patients originally evaluated at the end of the first vaccination cycle (time 1), 344 individuals were re-evaluated after a 6-month period (time 2), and 244 after the booster vaccine dose (time 3). The immunogenicity of mRNA COVID-19 vaccines (BNT162b2 and mRNA-1273) was assessed by measuring serum IgG-neutralizing antibody (NAb) on samples obtained at the three time points in both patients and 502 age-matched controls.

In the 244 ASD group that received booster vaccine and monitored over the entire follow-up, the mean serum NAb levels (time 1, 2, and 3: 696.8 ± 52.68, 370.8 ± 41.92, and 1527 ± 74.16SD BAU/mL, respectively; p < 0.0001) were constantly lower compared to controls (p < 0.0001), but they significantly increased after the booster dose compared to the first two measurements (p < 0.0001). The percentage of patients with absent/suboptimal response to vaccine significantly decreased after the booster dose compared to the first and second evaluations (time 1, 2, and 3: from 28.2% to 46.3%, and to 7.8%, respectively; p < 0.0001). Of note, the percentage of patients with absent/suboptimal response after the booster dose was significantly higher compared to controls (19/244, 7.8% vs 1/502, 0.2%; p < 0.0001). Similarly, treatment with immune-modifiers increased the percentage of patients exhibiting absent/suboptimal response (16/122, 13.1% vs 3/122, 2.46%; p = 0.0031). Overall, the above findings indicate the usefulness of booster vaccine administration in ASD patients. Moreover, the persistence of a significantly higher percentage of individuals without effective seroconversion (7.8%), even after the booster dose, warrants for careful monitoring of NAb levels in all ASD patients to identify those with increased risk of infection. In this particularly frail patients’ setting, tailored vaccination and/or therapeutic strategy are highly advisable.

Prevalence and death rate of COVID-19 in systemic autoimmune diseases in the first three pandemic waves. Relationship to disease subgroups and ongoing therapies

OBJECTIVE

Autoimmune systemic diseases (ASD) represent a predisposing condition to COVID-19. Our prospective, observational multicenter telephone survey study aimed to investigate the prevalence, prognostic factors, and outcomes of COVID-19 in Italian ASD patients.

METHOD

The study included 3,918 ASD pts (815 M, 3103 F; mean age 59±12SD years) consecutively recruited between March 2020 and May 2021 at the 36 referral centers of COVID-19 & ASD Italian Study Group. The possible development of COVID-19 was recorded by means of a telephone survey using a standardized symptom assessment questionnaire.

RESULTS

ASD patients showed a significantly higher prevalence of COVID-19 (8.37% vs 6.49%; p<0.0001) but a death rate statistically comparable to the Italian general population (3.65% vs 2.95%). Among the 328 ASD patients developing COVID-19, 17% needed hospitalization, while mild-moderate manifestations were observed in 83% of cases. Moreover, 12/57 hospitalized patients died due to severe interstitial pneumonia and/or cardiovascular events; systemic sclerosis (SSc) patients showed a significantly higher COVID-19-related death rate compared to the general population (6.29% vs 2.95%; p=0.018). Major adverse prognostic factors to develop COVID-19 were: older age, male gender, SSc, pre-existing ASD-related interstitial lung involvement, and long-term steroid treatment. Of note, patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) showed a significantly lower prevalence of COVID-19 compared to those without (3.58% vs 46.99%; p=0.000), as well as the SSc patients treated with low dose aspirin (with 5.57% vs without 27.84%; p=0.000).

CONCLUSION

During the first three pandemic waves, ASD patients showed a death rate comparable to the general population despite the significantly higher prevalence of COVID-19. A significantly increased COVID-19-related mortality was recorded in only SSc patients' subgroup, possibly favored by preexisting lung fibrosis. Moreover, ongoing long-term treatment with csDMARDs in ASD might usefully contribute to the generally positive outcomes of this frail patients' population.

Frequency, characteristics and outcome of corona virus disease 2019 (COVID-19) infection in Iranian patients with rheumatic diseases

Aim of the work

To investigate the frequency, clinical characteristics and outcome of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in rheumatic diseases patients.

Patients and methods

One thousand patients with rheumatic diseases including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (SpA), systemic sclerosis (SSc), Sjögren's syndrome (SS), Behçets disease (BD), vasculitis, idiopathic inflammatory myositis (IIM), relapsing polychondritis, sarcoidosis and antiphospholipid syndrome (APS) were studied. The following data were collected: age, sex, disease diagnosis, rheumatic disease medication. Rheumatic diseases patients were divided into two groups of infected and non-infected patients with COVID-19 and collected data were compared.

