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Zhao X, Wu H, Li S, Gao C, Wang J, Ge L, Song Z, Ni B, You Y. The impact of the COVID-19 pandemic on SLE. Mod Rheumatol 2024; 34:247-264. [PMID: 36961736 DOI: 10.1093/mr/road030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/21/2023] [Accepted: 03/11/2023] [Indexed: 03/25/2023]
Abstract
Little is known about the association between coronavirus disease 2019 (COVID-19) and autoimmune diseases, especially in the case of systemic lupus erythematosus (SLE). SLE patients met with many questions during the pandemic in COVID-19, such as how to minimize risk of infection, the complex pathological features and cytokine profiles, diagnosis and treatment, rational choice of drugs and vaccine, good nursing, psychological supervision, and so on. In this study, we review and discuss the multifaceted effects of the COVID-19 pandemic on patients living with SLE using the available literature. Cross-talk in implicated inflammatory pathways/mechanisms exists between SLE and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and SARS-CoV-2 displays similar clinical characteristics and immuno-inflammatory responses to SLE. Current epidemiological data inadequately assess the risk and severity of COVID-19 infection in patients with SLE. More evidence has shown that hydroxychloroquine and chloroquine cannot prevent COVID-19. During the pandemic, patients with SLE had a higher rate of hospitalization. Vaccination helps to reduce the risk of infection. Several therapies for patients with SLE infected with COVID-19 are discussed. The cases in the study can provide meaningful information for clinical diagnosis and management. Our main aim is to help preventing infection and highlight treatment options for patients with SLE infected with COVID-19.
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Affiliation(s)
- Xingwang Zhao
- Department of Dermatology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Haohao Wu
- Department of Dermatology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shifei Li
- Department of Dermatology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Cuie Gao
- Department of Dermatology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Juan Wang
- Department of Dermatology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Lan Ge
- Department of Dermatology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhiqiang Song
- Department of Dermatology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Bing Ni
- Department of Pathophysiology, College of High Altitude Military Medicine, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yi You
- Department of Dermatology, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Breakthrough SARS-CoV-2 infections, morbidity, and seroreactivity following initial COVID-19 vaccination series and additional dose in patients with SLE in New York City. THE LANCET RHEUMATOLOGY 2022; 4:e582-e585. [PMID: 35856060 PMCID: PMC9275793 DOI: 10.1016/s2665-9913(22)00190-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Simon D, Tascilar K, Fagni F, Kleyer A, Krönke G, Meder C, Dietrich P, Orlemann T, Mößner J, Taubmann J, Mutlu MY, Knitza J, Kemenes S, Liphardt AM, Schönau V, Bohr D, Schuster L, Hartmann F, Minopoulou I, Leppkes M, Ramming A, Pachowsky M, Schuch F, Ronneberger M, Kleinert S, Hueber AJ, Manger K, Manger B, Atreya R, Berking C, Sticherling M, Neurath MF, Schett G. Intensity and longevity of SARS-CoV-2 vaccination response in patients with immune-mediated inflammatory disease: a prospective cohort study. THE LANCET RHEUMATOLOGY 2022; 4:e614-e625. [PMID: 35966645 PMCID: PMC9363042 DOI: 10.1016/s2665-9913(22)00191-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Concerns have been raised about the reduced immunogenicity of vaccines against SARS-CoV-2 in patients with immune-mediated inflammatory diseases and the higher risk of breakthrough infections. The objective of our study was to investigate the intensity and longevity of SARS-CoV-2 vaccination responses in patients with immune-mediated inflammatory diseases, and to assess the effects of diagnosis, treatment, and adapted vaccination schedules. Methods SARS-CoV-2 IgG antibody response after SARS-CoV-2 vaccination was measured over time in a large prospective cohort of healthy controls and participants with immune-mediated inflammatory diseases (attending or admitted to affiliated centres) between Dec 15, 2020, and Dec 