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Léo JGP, Siqueira CB, Motta JDOCD, Vasconcellos IFD, Araujo YRD, Glehn FV, Kurizky PS, Gomes CM, Porto C, Feitosa MSC. The use of intravenous immunoglobulin as a rescue therapy for refractory parainfectious leprosy-related neuritis: a case series. An Bras Dermatol 2024; 99:736-739. [PMID: 38834395 PMCID: PMC11342985 DOI: 10.1016/j.abd.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/23/2023] [Accepted: 09/12/2023] [Indexed: 06/06/2024] Open
Affiliation(s)
| | | | | | | | | | - Felipe Von Glehn
- Department of Neurology, Hospital Universitário de Brasília, Brasília, DF, Brazil
| | - Patrícia Shu Kurizky
- Department of Dermatology, Hospital Universitário de Brasília, Brasília, DF, Brazil
| | - Ciro Martins Gomes
- Department of Dermatology, Hospital Universitário de Brasília, Brasília, DF, Brazil
| | - Cláudia Porto
- Department of Dermatology, Hospital Regional da Asa Norte, Brasília, DF, Brazil
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2
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Fróes LAR, Toma TS, Poderoso RE, Trindade MÂB. Viral co-infections in leprosy: a scoping review. Int J Dermatol 2023; 62:547-557. [PMID: 36738114 DOI: 10.1111/ijd.16613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/09/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023]
Abstract
CONTEXT The most reported viral co-infections in leprosy are human immunodeficiency virus (HIV), human T-cell lymphotropic virus (HTLV), hepatitis B virus (HBV), hepatitis C virus (HCV), and SARS-CoV-2. In co-infections, the burden of an agent can be increased or decreased by the presence of others. To address this issue, we need to fully understand their prevalence, risk factors, immunology, clinical manifestations, and treatment. The purpose of this scoping review is to describe the clinical and epidemiological characteristics of the most reported viral co-infections in leprosy to inform clinicians and guide future research. METHODS The authors conducted a literature search of five databases for articles on each of the aforementioned co-infections published prior to October 2022. Two independent reviewers conducted the selection process and identified 53 papers meeting the study inclusion criteria. The data extraction process and evidence synthesis were conducted by one reviewer and double-checked by a second one, consistent with best practice recommendations for scoping reviews. RESULTS For all assessed viruses, most studies reported prevalence rates in leprosy patients higher than the general population. Studies found that HTLV, HBV, and HCV chronic infections were highest in multibacillary leprosy, whereas HIV was mostly found in paucibacillary leprosy, and SARS-Cov-2 affected leprosy subtypes equally. Overall, co-infections were also associated with higher rates of leprosy reactions, except for COVID-19. Forty-six percent of the studies discussed issues related to treatment, which led to favorable outcomes for the most part. CONCLUSIONS This review summarizes the existing literature on viral co-infections in leprosy patients, generating valuable insights and recommending areas for future research.