Results

The 1000 patients mean age was 43.4 ± 13 years and 84.1% were females. The main diagnosis was RA (37.1%), followed by SLE (23.8%), SpA (13.4%), SSc (12.4%), vasculitis, BD and rhupus in 2.4%, 2.3% and 2.2% respectively, SS and SSc in 0.7% each. Most patients were taking glucocorticoids (78.4%). A large majority of patients were taking at least one of the cDMARDs. 16.1% were taking biologic therapy. 221 rheumatic diseases patients with COVID-19 were identified. Of these, 38 patients (17.2%) were hospitalized and 9 patients (4.1%) died. No significant difference was observed for compared variables in patients with and without COVID-19 except for prednisolone >20 mg/d (0.64% vs 2.26%; p = 0.048).

Conclusion

Most rheumatic diseases do not seem to be a risk factor for developing COVID-19 infection and despite immunosuppressive therapies, there is no poorer outcome. Only, patients using prednisolone >20 mg/d are at higher risk of developing COVID-19 infection.

Clinical course, chest computed tomography severity score and outcome of coronavirus disease 2019 (COVID-19) in patients with rheumatic diseases

Aim of the work

To assess the clinical manifestations, imaging findings and outcomes of corona virus disease 2019 (COVID-19) in patients with rheumatic diseases.

Patients and methods

In a three-center study, patients with rheumatic diseases who developed COVID-19 were included. Patients were classified into two groups, i) inflammatory arthritis including rheumatoid arthritis (RA), spondyloarthritis (SpA) and undifferentiated arthritis, ii) connective tissue diseases (CTDs) including systemic lupus erythematosus (SLE), vasculitis and others. COVID-19 outcomes were assessed based on chest computed tomography severity score (CT-ss), the level of care, the number of patients who died and flare of underlying rheumatic disease.

Results

One hundred ninety-six patients with a mean age of 47.9 ± 15.1 years, 73.5% female, were included. Underlying rheumatic diseases were RA (57.7%), SLE and other CTDs (17.9%), SpA (11.2%), vasculitis (11.2%) and undifferentiated arthritis (2%). Myalgia, malaise and fever were the most common clinical manifestations of COVID-19. Pneumonia on computerized tomography (CT), hospitalization, admission in intensive care unit and need to mechanical ventilation were observed in 75.5, 37.2%, 10.7% and 6.6% of patients, respectively. Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids, diabetes and underlying pulmonary disease were predictors of moderate to severe pneumonia and hospitalization. Fifteen (7.6%) patients died. Flare of underlying rheumatic disease occurred in 16.3% of patients. Flare of disease in patients with CTDs was significantly more than other rheumatic diseases.

Conclusions

In rheumatic patients, treatment with NSAIDs or prednisolone, diabetes and pulmonary disease are risk factors of moderate to high CT-ss and hospitalization during COVID-19.

Clinical outcomes of patients with COVID-19 and inflammatory rheumatic diseases receiving biological/targeted therapy

BACKGROUND

Anti-cytokine treatments are used in the treatment of severe COVID-19. Other studies have shown statistical significance with TNF inhibitors but not with other biological/targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARD).

OBJECTIVES

Compare the rate of severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) infection and the course and incidence of COVID-19 infection in patients who received b/tsDMARD with control patients.

DESIGN

Analytical cross-sectional SETTINGS: Tertiary care hospital PATIENTS AND METHODS: All patients who applied to the rheumatology outpatient clinic between June 2020-March 2021 and received b/tsDMARD were included in the study. All patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis who applied to the rheumatology outpatient clinic in the three months before March 2021 and did not receive b/tsDMARD were included as the control group. History of COVID-19 infection and treatments were recorded. Multivariate analysis was performed to assess factors associated with use of tumor necrosis factor (TNF) inhibitors and differences between specific biologic drugs.

MAIN OUTCOME MEASURES

Rate of COVID-19 disease among patients using biological/targeted synthetic therapy and non-biological/targeted synthetic therapy. COVID-19 clinical outcomes (hospitalization, intensive care admission, mechanical ventilation and death).

SAMPLE SIZE

533 in total; 341 received b/tsDMARD, 212 in the control group that did not receive b/tsDMARD.

RESULTS

One hundred patients (18%) had been infected with SARS-COV-2. The difference in SARS-COV-2 infection between b/tsDMARD and the control was statistically significant (13, 2% vs. 25, 9%, respectively) (P<.001). The hospital stays were longer in the controls (P<.001). Multinomial regression analysis revealed that COVID-19 negative patients were more likely to use tumor necrosis factor (TNF) inhibitors (OR: 2, 911; 95% CI: 1.727-4.908; P<.001) compared to COVID-19 positive participants. Multinomial logistic regression analysis indicated that hospitalized patients were more likely to use TNF inhibitors (OR: 11, 006; 95% CI: 3.447-35.138; P<.001) and there was no significant difference between b/tsDMARDs other than TNF inhibitors in frequency of hospitalization.