1, 2021. Cohort participants with immune-mediated inflammatory diseases and control participants with no diagnosis of immune-mediated inflammatory diseases, were eligible for this analysis. Demographic data and disease-specific data were collected using a questionnaire. Humoral response was compared across treatment and disease groups, and with respect to the receipt of additional vaccinations. SARS-CoV-2 antibody response was measured by ELISA using optical density ratio units and modelled over time with age and sex adjustment using mixed-effects models. Using these models, marginal mean antibody titres and marginal risks of a poor response (optical density ratio <1·1) were calculated for each week starting from week 8 after the first vaccination to week 40. Findings Among 5076 individuals registered, 2535 participants with immune-mediated inflammatory diseases (mean age 55·0 [15·2] years; 1494 [58·9%] women and 1041 [41·1%] men) and 1198 healthy controls (mean age 40·7 [13·5] years; 554 [46·2%] women and 644 [53·8%] men) were included in this analysis. Mean antibody titres were higher in healthy controls compared with people with immune-mediated inflammatory diseases at all timepoints, with a peak antibody response in healthy controls (mean optical density ratio 12·48; 95% CI 11·50–13·53) of more than twice that in participants with immune-mediated inflammatory diseases (5·50; 5·23–5·77; mean difference 6·98; 5·92–8·04). A poor response to vaccination was observed in participants with immune-mediated inflammatory diseases who were taking B-cell inhibitors (peak mean difference from healthy controls 11·68; 10·07–13·29) and T-cell inhibitors (peakmean difference from healthy controls 10·43; 8·33–12·53). Mean differences in antibody responses between different immune-mediated inflammatory diseases were small. Participants with immune-mediated inflammatory diseases who were given a third vaccine dose had higher mean antibody titres than did healthy controls vaccinated with two vaccine doses at 40 weeks after the initial vaccination (mean difference 1·34; 0·01–2·69). Interpretation People with immune-mediated inflammatory diseases show a lower and less durable SARS-CoV-2 vaccination response and are at risk of losing humoral immune protection. Adjusted vaccination schedules with earlier booster doses or more frequent re-doses, or both, could better protect people with immune-mediated inflammatory diseases. Funding Deutsche Forschungsgemeinschaft, Bundesministerium für Bildung und Forschung, European Research Council, Innovative Medicine Initiative, Friedrich-Alexander-Universität Erlangen-Nürnberg, Else Kröner-Memorial Foundation.
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Glucocorticoids' treatment impairs the medium-term immunogenic response to SARS-CoV-2 mRNA vaccines in Systemic Lupus Erythematosus patients. Sci Rep 2022; 12:14772. [PMID: 36042275 PMCID: PMC9427088 DOI: 10.1038/s41598-022-18996-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Limited data exists on SARS-CoV-2 sustained-response to vaccine in patients with rheumatic diseases. This study aims to evaluate neutralizing antibodies (nAB) induced by SARS-CoV-2 vaccine after 3 to 6 months from administration in Systemic Lupus Erythematosus (SLE) patients, as a surrogate of sustained-immunological response. This cross-sectional study compared nAB titre of 39 SLE patients and 37 Healthy individuals with no previous SARS-CoV-2 infection, who had all received a complete regimen of a mRNA SARS-CoV-2 vaccine within the last 3 to 6 months. We included four lines of SLE treatment including Not-treated, Hydroxychloroquine, immunosuppressive drugs and biological therapy. Glucocorticoids were allowed in all groups. Healthy and Not-treated individuals showed the highest levels of nAB. Treated patients presented lower nAB titres compared to Healthy: a 73% decrease for First-Line patients, 56% for Second-Line treatment and 72% for Third-Line. A multivariate analysis pointed to Glucocorticoids as the most associated factor with declining nAB levels (75% decrease) in treated SLE. Furthermore, a significant reduction in nAB titres was observed for Rituximab-users compared to Healthy subjects (89% decrease). Medium-term response of SLE patients to SARS-CoV-2 mRNA vaccines is negatively impacted in Glucocorticoids and Rituximab users. These findings might help to inform recommendations in vaccination protocols for SLE patients.