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Affiliation(s)
- Luis Alberto Ribeiro Fróes
- Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, Av Dr Arnaldo, 455, São Paulo, 01246-903, SP, Brazil
| | - Tereza Setsuko Toma
- Núcleo de Evidências, Instituto de Saúde, Secretaria de Estado da Saúde, São Paulo, SP, Brazil
| | | | - Maria Ângela Bianconcini Trindade
- LIM56, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.,Núcleo de Evidências, Instituto de Saúde, Secretaria de Estado da Saúde, São Paulo, SP, Brazil
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Sarker B, Rahaman MM, Islam MA, Alamin MH, Husain MM, Ferdousi F, Ahsan MA, Mollah MNH. Identification of host genomic biomarkers from multiple transcriptomics datasets for diagnosis and therapies of SARS-CoV-2 infections. PLoS One 2023; 18:e0281981. [PMID: 36913345 PMCID: PMC10010564 DOI: 10.1371/journal.pone.0281981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/05/2023] [Indexed: 03/14/2023] Open
Abstract
The pandemic of COVID-19 is a severe threat to human life and the global economy. Despite the success of vaccination efforts in reducing the spread of the virus, the situation remains largely uncontrolled due to the random mutation in the RNA sequence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which demands different variants of effective drugs. Disease-causing gene-mediated proteins are usually used as receptors to explore effective drug molecules. In this study, we analyzed two different RNA-Seq and one microarray gene expression profile datasets by integrating EdgeR, LIMMA, weighted gene co-expression network and robust rank aggregation approaches, which revealed SARS-CoV-2 infection causing eight hub-genes (HubGs) including HubGs; REL, AURKA, AURKB, FBXL3, OAS1, STAT4, MMP2 and IL6 as the host genomic biomarkers. Gene Ontology and pathway enrichment analyses of HubGs significantly enriched some crucial biological processes, molecular functions, cellular components and signaling pathways that are associated with the mechanisms of SARS-CoV-2 infections. Regulatory network analysis identified top-ranked 5 TFs (SRF, PBX1, MEIS1, ESR1 and MYC) and 5 miRNAs (hsa-miR-106b-5p, hsa-miR-20b-5p, hsa-miR-93-5p, hsa-miR-106a-5p and hsa-miR-20a-5p) as the key transcriptional and post-transcriptional regulators of HubGs. Then, we conducted a molecular docking analysis to determine potential drug candidates that could interact with HubGs-mediated receptors. This analysis resulted in the identification of top-ranked ten drug agents, including Nilotinib, Tegobuvir, Digoxin, Proscillaridin, Olysio, Simeprevir, Hesperidin, Oleanolic Acid, Naltrindole and Danoprevir. Finally, we investigated the binding stability of the top-ranked three drug molecules Nilotinib, Tegobuvir and Proscillaridin with the three top-ranked proposed receptors (AURKA, AURKB, OAS1) by using 100 ns MD-based MM-PBSA simulations and observed their stable performance. Therefore, the findings of this study might be useful resources for diagnosis and therapies of SARS-CoV-2 infections.
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Affiliation(s)
- Bandhan Sarker
- Faculty of Science, Department of Statistics, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, Bangladesh
- Department of Statistics, Bioinformatics Laboratory (Dry), University of Rajshahi, Rajshahi, Bangladesh
| | - Md. Matiur Rahaman
- Faculty of Science, Department of Statistics, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, Bangladesh
| | - Md. Ariful Islam
- Department of Statistics, Bioinformatics Laboratory (Dry), University of Rajshahi, Rajshahi, Bangladesh
| | - Muhammad Habibulla Alamin
- Faculty of Science, Department of Statistics, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, Bangladesh
| | - Md. Maidul Husain
- Faculty of Science, Department of Statistics, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, Bangladesh
| | - Farzana Ferdousi
- Faculty of Science, Department of Statistics, Bangabandhu Sheikh Mujibur Rahman Science and Technology University, Gopalganj, Bangladesh
| | - Md. Asif Ahsan
- Department of Statistics, Bioinformatics Laboratory (Dry), University of Rajshahi, Rajshahi, Bangladesh
- Liangzhu Laboratory, Zhejiang University Medical Center, Zhejiang University, Hangzhou, Zhejiang, China
| | - Md. Nurul Haque Mollah
- Department of Statistics, Bioinformatics Laboratory (Dry), University of Rajshahi, Rajshahi, Bangladesh