CONCLUSIONS

Patients who were medicated with b/tsDMARD were less likely to be infected with COVID-19 and be hospitalized due to the infection. We have found that this effect was particularly dependent on the use of TNF inhibitors.

LIMITATIONS

Conducted in a single center and unable to provide a homogeneous study population.

CONFLICT OF INTEREST

None.

Clinical course of idiopathic inflammatory myopathies in COVID-19 pandemic: a single-center experience

Aim: To evaluate the clinical course of idiopathic inflammatory myopathy (IIM) patients in COVID-19 pandemic, and to assess the COVID-19 outcomes in infected IIM patients. Materials & methods: In this study, 39 patients were evaluated retrospectively. Myositis disease activity, myositis damage index, depression, fatigue, active medical treatment, drug compliance and SARS-CoV-2 PCR test results in COVID-19 pandemic were collected. Results: Fourteen of these patients (35%) were detected to have a positive SARS-CoV-2 PCR test. The demographic and clinical characteristics, active medical treatment, disease activity, depression and fatigue of the patients who had undergone or not SARS-CoV-2 were similar. Conclusion: Our results have shown that although prevalence of COVID-19 seems to be increased in IIM patients under immunosuppressive treatment, hospitalization rates were lower and no intensive care unit admissions or deaths were observed.

Mortality related to COVID-19 in patients with rheumatic and musculoskeletal diseases, first wave of the outbreak: a single-center study

Objectives

The aim of this study was to assess the cause-specific mortality rate related to COVID-19 (CMR) in patients with rheumatic and musculoskeletal diseases (RMDs) and COVID-19 and to analyze the role of the different RMDs in their mortality risk.

Methods

An observational longitudinal study was conducted during the first pandemic wave in our center. Patients with the diagnosis of RMDs and COVID-19 were included. Main outcome is the death related to COVID-19. Independent variable - type of RMDs: autoimmune rheumatic diseases (ARD), such as chronic inflammatory arthritis (CIA) and connective tissue diseases (CTD) and non-autoimmune Rheumatic Diseases (non-ARD). Survival techniques were used to estimate the CMR per 1000 patients-month with a 95% confidence interval (CI), and Cox multivariate regression analysis was run to examine the effect of ARD compared to non-ARD on mortality risk adjusted by confounders. Results were expressed by Hazard Ratio (HR) and CI.

Results

Overall, 405 patients were included (642.5 patients-month). During the study period, 44 (10.86%) deaths were recorded. CMR was 68.48 (50.96-92.01). After adjusting for confounders, HR of mortality in ARD compared to non-ARD did not achieve statistical significance [HR: 1.15 (0.64-2.07)], neither CTD versus CIA nor CTD versus non-ARD. Age and certain comorbidities which are being diagnosed in March compared to April or May [HR: 2.43 (1.1-5.55)] increased the mortality risk. Glucocorticoids and disease-modifying antirheumatic drugs (DMARDs) dropped from the final model.

Conclusion

In patients with RMDs and COVID-19, CMR was 6.8% patients-month. This study shows that mortality risk is higher in males, older patients, and similar between CTD, CIA, and non-ARD. COVID-19 management improved after the first month of pandemic.

Plain Language Summaries

Mortality related to the outbreak of COVID-19 in patients with rheumatic and musculoskeletal diseases Why was this study done? - To report the COVID-19-specific mortality rate in patients with a variety of RMDs during the first pandemic peak in a tertiary hospital in Madrid and to analyze the role of specific types of ARD and other possible factors in the risk of death related to COVID-19. What did the researchers do? - We performed a retrospective observational study during the first wave of the COVID-19 pandemic in Madrid, Spain. What did the researchers find? - In this study, neither the different diagnoses of RMDs, including CIA, CTD, or non-ARD disease or its treatment were not implicated as a potential risk of death related to COVID-19- In consonance with other studies, RMDs patients and COVID-19, older age, male sex, and certain comorbidities implied more mortality risk- Our data reflect COVID-19 severity in a particular context, time, and population. In times of the absence of COVID-19 vaccine, healthcare, social, and political measures taken to contain the coronavirus outbreak have worked properly. What do the findings mean? - The presence of comorbidities in RMDs patients represents a greater risk than the different types of RMDs themselves, in the development of COVID-19 fatal outcome. It is important to integrate the control of comorbidities in the daily management.