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Humoral and cellular response in convalescent COVID-19 lupus patients. Sci Rep 2022; 12:13787. [PMID: 35962159 PMCID: PMC9374301 DOI: 10.1038/s41598-022-17334-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 07/25/2022] [Indexed: 01/08/2023] Open
Abstract
In SLE, underlying immune dysregulation and immunosuppression may increase the susceptibility to COVID-19 and impair the humoral and adaptive response. We aimed to characterize COVID-19 infection, identifying susceptibility and severity risk factors, assessing the presence of SARS-CoV-2 IgG antibodies and analyzing the cellular response. We established a prospective cohort of lupus patients to estimate the COVID-19 incidence compared to the reference general population. Data were collected via telephone interviews and medical record review. SARS-CoV-2 IgG antibodies were measured cross-sectionally as part of routine surveillance. Longitudinal changes in antibody titers and immunological profile from convalescent COVID-19 patients were evaluated at 6, 12 and 24 week after symptom onset. From immunological studies, PBMCs from convalescent patients were extracted and analyzed by flow cytometry and gene expression analysis. We included 725 patients, identifying 29 with PCR-confirmed COVID-19 infection and 16 with COVID-19-like symptoms without PCR-testing. Of the 29 confirmed cases, 7 had severe disease, 8 required hospital admission (27.6%), 4 intensive care, and 1 died. COVID-19 accumulated incidence was higher in lupus patients. Health care workers and anti-SSA/Ro52 antibody positivity were risk factors for COVID-19 susceptibility, and hypocomplementemia for severity. SARS-CoV-2 IgG antibodies were detected in 8.33% of patients. Three fourths of confirmed COVID-19 cases developed antibodies. High prednisone doses were associated with lack of antibody response. Antibody titers declined over time (39%). Convalescent patients at week 12 after symptom onset displayed a CD8+T cell reduction and predominant Th17 with a mild Th2 response, more pronounced in severe COVID-19 disease. Longitudinal immune response analysis showed a progressive sustained increase in CD8+ T and B memory cells with a decrease of Th17 signaling. Lupus patients are at higher risk of COVID-19 infection and new susceptibility and severity risk factors were identified. Lupus patients were able to mount humoral and cellular responses despite immunosuppressive therapy.
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Cruz-Machado AR, Barreira SC, Bandeira M, Veldhoen M, Gomes A, Serrano M, Duarte C, Rato M, Miguel Fernandes B, Garcia S, Pinheiro F, Bernardes M, Madeira N, Miguel C, Torres R, Bento Silva A, Pestana J, Almeida D, Mazeda C, Cunha Santos F, Pinto P, Sousa M, Parente H, Sequeira G, Santos MJ, Fonseca JE, Romão VC. Risk Factors for Infection, Predictors of Severe Disease, and Antibody Response to COVID-19 in Patients With Inflammatory Rheumatic Diseases in Portugal-A Multicenter, Nationwide Study. Front Med (Lausanne) 2022; 9:901817. [PMID: 35770002 PMCID: PMC9234392 DOI: 10.3389/fmed.2022.901817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/16/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To identify risk factors for SARS-CoV-2 infection and for severe/critical COVID-19, and to assess the humoral response after COVID-19 in these patients. Methods Nationwide study of adult patients with inflammatory RMDs prospectively followed in the Rheumatic Diseases Portuguese Register-Reuma.pt-during the first 6 months of the pandemic. We compared patients with COVID-19 with those who did not develop the disease and patients with mild/moderate disease with those exhibiting severe/critical COVID-19. IgG antibodies against SARS-CoV-2 were measured ≥3 months after infection and results were compared with matched controls. Results 162 cases of COVID-19 were registered in a total of 6,363 appointments. Patients treated with TNF inhibitors (TNFi; OR = 0.160, 95% CI 0.099-0.260, P < 0.001) and tocilizumab (OR 0.147, 95% CI 0.053-0.408, P < 0.001) had reduced odds of infection. Further, TNFi tended to be protective of severe and critical disease. Older age, major comorbidities, and rituximab were associated with an increased risk of infection and worse prognosis. Most patients with inflammatory RMDs (86.2%) developed a robust antibody response. Seroconversion was associated with symptomatic disease (OR 13.46, 95% CI 2.21-81.85, P = 0.005) and tended to be blunted by TNFi (OR 0.17, 95% CI 0.03-1.05; P = 0.057). Conclusions TNFi and tocilizumab reduced the risk of infection by SARS-CoV-2. Treatment with TNFi also tended to reduce rates of severe disease and seroconversion. Older age, general comorbidities and rituximab were associated with increased risk for infection and worse prognosis, in line with previous reports. Most patients with RMDs developed a proper antibody response after COVID-19, particularly if they had symptomatic disease.