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Zhang W, Yang Z, Zhou F, Wei Y, Ma X. Network Pharmacology and Bioinformatics Analysis Identifies Potential Therapeutic Targets of Paxlovid Against LUAD/COVID-19. Front Endocrinol (Lausanne) 2022; 13:935906. [PMID: 36157452 PMCID: PMC9493477 DOI: 10.3389/fendo.2022.935906] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused a pandemic in many countries around the world. The virus is highly contagious and has a high fatality rate. Lung adenocarcinoma (LUAD) patients may have higher susceptibility and mortality to COVID-19. While Paxlovid is the first oral drug approved by the U.S. Food and Drug Administration (FDA) for COVID-19, its specific drug mechanism for lung cancer patients infected with COVID-19 remains to be further studied. Methods COVID-19 related genes were obtained from NCBI, GeneCards, and KEGG, and then the transcriptome data for LUAD was downloaded from TCGA. The drug targets of Paxlovid were revealed through BATMAN-TCM, DrugBank, SwissTargetPrediction, and TargetNet. The genes related to susceptibility to COVID-19 in LUAD patients were obtained through differential analysis. The interaction of LUAD/COVID-19 related genes was evaluated and displayed by STRING, and a COX risk regression model was established to screen and evaluate the correlation between genes and clinical characteristics. The Venn diagram was drawn to select the candidate targets of Paxlovid against LUAD/COVID-19, and the functional analysis of the target genes was performed using KEGG and GO enrichment analysis. Finally, Cytoscape was used to screen and visualize the Hub Gene, and Autodock was used for molecular docking between the drug and the target. Result Bioinformatics analysis was performed by combining COVID-19-related genes with the gene expression and clinical data of LUAD, including analysis of prognosis-related genes, survival rate, and hub genes screened out by the prognosis model. The key targets of Paxlovid against LUAD/COVID-19 were obtained through network pharmacology, the most important targets include IL6, IL12B, LBP. Furthermore, pathway analysis showed that Paxlovid modulates the IL-17 signaling pathway, the cytokine-cytokine receptor interaction, during LUAD/COVID-19 treatment. Conclusions Based on bioinformatics and network pharmacology, the prognostic signature of LUAD/COVID-19 patients was screened. And identified the potential therapeutic targets and molecular pathways of Paxlovid Paxlovid in the treatment of LUAD/COVID. As promising features, prognostic signatures and therapeutic targets shed light on improving the personalized management of patients with LUAD.
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Affiliation(s)
- Wentao Zhang
- Tumor Research and Therapy Center, Shandong Provincial Hospital Affiliated to Shandong First Medical Unversity, Jinan, China
- Shandong First Medical Unversity, Jinan, China
| | - Zhe Yang
- Tumor Research and Therapy Center, Shandong Provincial Hospital Affiliated to Shandong First Medical Unversity, Jinan, China
| | - Fengge Zhou
- Tumor Research and Therapy Center, Shandong Provincial Hospital Affiliated to Shandong First Medical Unversity, Jinan, China
| | - Yanjun Wei
- Tumor Research and Therapy Center, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoqing Ma
- Shandong First Medical Unversity, Jinan, China
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5
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Repsold TAR, Collin SM, Bouth RC, Cerqueira SRPS, Brezinscki MS, Peixoto RRGB, Fonseca AMFDA, Peixoto MLDS, Rabelo Mendes S, Gomes CM, Salgado CG, Deps PD. Hansen's disease and COVID-19 co-infection in Brazil. Int J Dermatol 2022; 61:1506-1510. [PMID: 35775153 PMCID: PMC9349626 DOI: 10.1111/ijd.16319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/07/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The implications of COVID-19 co-infection in patients under treatment for Hansen's disease (HD, leprosy) remain uncertain. We aimed to describe clinical characteristics, treatments, and outcomes in patients with HD and COVID-19 in Brazil. METHODS Cross-sectional study recruiting adult HD patients with PCR-confirmed COVID-19 from five HD treatment centers in Brazil between March 1, 2020, and March 31, 2021. At the time of this study, no patient had received COVID-19 vaccine. RESULTS Of 1377 patients under treatment for HD, 70 (5.1%) were diagnosed with COVID-19. Of these, 41 (58.6%) had PCR-confirmed COVID-19, comprising 19 men and 22 women, aged 24-67 (median 45) years. HD was multibacillary in 39/41 patients. Eight patients ceased WHO Multi-Drug Therapy for HD, three for lack of drugs, two because of COVID-19, and three for other reasons. Of the 33 who continued treatment, 26 were on the standard regimen and seven an alternative regimen. Seventeen patients were receiving oral prednisone, including nine patients with type 1 reaction, four with type 2 reaction, three with neuritis, and one with rheumatologic disease. Twelve patients were hospitalized for COVID-19, and six patients died, of whom three had hypertension and one also had type 2 diabetes and obesity. CONCLUSIONS COVID-19 and Hansen's disease co-infection did not appear to change the clinical picture of either disease in this cross-sectional study. The wider impact of the pandemic on persons affected by HD requires follow-up and monitoring.