Evaluation of favipiravir in the treatment of COVID-19 based on the real-world

BACKGROUND

The role of favipiravir (FVP) as a COVID-19 treatment is recognized but not fully elucidated. We aimed to evaluate whether FVP has definite clinical efficacy and safety in the treatment of COVID-19.

METHODS

International and Chinese databases were searched for randomized controlled clinical trials evaluating FVP for the treatment of COVID-19. A meta-analysis was performed and published literature was synthesized to evaluate the corresponding therapeutic effects.

RESULTS

We included 13 studies (1430 patients in total). Meta-analysis showed that patients with mild-to-moderate disease treated with FVP had a significantly higher viral clearance rate than those in the control group 10 and 14 days after initiation of treatment [RR: 1.13 (95% CI: 1.00, 1.28), P = 0.04; I² = 39% for day 10 and RR: 1.16 (95% CI: 1.04, 1.30), P = 0.008; I² = 38% for day 14] and a significantly shorter hospital stay [MD: -1.52 (95% CI: -2.82, -0.23), P = 0.02; I² = 0%].

CONCLUSIONS

FVP significantly promotes viral clearance and reduces the hospitalization duration in mild-to-moderate COVID-19 patients, which can reduce the risk of severe disease outcomes in patients. However, more importantly, the results showed no benefit of FVP in severe patients, and caution should be taken regarding the treatment options of FVP in severe patients.

Spontaneous Pneumo-Mediastinum in a Post-COVID-19 Patient with Systemic Sclerosis

Pulmonary involvement is the most common cause of death among patients with systemic sclerosis (SSc). The current coronavirus disease 2019 (COVID-19) is particularly problematic to manage in SSc patients since they may experience a more severe evolution of COVID-19 due to the pre-existent interstitial lung disease (ILD) and the administration of immunosuppressive treatments. In addition, the remarkable radiological similarities between SSc-ILD and COVID-19 complicate the differential diagnosis between these two entities. Herein, we present the first case of spontaneous pneumo-mediastinum in a post-COVID-19 patient with SSc. In our patient, both smoking and pulmonary fibrosis could lead to cyst formation, which possibly spontaneously broke and caused pneumo-mediastinum. Moreover, megaesophagus perforation due to the smooth muscle atrophy, replacement with fibrosis, and achalasia may extend into the mediastinum or pleural space and has also been described as a rare case of spontaneous pneumo-pericardium. Finally, spontaneous pneumo-mediastinum and pneumothorax have been recently reported as an established complication of severe COVID-19 pneumonia and among COVID-19 long-term complication. This case report underlines that the worsening of respiratory symptoms in SSc patients, especially when recovered from COVID-19, requires further investigations for ruling out other tentative diagnoses besides the evolution of the SSc-ILD.

Risk factors for COVID-19 among persons with substance use disorder (PWSUD) with hospital visits - United States, April 2020-December 2020

INTRODUCTION

Sociodemographic factors and chronic conditions associated with coronavirus disease 2019 (COVID-19) among persons with substance use disorder (PWSUD) are not well understood. We identified risk factors associated with COVID-19 among PWSUD with hospital visits.

METHODS

Using the Premier Healthcare Database Special COVID-19 Release, we conducted a case-control study using ICD-10-CM codes to identify PWSUD aged 12 years and older with hospital visits for any reason during April-December 2020. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) to identify factors associated with COVID-19 diagnosis among PWSUD (age, sex, race/ethnicity, U.S. Census Region, urban/rural classification, insurance payor type, comorbidities, and substance use disorder [SUD] type), and then stratified by SUD type.

RESULTS

From April-December 2020, 18,298 (1.3%) of 1,429,154 persons with SUD in the database had a COVID-19 diagnosis. Among PWSUD, opioid use disorder (OUD; aOR = 1.24, 95% CI = 1.18-1.32), alcohol use disorder (AUD; aOR = 1.16, 95% CI = 1.11-1.22), cocaine or other stimulant use disorder (COUD; aOR = 1.28, 95% CI = 1.22-1.34), and multiple SUDs (aOR = 1.20, 95% CI = 1.15-1.26) were associated with higher odds of COVID-19, as were comorbidities such as chronic lower respiratory disease (aOR = 1.32, 95% CI = 1.26-1.37), chronic hepatitis (aOR = 1.45, 95% CI = 1.34-1.57), and diabetes (aOR = 1.78, 95% CI = 1.71-1.86).

CONCLUSIONS

Among a sample of PWSUD, OUD, AUD, COUD, multiple SUDs, and associated comorbidities were associated with COVID-19 diagnosis. Integration of COVID-related care, care of other comorbidities, and SUD treatment may benefit PWSUD. Future studies are needed to better understand COVID-19 prevention in this population and to reduce disparities among subpopulations at increased risk.