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Affiliation(s)
- Ana Rita Cruz-Machado
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Center and European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ERN-ReCONNET), Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Sofia C. Barreira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Center and European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ERN-ReCONNET), Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Matilde Bandeira
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Center and European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ERN-ReCONNET), Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Marc Veldhoen
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Andreia Gomes
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Marta Serrano
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Catarina Duarte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Center and European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ERN-ReCONNET), Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Maria Rato
- Rheumatology Department, Centro Hospitalar Universitário de São João EPE, Porto, Portugal
| | - Bruno Miguel Fernandes
- Rheumatology Department, Centro Hospitalar Universitário de São João EPE, Porto, Portugal
| | - Salomé Garcia
- Rheumatology Department, Centro Hospitalar Universitário de São João EPE, Porto, Portugal
| | - Filipe Pinheiro
- Rheumatology Department, Centro Hospitalar Universitário de São João EPE, Porto, Portugal
| | - Miguel Bernardes
- Rheumatology Department, Centro Hospitalar Universitário de São João EPE, Porto, Portugal
| | - Nathalie Madeira
- Rheumatology Department, Instituto Português de Reumatologia, Lisbon, Portugal
| | - Cláudia Miguel
- Rheumatology Department, Instituto Português de Reumatologia, Lisbon, Portugal
| | - Rita Torres
- Rheumatology Department, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Ana Bento Silva
- Rheumatology Department, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Jorge Pestana
- Rheumatology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Diogo Almeida
- Rheumatology Department, Hospital de Braga, Braga, Portugal
| | - Carolina Mazeda
- Rheumatology Department, Centro Hospitalar do Baixo Vouga and iBiMED, Institute for Biomedicine, University of Aveiro, Aveiro, Portugal
| | | | - Patrícia Pinto
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Marlene Sousa
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Hugo Parente
- Rheumatology Department, Unidade Local de Saúde do Alto Minho, Ponte de Lima, Portugal
| | - Graça Sequeira
- Rheumatology Department, Centro Hospitalar Universitário do Algarve, Faro, Portugal
| | | | - João Eurico Fonseca
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Center and European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ERN-ReCONNET), Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Vasco C. Romão
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Center and European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ERN-ReCONNET), Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Simon D, Tascilar K, Kleyer A, Fagni F, Krönke G, Meder C, Dietrich P, Orlemann T, Kliem T, Mößner J, Liphardt A, Schönau V, Bohr D, Schuster L, Hartmann F, Leppkes M, Ramming A, Pachowsky M, Schuch F, Ronneberger M, Kleinert S, Hueber AJ, Manger K, Manger B, Atreya R, Berking C, Sticherling M, Neurath MF, Schett G. Impact of Cytokine Inhibitor Therapy on the Prevalence, Seroconversion Rate, and Longevity of the Humoral Immune Response Against SARS-CoV-2 in an Unvaccinated Cohort. Arthritis Rheumatol 2022; 74:783-790. [PMID: 34951137 PMCID: PMC9011429 DOI: 10.1002/art.42035] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/17/2021] [Accepted: 11/24/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To investigate the impact of biologic disease-modifying antirheumatic drug (bDMARD) treatment on the prevalence, seroconversion rate, and longevity of the humoral immune response against SARS-CoV-2 in patients with immune-mediated inflammatory diseases (IMIDs). METHODS Anti-SARS-CoV-2 IgG antibodies were measured in a prospective cohort of health care professional controls and non-health care controls and IMID patients receiving no treatment or receiving treatment with conventional or biologic DMARDs during the first and second COVID-19 waves. Regression models adjusting for age, sex, sampling time, and exposure risk behavior were used to calculate relative risks (RRs) of seropositivity. Seroconversion rates were assessed in participants with polymerase chain reaction (PCR)-positive SARS-CoV-2 infection. Antibody response longevity was evaluated by reassessing participants who tested positive during the first wave. RESULTS In this study, 4,508 participants (2,869 IMID patients and 1,639 controls) were analyzed. The unadjusted RR (0.44 [95% confidence interval (95% CI) 0.31-0.62]) and adjusted RR (0.50 [95% CI 0.34-0.73]) for SARS-CoV-2 IgG antibodies were significantly lower in IMID patients treated with bDMARDs compared to non-health care controls (P < 0.001), primarily driven by treatment with tumor necrosis factor inhibitors, interleukin-17 (IL-17) inhibitors, and IL-23 inhibitors. Adjusted RRs for untreated IMID patients (1.12 [95% CI 0.75-1.67]) and IMID patients receiving conventional synthetic DMARDs (0.70 [95% CI 0.45-1.08]) were not significantly different from non-health care controls. Lack of seroconversion in PCR-positive participants was more common among bDMARD-treated patients (38.7%) than in non-health care controls (16%). Overall, 44% of positive participants lost SARS-CoV-2 antibodies by follow-up, with higher rates in IMID patients treated with bDMARDs (RR 2.86 [95% CI 1.43-5.74]). CONCLUSION IMID patients treated with bDMARDs have a lower prevalence of SARS-CoV-2 antibodies, seroconvert less frequently after SARS-CoV-2 infection, and may exhibit a reduced longevity of their humoral immune response.