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Affiliation(s)
- Taynah Alves Rocha Repsold
- Programa de Pós-Graduação em Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil
| | - Simon M Collin
- Programa de Pós-Graduação em Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil.,Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use, and Sepsis Division, United Kingdom Health Security Agency, London, UK
| | | | | | | | | | | | | | - Seyna Rabelo Mendes
- Serviço de Referência em Hansenologia, Secretaria Municipal de Saúde de Palmas, Tocantins, Brazil
| | | | | | - Patrícia D Deps
- Programa de Pós-Graduação em Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitória, Brazil.,Departamento de Medicina Social, Universidade Federal do Espírito Santo, Vitória, Brazil
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6
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Saraswat N, Tripathy DM, Kumar S, Awasthi P, Gopal MM. A spectrum of leprosy reactions triggered by Covid-19 vaccination: a series of four cases. J Eur Acad Dermatol Venereol 2022; 36:e858-e860. [PMID: 35766884 PMCID: PMC9350223 DOI: 10.1111/jdv.18339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- N Saraswat
- Department of Dermatology, Military Hospital, Agra, India
| | - D M Tripathy
- Department of Dermatology, Military Hospital, Agra, India
| | - S Kumar
- Department of Dermatology, Motilal Nehru Medical College, Allahabad, India
| | - P Awasthi
- Department of Radiodiagnosis & Imaging, Military Hospital, Agra, India
| | - M M Gopal
- Department of Pathology & Histopathology, Command Hospital, Lucknow, India
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7
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Mendes AFM, Gomes CM, Kurizky PS, Ianhez M. Case Report: A Case Series of Immunobiological Therapy (Anti-TNF-α) for Patients With Erythema Nodosum Leprosum. Front Med (Lausanne) 2022; 9:879527. [PMID: 35814767 PMCID: PMC9263440 DOI: 10.3389/fmed.2022.879527] [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: 02/19/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
Patients with leprosy may experience a chronic and severe type II leprosy reaction (ENL) erythema nodosum leprosum that may not respond to thalidomide and systemic immunosuppressants or may even cause serious adverse events. We here present four patients in whom anti-TNF-α therapy was used with successful results and compare our findings with other published cases. Four patients with chronic and severe ENL who did not respond to, at least, thalidomide and steroids (high doses) were followed up at two reference centers in Brazil. A thorough laboratory investigation was performed to exclude tuberculosis and other diseases before the start of immunobiological medication. Three patients were started on etanercept, and one patient was started on adalimumab. Of all patients, three developed severe adverse events resulting from the use of classical immunosuppressants for ENL (cataracts, deep vein thrombosis, diabetes, and osteoporosis). In all cases, a reduction in the number of ENL and, at least half of the immunosuppressant dose between 6 months and 2 years, were observed. Long-term follow-up of one patient revealed a dramatic reduction in hospital admissions due to ENL, from 12 instances in 1 year (before biologic therapy) to none (after biologic therapy), along with an improvement in condyloma acuminatum. In addition, no direct adverse events were observed with biologics. Treatment with anti-TNF-α therapy may be used as an alternative in patients with chronic and severe ENL who do not respond to traditional treatment (e.g., thalidomide, steroids, and other immunosuppressants). This treatment can help reduce the frequency of ENL, the immunosuppressive burden, and the number of hospital admissions.