Adverse Reactions to Anti-SARS-CoV-2 Vaccine: A Prospective Cohort Study Based on an Active Surveillance System

To date, Coronavirus disease (COVID-19) has caused high morbidity and mortality worldwide. To counteract the pandemic scenario, several vaccines against the etiological factor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were developed and tested. At the end of December 2020, BNT162b2 (Comirnaty, Pfizer-BioNTech) was the first and only authorized vaccine in Italy for selected categories, such as healthcare workers, fragile patients and people aged over 80 years old. To master our knowledge about BNT162b2 adverse reactions (ARs), an active surveillance system based on instant messaging was realized for voluntary participants who had been vaccinated at COVID-19 Vaccination Center of the Palermo University Hospital. Overall, 293 vaccinated persons were included in this study, which were more frequently healthcare workers (n = 207, 70.6% with a median age of 36 years, IQR = 29−55) followed by health professional students (n = 31, 10.6% with a median age of 27 years, IQR = 25−29), reporting 82.6% of at least one local or systemic AR. In details, the frequency of at least one local or systemic AR after the second dose of Comirnaty (n = 235, 80.2%) was statistically significant with higher value in comparison to the first one (n = 149, 50.9%; p < 0.001). However, local pain, swelling, joint pain and muscular pain after the second dose were the symptom causing a statistically significant working limitation. The youngest persons showed a higher risk to have either local or systemic ARs (aOR = 7.5, CI 95% = 2.9−18.9), while females had a higher risk of having systemic ARs (aOR = 1.8, CI 95% = 1.1−3.0). Despite the small sample examined, this active surveillance system by instant messaging seems to detect a higher ARs prevalence with respect to data obtained by the passive surveillance. Further studies could be required in order to optimize this clinical monitoring that could be considered an efficient and timely active surveillance.

Severity and mortality of COVID-19 in patients with systemic sclerosis: a Brazilian multicenter study

Introduction

COVID-19 may be associated with greater severity and mortality in patients with systemic sclerosis (SSc). The present study aimed to evaluate the prevalence, severity and mortality of COVID-19 in a Brazilian cohort of SSc patients.

Methods

This multicenter, retrospective, observational study included 1,042 SSc patients followed in four centers of São Paulo between March 2020 and June 2021. Diagnosis of COVID-19 was established by proper positive RT-PCR testing or by highly suspicious infection. Patients were grouped into mild (outpatient setting treatment and no need for oxygen support) and moderate-to-severe (hospitalization and/or need for oxygen support) COVID-19.

Results

Of the 1,042 SSc patients, 118 patients were diagnosed with COVID-19. Interstitial lung disease (SSc-ILD) was present in 65.6% of the total cohort and in 46.3% of SSc patients with COVID-19. There were 78 (66.1%) cases of mild COVID-19, and 40 (33.9%) cases of moderate-to-severe disease, with 6 (5.1%) deaths. By univariate analysis, pulmonary arterial hypertension (OR 9.50, p=0.006), SSc-ILD (OR 3.90, p=0.007), FVC <80% (OR 2.90, p=0.01), cardiac involvement (OR 5.53, p=0.003), and use of rituximab (OR 3.92, p=0.039), but not age, gender, comorbidities or use of corticosteroids, were predictors of worse outcome for COVID-19. Using multivariate analysis, only SSc-ILD was significantly associated to a higher risk of moderate-to-severe COVID-19 (OR 2.73, 95% CI 1.12-6.69, p=0.02). Forty percent of the patients remained with symptoms after presenting COVID-19, predominantly dyspnea and/or cough (17%).

Conclusion

In this cohort of patients with SSc, those with SSc-ILD were highly impacted by COVID-19, with a higher risk of moderate-to-severe COVID-19 infection and death.

COVID GEAS: COVID-19 National Survey in Patients With Systemic Autoimmune Diseases

Objectives

COVID-19 outcomes in population with systemic autoimmune diseases (SAD) remain poorly understood. The aim was to examine demographic and clinical factors associated with COVID-19 infection in people with rheumatic disease.

Methods

Two phases cross-sectional survey of individuals with rheumatic disease in April 2020 and October 2020. COVID infection, severity of disease, age, sex, smoking status, underlying rheumatic disease diagnosis, comorbidities and rheumatic disease medications taken immediately prior to infection were analyzed.

Results

A total of 1,529 individuals with autoimmunity disease diagnosis were included. Out of 50 positive patients, 21 required telephone medical assistance, 16 received assessment by primary care physician, 9 were evaluated in Emergency Department and 4 patient required hospitalization. Multivariate analysis was performed without obtaining differences in any of the systemic autoimmune diseases. Regarding the treatments, significant differences were found (p 0.011) in the treatment with anti-TNF-alpha agents with OR 3.422 (1.322–8.858) and a trend to significance (p 0.094) was observed in patients receiving mycophenolate treatment [OR 2.016 (0.996–4-081)].