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Affiliation(s)
- David Simon
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Koray Tascilar
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Arnd Kleyer
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Filippo Fagni
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Gerhard Krönke
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Christine Meder
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Peter Dietrich
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Till Orlemann
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Thorsten Kliem
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Johanna Mößner
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Anna‐Maria Liphardt
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Verena Schönau
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Daniela Bohr
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Louis Schuster
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Fabian Hartmann
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Moritz Leppkes
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Andreas Ramming
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Milena Pachowsky
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | | | | | | | - Axel J. Hueber
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany, and Rheumatology SectionSozialstiftung Bamberg, BambergGermany
| | | | - Bernhard Manger
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Raja Atreya
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Carola Berking
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Michael Sticherling
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Markus F. Neurath
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
| | - Georg Schett
- Friedrich‐Alexander University Erlangen‐Nuremberg and Universitätsklinikum ErlangenErlangenGermany
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Aringer M, Alarcón-Riquelme ME, Clowse M, Pons-Estel GJ, Vital EM, Dall’Era M. A glimpse into the future of systemic lupus erythematosus. Ther Adv Musculoskelet Dis 2022; 14:1759720X221086719. [PMID: 35368371 PMCID: PMC8972918 DOI: 10.1177/1759720x221086719] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/23/2022] [Indexed: 12/17/2022] Open
Abstract
This viewpoint article on a forecast of clinically meaningful changes in the management of systemic lupus erythematosus (SLE) in the next 10 years is based on a review of the current state of the art. The groundwork has been laid by a robust series of classification criteria and treatment recommendations that have all been published since 2019. Building on this strong foundation, SLE management predictably will take significant steps forward. Assessment for lupus arthritis will presumably include musculoskeletal sonography. Large-scale polyomics studies are likely to unravel more of the central immune mechanisms of the disease. Biomarkers predictive of therapeutic success may enter the field; the type I interferon signature, as a companion for use of anifrolumab, an antibody against the common type I interferon receptor, is one serious candidate. Besides anifrolumab for nonrenal SLE and the new calcineurin inhibitor voclosporin in lupus nephritis, both of which are already approved in the United States and likely to become available in the European Union in 2022, several other approaches are in advanced clinical trials. These include advanced B cell depletion, inhibition of costimulation via CD40 and CD40 ligand (CD40L), and Janus kinase 1 (Jak1) and Tyrosine kinase 2 (Tyk2) inhibition. At the same time, essentially all of our conventional therapeutic armamentarium will continue to be used. The ability of patients to have successful SLE pregnancies, which has become much better in the last decades, should further improve, with approaches including tumor necrosis factor blockade and self-monitoring of fetal heart rates. While we hope that the COVID-19 pandemic will soon be controlled, it has highlighted the risk of severe viral infections in SLE, with increased risk tied to certain therapies. Although there are some data that a cure might be achievable, this likely will remain a challenge beyond 10 years from now.
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Affiliation(s)
- Martin Aringer
- Professor of Medicine (Rheumatology), Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine, TU Dresden, 01307 Dresden, Germany
| | - Marta E. Alarcón-Riquelme
- Department of Medical Genomics, GENYO, Pfizer-University of Granada-Andalusian Government Center for Genomics and Oncological Research, Granada, Spain
| | - Megan Clowse
- Division of Rheumatology & Immunology, Duke University, Durham, NC, USA
| | - Guillermo J. Pons-Estel
- Department of Rheumatology, Grupo Oroño–Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Edward M. Vital
- University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maria Dall’Era