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Affiliation(s)
| | - Ciro Martins Gomes
- Departamento de Dermatologia, Universidade de Brasília (UnB), Brasília, Brazil
| | | | - Mayra Ianhez
- Dermatologia, Hospital de Doenças Tropicais, Goiânia, Brazil
- Dermatologia, Universidade Federal de Goiás (UFG), Goiânia, Brazil
- *Correspondence: Mayra Ianhez
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de Oliveira JADP, de Athaide MM, Rahman AU, de Mattos Barbosa MG, Jardim MM, Moraes MO, Pinheiro RO. Kynurenines in the Pathogenesis of Peripheral Neuropathy During Leprosy and COVID-19. Front Cell Infect Microbiol 2022; 12:815738. [PMID: 35281455 PMCID: PMC8907883 DOI: 10.3389/fcimb.2022.815738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/27/2022] [Indexed: 11/18/2022] Open
Abstract
Inflammatory disorders are associated with the activation of tryptophan (TRYP) catabolism via the kynurenine pathway (KP). Several reports have demonstrated the role of KP in the immunopathophysiology of both leprosy and coronavirus disease 19 (COVID-19). The nervous system can be affected in infections caused by both Mycobacterium leprae and SARS-CoV-2, but the mechanisms involved in the peripheral neural damage induced by these infectious agents are not fully understood. In recent years KP has received greater attention due the importance of kynurenine metabolites in infectious diseases, immune dysfunction and nervous system disorders. In this review, we discuss how modulation of the KP may aid in controlling the damage to peripheral nerves and the effects of KP activation on neural damage during leprosy or COVID-19 individually and we speculate its role during co-infection.
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Affiliation(s)
| | | | - Atta Ur Rahman
- Leprosy Laboratory, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Marcia Maria Jardim
- Leprosy Laboratory, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- Department of Neurology, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Milton Ozório Moraes
- Leprosy Laboratory, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Roberta Olmo Pinheiro
- Leprosy Laboratory, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- *Correspondence: Roberta Olmo Pinheiro,
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Cerqueira SRPS, Deps PD, Cunha DV, Bezerra NVF, Barroso DH, Pinheiro ABS, Pillegi GS, Repsold TAR, Kurizky PS, Collin SM, Gomes CM. The influence of leprosy-related clinical and epidemiological variables in the occurrence and severity of COVID-19: A prospective real-world cohort study. PLoS Negl Trop Dis 2021; 15:e0009635. [PMID: 34319982 PMCID: PMC8351963 DOI: 10.1371/journal.pntd.0009635] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 08/09/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Protective effects of Bacillus Calmette-Guérin (BCG) vaccination and clofazimine and dapsone treatment against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported. Patients at risk for leprosy represent an interesting model for assessing the effects of these therapies on the occurrence and severity of coronavirus disease 2019 (COVID-19). We assessed the influence of leprosy-related variables in the occurrence and severity of COVID-19. METHODOLOGY/PRINCIPAL FINDINGS We performed a 14-month prospective real-world cohort study in which the main risk factor was 2 previous vaccinations with BCG and the main outcome was COVID-19 detection by reverse transcription polymerase chain reaction (RT-PCR). A Cox proportional hazards model was used. Among the 406 included patients, 113 were diagnosed with leprosy. During follow-up, 69 (16.99%) patients contracted COVID-19. Survival analysis showed that leprosy was associated with COVID-19 (p<0.001), but multivariate analysis showed that only COVID-19-positive household contacts (hazard ratio (HR) = 8.04; 95% CI = 4.93-13.11) and diabetes mellitus (HR = 2.06; 95% CI = 1.04-4.06) were significant risk factors for COVID-19. CONCLUSIONS/SIGNIFICANCE Leprosy patients are vulnerable to COVID-19 because they have more frequent contact with SARS-CoV-2-infected patients, possibly due to social and economic limitations. Our model showed that the use of corticosteroids, thalidomide, pentoxifylline, clofazimine, or dapsone or BCG vaccination did not affect the occurrence or severity of COVID-19.
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Affiliation(s)
- Selma Regina Penha Silva Cerqueira
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
- Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
| | - Patrícia Duarte Deps
- Post-Graduation Programme of Infectious Diseases, Federal University of Espírito Santo, Vitória, Brazil
| | - Débora Vilela Cunha
- Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
| | | | - Daniel Holanda Barroso
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
- Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
| | | | | | | | - Patrícia Shu Kurizky
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
- Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
| | - Simon M. Collin
- Post-Graduation Programme of Infectious Diseases, Federal University of Espírito Santo, Vitória, Brazil
| | - Ciro Martins Gomes
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
- Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
- Programa de Pós-Graduação em Medicina Tropical, Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
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