Conclusions

Anti-TNF-alpha treatment was associated with more than 3-fold risk of suffering from SARS-CoV-2 infection, although in all cases infection was mild. Cumulative incidence in patients with SAD was up to 5 times higher than general population but with great differences between autoimmune diseases.

Novel Immune-Related Genetic Expression for Primary Sjögren's Syndrome

Objective: To identify novel immune-related genes expressed in primary Sjögren's syndrome (pSS).

Methods: Gene expression profiles were obtained from the Gene Expression Omnibus (GEO) database, and differentially expressed genes (DEGs) were screened. The differences in immune cell proportion between normal and diseased tissues were compared, weighted gene co-expression network analysis was conducted to identify key modules, followed by a protein–protein interaction (PPI) network generation and enrichment analysis. The feature genes were screened and verified using the GEO datasets and quantitative real-time PCR (RT-qPCR).

Results: A total of 345 DEGs were identified, and the proportions of gamma delta T cells, memory B cells, regulatory T cells (Tregs), and activated dendritic cells differed significantly between the control and pSS groups. The turquoise module indicated the highest correlation with pSS, and 252 key genes were identified. The PPI network of key genes showed that RPL9, RBX1, and RPL31 had a relatively higher degree. In addition, the key genes were mainly enriched in coronavirus disease-COVID-2019, hepatitis C, and influenza A. Fourteen feature genes were obtained using the support vector machine model, and two subtypes were identified. The genes in the two subtypes were mainly enriched in the JAK-STAT, p53, and toll-like receptor signaling pathways. The majority of the feature genes were upregulated in the pSS group, verified using the GEO datasets and RT-qPCR analysis.

Conclusions: Memory B cells, gamma delta T cells, Tregs, activated dendritic cells, RPL9, RBX1, RPL31, and the feature genes possible play vital roles in the development of pSS.

COVID-19 Disease and Dermatomyositis: A Mini-Review

The pandemic of coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 has caused a large number of deaths, and there is still no effective treatment. COVID-19 can induce a systemic inflammatory response, and its clinical manifestations are diverse. Recently, it has been reported that COVID-19 patients may develop myositis and interstitial pulmonary disease similar to dermatomyositis (DM). This condition is similar to the rapidly progressive interstitial lung disease associated with MDA5+ DM that has a poor prognosis and high mortality, and this poses a challenge for an early identification. Suppression of the immune system can protect COVID-19 patients by preventing the production of inflammatory cytokines. This article attempts to explore the possibility of a relationship between COVID-19 and DM in terms of the potential pathogenesis and clinical features and to analyze the therapeutic effect of the immunosuppressive drugs that are commonly used for the treatment of both DM and COVID-19.

The clinical implications of serum ferritin in Kawasaki disease: a helpful biomarker for evaluating therapeutic responsiveness, coronary artery involvement and the tendency of macrophage activation syndrome

INTRODUCTION

Serum ferritin (SF) is an acute-phase reactant in inflammatory diseases. Our aim was to analyze the clinical implications of SF in Kawasaki disease (KD).

METHODS

244 KD children were divided into 6 subgroups. SF, inflammatory mediators and blood cell counts were detected.

RESULTS

(1) SF dramatically increased in the acute phase of KD and maintained after IVIG therapy; (2) SF increased in IVIG-nonresponsive KD patients (AUC = 0.705; sensitivity: 57.10%; specificity: 82.90%); SF positively correlated with the internal diameter of the coronary artery (AUC = 0.603; sensitivity: 92.30%; specificity: 37.70%); (3) SF increased in 4 patients with the macrophage activation syndrome (MAS)/MAS tendency (979.03 ±474.19 μg/l).

CONCLUSIONS

SF is implied to be a helpful biomarker for forecasting IVIG-nonresponsive KD, coronary artery abnormalities (CAAs) and MAS tendency.

COVID-19 Mortality in Patients with Rheumatic Diseases: A Real Concern

BACKGROUND

Coronavirus disease 2019 (COVID 19) is a worldwide pandemic that has devastated the world in a way that has not been witnessed since the Spanish Flu in 1918. In this study, we aim to investigate the outcomes of patients with rheumatic diseases infected with COVID-19 in Oman.

METHODS

A multi-center retrospective cohort study included patients with underlying rheumatological conditions and COVID-19 infection. Data were collected through the electronic record system and by interviewing the patients through a standard questionnaire.