- Lupus Clinic and Rheumatology Clinical Research Center, Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Izmirly PM, Kim MY, Samanovic M, Fernandez‐Ruiz R, Ohana S, Deonaraine KK, Engel AJ, Masson M, Xie X, Cornelius AR, Herati RS, Haberman RH, Scher JU, Guttmann A, Blank RB, Plotz B, Haj‐Ali M, Banbury B, Stream S, Hasan G, Ho G, Rackoff P, Blazer AD, Tseng C, Belmont HM, Saxena A, Mulligan MJ, Clancy RM, Buyon JP. Evaluation of Immune Response and Disease Status in Systemic Lupus Erythematosus Patients Following SARS-CoV-2 Vaccination. Arthritis Rheumatol 2022; 74:284-294. [PMID: 34347939 PMCID: PMC8426963 DOI: 10.1002/art.41937] [Citation(s) in RCA: 99] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/09/2021] [Accepted: 07/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate seroreactivity and disease flares after COVID-19 vaccination in a multiethnic/multiracial cohort of patients with systemic lupus erythematosus (SLE). METHODS Ninety SLE patients and 20 healthy controls receiving a complete COVID-19 vaccine regimen were included. IgG seroreactivity to the SARS-CoV-2 spike receptor-binding domain (RBD) and SARS-CoV-2 microneutralization were used to evaluate B cell responses; interferon-γ (IFNγ) production was measured by enzyme-linked immunospot (ELISpot) assay in order to assess T cell responses. Disease activity was measured by the hybrid SLE Disease Activity Index (SLEDAI), and flares were identified according to the Safety of Estrogens in Lupus Erythematosus National Assessment-SLEDAI flare index. RESULTS Overall, fully vaccinated SLE patients produced significantly lower IgG antibodies against SARS-CoV-2 spike RBD compared to fully vaccinated controls. Twenty-six SLE patients (28.8%) generated an IgG response below that of the lowest control (<100 units/ml). In logistic regression analyses, the use of any immunosuppressant or prednisone and a normal anti-double-stranded DNA antibody level prior to vaccination were associated with decreased vaccine responses. IgG seroreactivity to the SARS-CoV-2 spike RBD strongly correlated with the SARS-CoV-2 microneutralization titers and correlated with antigen-specific IFNγ production determined by ELISpot. In a subset of patients with poor antibody responses, IFNγ production was similarly diminished. Pre- and postvaccination SLEDAI scores were similar in both groups. Postvaccination flares occurred in 11.4% of patients; 1.3% of these were severe. CONCLUSION In a multiethnic/multiracial study of SLE patients, 29% had a low response to the COVID-19 vaccine which was associated with receiving immunosuppressive therapy. Reassuringly, severe disease flares were rare. While minimal protective levels remain unknown, these data suggest that protocol development is needed to assess the efficacy of booster vaccination.
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Affiliation(s)
| | - Mimi Y. Kim
- Albert Einstein College of MedicineNew YorkNew York
| | - Marie Samanovic
- New York University Grossman School of MedicineNew YorkNew York
| | | | - Sharon Ohana
- New York University Grossman School of MedicineNew YorkNew York
| | | | - Alexis J. Engel
- New York University Grossman School of MedicineNew YorkNew York
| | - Mala Masson
- New York University Grossman School of MedicineNew YorkNew York
| | - Xianhong Xie
- Albert Einstein College of MedicineNew YorkNew York
| | | | - Ramin S. Herati
- New York University Grossman School of MedicineNew YorkNew York
| | | | - Jose U. Scher
- New York University Grossman School of MedicineNew YorkNew York
| | | | | | - Benjamin Plotz
- New York University Grossman School of MedicineNew YorkNew York
| | - Mayce Haj‐Ali
- New York University Grossman School of MedicineNew YorkNew York
| | | | - Sara Stream
- New York University Grossman School of MedicineNew YorkNew York
| | - Ghadeer Hasan
- New York University Grossman School of MedicineNew YorkNew York
| | - Gary Ho
- New York University Grossman School of MedicineNew YorkNew York
| | - Paula Rackoff
- New York University Grossman School of MedicineNew YorkNew York
| | | | - Chung‐E Tseng
- New York University Grossman School of MedicineNew YorkNew York
| | | | - Amit Saxena
- New York University Grossman School of MedicineNew YorkNew York
| | | | | | - Jill P. Buyon
- New York University Grossman School of MedicineNew YorkNew York
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10
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Zhou B, Li S, Ye J, Liu Y, Hu L, Tang Y, Wu Z, Zhang P. Immunopathological events surrounding IL-6 and IFN-α: A bridge for anti-lupus erythematosus drugs used to treat COVID-19. Int Immunopharmacol 2021; 101:108254. [PMID: 34710657 PMCID: PMC8527889 DOI: 10.1016/j.intimp.2021.108254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/26/2021] [Accepted: 10/08/2021] [Indexed: 01/11/2023]
Abstract
With the outbreak and rapid spread of COVID-19, the world health situation is unprecedentedly severe. Systemic lupus erythematosus (SLE) is a common autoimmune disease, which can cause multiple organ damage. Numerous studies have shown that immune factors have important roles in the pathogenesis of both COVID-19 and SLE. In the early stages of COVID-19 and SLE pathogenesis, IFN-α expression is frequently increased, which aggravates the virus infection and promotes SLE development. In addition, increased IL-6 levels, caused by different mechanisms, are observed in the peripheral blood of patients with severe COVID-19 and SLE, stimulating a series of immune cascades that lead to a cytokine storm, as well as causing B cell hyperfunction and production of numerous of antibodies, aggravating both COVID-19 and SLE. In this review, we explore the background immunopathological mechanisms in COVID-19 and SLE and analyze the advantages and disadvantages of commonly used SLE drugs for patients with COVID-19, to optimize treatment plans for patients with SLE who develop COVID-19.
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Affiliation(s)
- Bangyi Zhou
- Nanfang Hospital, Southern Medical University/The First School of Clinical Medicine, Southern Medical University, People’s Republic of China,Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou 510282, Guangdong, People’s Republic of China
| | - Siying Li
- School of Traditional Chinese Medicine, Southern Medical University, People’s Republic of China
| | - Jujian Ye
- Zhujiang Hospital, Southern Medical University/The Second School of Clinical Medicine, Southern Medical University, People’s Republic of China,Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou 510282, Guangdong, People’s Republic of China
| | - Yi Liu
- School of Laboratory Medicine and Biotechnology, Southern Medical University, People’s Republic of China
| | - Longtai Hu
- School of Traditional Chinese Medicine, Southern Medical University, People’s Republic of China
| | - Yan Tang
- Zhujiang Hospital, Southern Medical University/The Second School of Clinical Medicine, Southern Medical University, People’s Republic of China
| | - Zhijian Wu
- Department of Cardiology, Boai Hospital of Zhongshan, Southern Medical University, People’s Republic of China,Corresponding authors
| | - Peidong Zhang
- Department of Cardiology, Heart Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou 510282, Guangdong, People’s Republic of China,Corresponding authors
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11
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Yuki EFN, Borba EF, Pasoto SG, Seguro LP, Lopes M, Saad CGS, Medeiros‐Ribeiro AC, Silva CA, de Andrade DCO, Kupa LDVK, Betancourt L, Bertoglio I, Valim J, Hoff C, Formiga FC, Pedrosa T, Kallas EG, Aikawa NE, Bonfa E. Impact of distinct therapies on antibody response to SARS-CoV-2 vaccine in systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2021; 74:562-571. [PMID: 34806342 PMCID: PMC9011410 DOI: 10.1002/acr.24824] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/03/2021] [Accepted: 11/18/2021] [Indexed: 11/07/2022]
Abstract
Objective To date, the only study that has assessed the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2 mRNA) vaccine in systemic lupus erythematosus (SLE) observed a moderate response, but the sample size precluded an accurate analysis of the effect of individual drugs. Therefore, we evaluated the immunogenicity of an inactivated SARS‐CoV‐2 vaccine (Sinovac‐CoronaVac) and the influence of different medications in SLE. Safety was also assessed. Methods We conducted a prospective controlled study of 232 SARS‐CoV‐2–naive SLE patients and 58 SARS‐CoV‐2–naive controls who were vaccinated with 2 doses of Sinovac‐CoronaVac with a 28‐day interval (day 0/day 28 [D0/D28]). Immunogenicity analysis at D0/D28 and D69 included anti‐SARS‐CoV‐2 S1/S2 IgG seroconversion (SC) and neutralizing antibodies (NAb) positivity. The influence of individual drugs on immune response and safety was assessed. Results Patients and controls were well balanced for age (P = 0.771). At D69, SLE patients showed a moderate SC (70.2% versus 98.1%; P < 0.001) and moderate frequency of NAb positivity (61.5% versus 84.6%; P = 0.002), although both frequencies were lower than in controls. Factors associated with lower SC in univariate analysis at D69 were prednisone use (odds ratio [OR] 0.215 [95% confidence interval (95% CI) 0.108–0.427], P < 0.001) and mycophenolate mofetil (MMF) use (OR 0.201 [95% CI 0.107–0.378], P < 0.001), whereas hydroxychloroquine (HCQ) use led to a 2.5 increase in SC (P = 0.011). SLE patients who were receiving HCQ monotherapy had similar SC to controls at D69 (100% versus 98.1%; P = 1.000). In multivariate analysis, prednisone and MMF use were independently associated with lower SC (P < 0.001) and NAb positivity (P < 0.001). Safety analysis revealed no moderate/severe adverse events. Conclusion Sinovac‐CoronaVac has a moderate immunogenicity in SARS‐CoV‐2–naive SLE patients with an excellent safety profile. We further demonstrate that HCQ may improve SC, whereas prednisone and MMF had a major deleterious effect in vaccine response, reinforcing the need to investigate the role of temporary MMF withdrawal or a vaccine‐booster dose (ClinicalTrials.gov identifier: NCT04754698).