RESULTS

113 patients with different rheumatic diseases were included with the following rheumatological diagnoses: rheumatoid arthritis (40.7%), systemic lupus erythematosus (23.1%), psoriatic arthritis (8%), Behcet's disease (7%), ankylosing spondylitis (6.2%), other vasculitides, including Kawasaki disease (4.4%), and other diagnoses (10.6%). The mean (SD) age of patients was 43 (14) years, and 82.3% were female. The diagnosis of COVID-19 was confirmed by PCR test in 84.1% of the patients. The most common symptoms at the time of presentation were fever (86%), cough (81%), headache (65%), and myalgia (60%). Hospitalization due to COVID-19 infection was reported in 24.1% of the patients, and 52.2% of these patients had received some form of treatment. In this cohort, the intake of immunosuppressive and immunomodulating medications was reported in 91.1% of the patients. During the COVID-19 infection, 68% of the patients continued taking their medications. Comorbidities were present in 39.8% of the patients. Pregnancy was reported in 2% of the patients. The 30 days mortality rate was found to be 3.5%. Diabetes, obesity, and interstitial lung diseases (ILD) were the strongest risk factor for mortality (p-value 0.000, 0.000, and 0.001, respectively). Rituximab was given in 3.8% of the patients, and it was significantly associated with increased mortality among the patients (p-value <0.001).

CONCLUSION

COVID-19 infection in patients with rheumatic diseases have an increased mortality rate in comparison to the general population, with diabetes, morbid obesity, chronic kidney diseases, interstitial lung disease, cardiovascular disease, obstructive lung disease, and liver diseases as comorbidities being the most severe risk factors associated with death. Greater care should be provided to this population, including the prompt need for vaccination.

Vitamin D deficiency: concern for rheumatoid arthritis and COVID-19?

Vitamin D is an immunomodulatory hormone with an established role in calcium and phosphate metabolism and skeletal mineralization. Evidence showing its immunological benefits by regulating essential components of the innate and adaptive immune system is prevalent. Vitamin D deficiency is reported worldwide and is thereby found to be associated with various immune-related diseases. Rheumatoid Arthritis and COVID-19 are two such diseases, sharing a similar hyperinflammatory response. Various studies have found an association of lower Vitamin D levels to be associated with both these diseases. However, contrasting data is also reported. We review here the available scientific data on risk factor association and supplementation benefits of Vitamin D in Rheumatoid Arthritis and COVID-19, intending to critically evaluate the literature.

Axial spondyloarthritis may protect against poor outcomes in COVID-19: propensity score matched analysis of 9766 patients from a nationwide multi-centric research network

Introduction

The outcomes of COVID-19 in patients with axial spondyloarthritis (ax-SpA) have not been explored in detail. Tumour necrosis factor inhibitors (TNFi) are commonly used for ax-SpA patients, and how they influence outcomes may have implications on COVID-19 management.

Methods

A nationwide multi-centric research network was queried for patients with ax-SpA, including ankylosing spondylitis (AS) and non-radiographic SpA (nr-SpA) who had developed COVID-19. An equal number of propensity score(PS) matched controls were extracted from the database amongst patients with COVID-19 who did not have any inflammatory arthritis. Outcomes included mortality and others including hospitalization, intensive care unit, ventilation, acute kidney injury (AKI), renal replacement therapy, acute respiratory distress syndrome, cerebral infarction, venous thromboembolism (VTE), and sepsis.

Results

We identified 9766 patients with ax-SpA (924 AS and 8842 nr-SpA) and 691,862 without SpA who had COVID-19. In the unmatched comparison, patients with ax-SpA had higher risk ratios (RR) for all outcomes. After matching for demographics and comorbidities, patients with ax-SpA had lower RR for mortality [RR: 0.707 (95% CI: 0.598–0.836), p < 0.0001], severe COVID-19 [RR: 0.791 (0.69–0.906), p = 0.0007], hospitalization [RR: 0.872 (0.826–0.921), p < 0.0001], and AKI [RR: 0.902 (0.816–0.997), p = 0.044]. Only the risk of VTE was higher in ax-SpA patients [RR: 1.219 (1.037–1.433), p = 0.016]. Amongst the ax-SpA group, males had worse outcomes in 9 out of the 11 domains except for VTE and cerebral infarction, while blacks had worse outcomes in all except for mortality and the need for renal replacement therapy. AS had similar risk ratios for all outcomes compared with nr-SpA except hospitalization [RR: 1.457 (1.03–2.06), p = 0.0318]. There was no difference in outcomes in patients who had received TNFi in the year previous to COVID-19 infection. Ax-SpA patients who had been prescribed non-steroidal anti-inflammatory drugs in the 3 months prior to COVID-19 had poorer outcomes.

Conclusion

In conclusion, COVID-19 outcomes were better in patients with ax-SpA as compared with PS matched controls except for increased risk for VTE. The use of TNFi is not associated with better or worse outcomes. These apparently protective effects observed need to be validated and explored further.

Key Points • Patients with axial spondyloarthritis have lower mortality and morbidity during COVID-19 infections as compared with propensity score matched controls. • Axial spondyloarthritis is associated with higher risks for venous thromboembolism during COVID-19. • There is no difference in outcomes between ankylosing spondylitis and non-radiographic spondyloarthritis except in rates of hospitalization, which were higher in ankylosing spondylitis. • Use of tumour necrosis factor inhibitors did not influence COVID-19 outcomes.

The incidence, clinical characteristics, and outcome of COVID-19 in a prospectively followed cohort of patients with Behçet's syndrome

Initial case series of small number of patients at the beginning of the pandemic reported a rather guarded prognosis for Behçet’s syndrome (BS) patients infected with SARS-CoV-2. In this prospective study, we describe the incidence, clinical characteristics, disease course, management, and outcome in a large cohort of BS patients with laboratory-confirmed infection of SARS-CoV-2. We defined a cohort of 1047 registered BS patients who were aged between 16 and 60 years and seen routinely before the pandemic at the multidisciplinary outpatient clinic. We followed prospectively this cohort from beginning of April 2020 until the end of April 2021. During 13 months of follow-up, of the 1047 (599 M/448 F) patients, 592 (56.5%) were tested for SARS-CoV-2 PCR at least once and 215 (20.5%; 95% CI 0.18–0.23) were tested positive. We observed 2 peaks which took place in December 2020 and April 2021. Of the 215 PCR positive patients, complete information was available in 214. Of these 214, 14 (6.5%) were asymptomatic for COVID-19. In the remaining, the most common symptoms were anosmia, fatigue, fever, arthralgia, and headache. A total of 40 (18.7%) had lung involvement, 25 (11.7%) were hospitalized, 1 was admitted to the intensive care unit while none died. Favipiravir was the most prescribed drug (74.3%), followed by colchicine (40.2%), and hydroxychloroquine (20.1%) in the treatment of COVID-19. After COVID-19, 5 patients (2.3%) were given supplemental O₂ and 31 (14.5%) antiaggregant or anticoagulants. During COVID-19, of the 214 PCR positive patients, 116 (54.2%) decreased the dose of their immunosuppressives or stopped taking completely; 36 (16.8%) experienced a BS flare which was mostly oral ulcers (10.3%). None of the patients reported a thrombotic event. A total of 93 (43.5%) patients reported BS flares after a median 45 days of COVID-19 infection and this was found to be significantly associated with immunosuppressive drug discontinuation. Multiple regression analysis adjusted for age and gender indicated that smoking and using interferon-alpha decreased the likelihood of getting COVID-19. The incidence and severity of COVID-19 did not differ between those who were using colchicine or not. The cumulative incidence of COVID-19 in this prospectively followed cohort of BS patients was almost two folds of that estimated for the general population living in Istanbul, Turkey, however, the clinical outcome of COVID-19 was not severe and there was no mortality. The protective effect of smoking and interferon deserves further investigation. On the other hand, colchicine did not have any positive or negative effect against COVID-19. Significant number of patients flared after COVID-19, however, this was significantly associated with immunosuppressive discontinuation during the infection. Contrary to our previous observations, COVID-19 did not seem to exacerbate thrombotic events during or after the infection.

Use of Monoclonal Antibodies Therapy for Treatment of Mild to Moderate COVID-19 in 4 Patients with Rheumatologic Disorders

BACKGROUND The use of monoclonal antibodies therapy (MAT) in early mild to moderate Coronavirus disease 2019 (COVID-19) has gained importance in recent times. However, there is limited information on the safety and efficacy of MAT in treating COVID-19 in patients with underlying rheumatologic diseases. Patients with rheumatologic diseases are usually on long-term corticosteroids and immunosuppressive therapy, which increases their risk for progressing to more severe forms of COVID-19. We report a case series of 4 patients with rheumatologic diseases who were treated with MAT for COVID-19. MATERIAL AND METHODS A retrospective observational study was conducted in our institution on patients with underlying rheumatological disorders who received MAT as per the EUA protocol of the FDA. RESULTS Two of the 4 patients were on immunosuppresive therapy at the time of receiving MAT. They recovered from COVID-19 without any adverse outcomes. No flare of underlying rheumatologic disease was noted. CONCLUSIONS MAT was observed to be a safe and effective therapy in 4 patients with rheumatological illnesses and COVID-19 treated at our hospital.