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Affiliation(s)
- Emily F. N. Yuki
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Eduardo F. Borba
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Sandra G. Pasoto
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Luciana P. Seguro
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Michelle Lopes
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Carla G. S. Saad
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | | | - Clovis A. Silva
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | | | | | - Lorena Betancourt
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Isabela Bertoglio
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Juliana Valim
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Camilla Hoff
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Francisco F. C. Formiga
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Tatiana Pedrosa
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Esper G. Kallas
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Nadia E. Aikawa
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
| | - Eloisa Bonfa
- Hospital das Clinicas HCFMUSP, Faculdade de MedicinaUniversidade de Sao PauloSao PauloBrazil
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12
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Sjöwall J, Azharuddin M, Frodlund M, Zhang Y, Sandner L, Dahle C, Hinkula J, Sjöwall C. SARS-CoV-2 Antibody Isotypes in Systemic Lupus Erythematosus Patients Prior to Vaccination: Associations With Disease Activity, Antinuclear Antibodies, and Immunomodulatory Drugs During the First Year of the Pandemic. Front Immunol 2021; 12:724047. [PMID: 34512651 PMCID: PMC8430325 DOI: 10.3389/fimmu.2021.724047] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/04/2021] [Indexed: 12/23/2022] Open
Abstract
Objectives Impact of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic on individuals with arthritis has been highlighted whereas data on other rheumatic diseases, e.g., systemic lupus erythematosus (SLE), are scarce. Similarly to SLE, severe SARS-CoV-2 infection includes risks for thromboembolism, an unbalanced type I interferon response, and complement activation. Herein, SARS-CoV-2 antibodies in longitudinal samples collected prior to vaccination were analyzed and compared with SLE progression and antinuclear antibody (ANA) levels. Methods One hundred patients (83 women) with established SLE and a regular visit to the rheumatologist (March 2020 to January 2021) were included. All subjects donated blood and had done likewise prior to the pandemic. SARS-CoV-2 antibody isotypes (IgG, IgA, IgM) to the cell receptor-binding S1-spike outer envelope protein were detected by ELISA, and their neutralizing capacity was investigated. IgG-ANA were measured by multiplex technology. Results During the pandemic, 4% had PCR-confirmed infection but 36% showed SARS-CoV-2 antibodies of ≥1 isotype; IgA was the most common (30%), followed by IgM (9%) and IgG (8%). The antibodies had low neutralizing capacity and were detected also in prepandemic samples. Plasma albumin (p = 0.04) and anti-dsDNA (p = 0.003) levels were lower in patients with SARS-CoV-2 antibodies. Blood group, BMI, smoking habits, complement proteins, daily glucocorticoid dose, use of hydroxychloroquine, or self-reported coronavirus disease 2019 (COVID-19) symptoms (except fever, >38.5°C) did not associate with SARS-CoV-2 antibodies. Conclusion Our data from early 2021 indicate that a large proportion of Swedish SLE patients had serological signs of exposure to SARS-CoV-2 but apparently with a minor impact on the SLE course. Use of steroids and hydroxychloroquine showed no distinct effects, and self-reported COVID-19-related symptoms correlated poorly with all antibody isotypes.
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Affiliation(s)
- Johanna Sjöwall
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Infectious Diseases, Linköping University, Linköping, Sweden
| | - Mohammad Azharuddin
- Department of Biomedical and Clinical Sciences, Division of Molecular Medicine and Virology, Linköping University, Linköping, Sweden
| | - Martina Frodlund
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, Linköping, Sweden
| | - Yuming Zhang
- Department of Biomedical and Clinical Sciences, Division of Molecular Medicine and Virology, Linköping University, Linköping, Sweden
| | - Laura Sandner
- Department of Biomedical and Clinical Sciences, Division of Molecular Medicine and Virology, Linköping University, Linköping, Sweden
| | - Charlotte Dahle
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Clinical Immunology & Transfusion Medicine, Linköping University, Linköping, Sweden
| | - Jorma Hinkula
- Department of Biomedical and Clinical Sciences, Division of Molecular Medicine and Virology, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, Linköping, Sweden
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13
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Systemic lupus erythematosus does not prevent antibody responses to SARS-CoV-2. THE LANCET RHEUMATOLOGY 2021; 3:e538-e540. [PMID: 34075357 PMCID: PMC8159186 DOI: 10.1016/s2665-9913(21)00153-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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