Polymyalgia rheumatica and giant cell arteritis following COVID-19 vaccination: Results from a nationwide survey

We conducted a national in-depth analysis including pharmacovigilance reports and clinical study to assess the reporting rate (RR) and to determine the clinical profile of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) in COVID-19-vaccinated individuals. First, based on the French pharmacovigilance database, we estimated the RR of PMR and GCA cases in individuals aged over 50 who developed their initial symptoms within one month of receiving the BNT162b2 mRNA, mRNA-1273, ChAdOx1 nCoV-19, and Ad26.COV2.S vaccines. We then conducted a nationwide survey to gather clinical profiles, therapeutic management, and follow-up data from individuals registered in the pharmacovigilance study. A total of 70 854 684 COVID-19 vaccine doses were administered to 25 260 485 adults, among which, 179 cases of PMR (RR 7. 1 cases/1 000 000 persons) and 54 cases of GCA (RR 2. 1 cases/1 000 000 persons) have been reported. The nationwide survey allowed the characterization of 60 PMR and 35 GCA cases. Median time to the onset of first symptoms was 10 (range 2-30) and 7 (range 2-25) days for PMR and GCA, respectively. Phenotype, GCA-related ischemic complications and -large vessel vasculitis as well as therapeutic management and follow-up seemed similar according to the number of vaccine shots received and when compared to the literature data of unvaccinated population. Although rare, the short time between immunization and the onset of first symptoms of PMR and GCA suggests a temporal association. Physician should be aware of this potential vaccine-related phenomenon.

[Colchicine and non-severe ocular inflammation excluding Behcet's disease: 16 cases and literature review]

INTRODUCTION

Colchicine is a narrow therapeutic margin drug that does not have the adverse effects of corticosteroids and immunosuppressants. Its use in non-severe ocular inflammatory disease excluding Behcet's disease has not been studied.

METHODS

We included patients seen in the internal medicine department of Dijon University Hospital consecutively between September 2020 and September 2021 if they had received colchicine during their pathology. Patients with suspected Behçet's disease were excluded. Treatment efficacy was studied in patients with at least one year of disease progression who had received more than one year of colchicine. Successful treatment was defined as a 50 % reduction in the number of annual relapses on colchicine.

RESULTS

Sixteen patients were included (9 women and 7 men). They had recurrent anterior uveitis (n=10), recurrent scleritis (n=5) and intermediate uveitis. Opthalmological involvement was neither severe nor complicated. All patients combined, the annual relapse ratio (ARR) decreased from 1.8 (0.8-3.5) to 0.3 (0-1.6), (P=0.06). Colchicine was considered effective in three of 10 analyzable patients. In only one patient, treatment was stopped for adverse effects after six weeks.

CONCLUSION

In view of the interesting benefit-risk ratio of colchicine, it seems appropriate to focus on this molecule in non-granulomatous anterior uveitis and non-severe recurrent scleritis.

T-cell immune response predicts the risk of critical SARS-Cov2 infection in hospitalized COVID-19 patients

INTRODUCTION

This study aimed to identify markers of disease worsening in patients hospitalized for SARS-Cov2 infection.

PATIENTS AND METHODS

Patients hospitalized for severe recent-onset (<1 week) SARS-Cov2 infection were prospectively included. The percentage of T-cell subsets and plasma IL-6 at admission (before any steroid therapy) were compared between patients who progressed to a critical infection and those who did not.

RESULTS

Thirty-seven patients (18 men, 19 women) were included; 11 (30%) progressed to critical infection. At admission, the critical infection patients were older (P = 0.021), had higher creatinine levels (P = 0.003), and decreased percentages of circulating B cells (P = 0.04), T cells (P = 0.009), and CD4+ T cells (P = 0.004) than those with a favorable course. Among T cell subsets, there was no significant difference between the two groups except for the percentage of Th17 cells, which was two-fold higher in patients who progressed to critical infection (P = 0.028). Plasma IL-6 at admission was also higher in this group (P = 0.018). In multivariate analysis, the percentage of circulating Th17 cells at admission was the only variable associated with higher risk of progression to critical SARS-Cov2 infection (P = 0.021).

CONCLUSION

This study suggests that an elevated percentage of Th17 cells in patients hospitalized for SARS-Cov2 infection is associated with an increased risk of progression to critical disease. If these data are confirmed in a larger study, this marker could be used to better target the population of patients in whom tocilizumab could decrease the risk of progression to critical COVID-19.

L’augmentation du pourcentage de lymphocytes Th17 est associée à un risque d’évolution vers une forme grave d’infection à SARS-CoV-2

Introduction

Depuis décembre 2019, plus de 20 millions de français ont été infectés par le SARS-CoV-2 et plus de 130 000 en sont décédés. La physiopathologie de cette infection n’est pas totalement élucidée. Il a été démontré qu’elle provoquait une importante sécrétion de cytokines pro-inflammatoires, en particulier d’interleukine-6 (IL-6) [1]. Lorsque les patients infectés sont hospitalisés, ils reçoivent généralement de la dexaméthasone et parfois un traitement anti-infectieux. Si la maladie s’aggrave, le tocilizumab peut être ajouté [2]. Actuellement, seule l’évolution clinique incite à débuter le tocilizumab, mais parfois trop tardivement. Il manque aux cliniciens un marqueur précoce leur permettant de prédire le risque d’aggravation de la maladie. Cette étude, menée chez des patients hospitalisés pour infection à SARS-CoV-2 pendant la 2^e vague, avait pour objectif de rechercher un marqueur d’aggravation de la maladie en comparant la réponse lymphocytaire entre les patients évoluant vers une forme grave et les autres.

Patients et méthodes

Les patients hospitalisés pour infection à SARS-CoV-2 prouvée par RT-PCR datant de moins d’une semaine ont été inclus prospectivement dans cette étude monocentrique. Une infection grave était définie par un transfert en soins intensifs, en réanimation ou le décès. Des prélèvements sanguins ont été obtenus à l’admission à l’hôpital et avant de débuter la corticothérapie afin d’étudier les sous-populations lymphocytaires par cytométrie en flux et doser l’IL-6 plasmatique par immunofluorimétrie. Les données sont exprimées en nombre (%) ou médiane (espace inter-quartile).

Résultats

De septembre à décembre 2020, 37 patients (18 hommes, 19 femmes) hospitalisés pour infection à SARS-Cov2 ont été inclus : âge = 81,7 (70,3–87,5) ans, IMC = 25,7 (23,7–29) kg/m², hypertension artérielle (54 %), diabète (24 %), dyslipidémie (35 %), tabagisme (24 %), cardiopathie ischémique (8 %), maladie cérébrovasculaire (11 %). La durée de suivi était de 10 (8–15) jours. Parmi les 37 patients inclus, 11 (30 %) ont présenté une infection à SARS-CoV-2 grave dont 4 transferts en réanimation et 8 décès. À l’admission, les patients ayant une infection évoluant vers une forme grave étaient plus âgés (p = 0,021), avaient une créatininémie plus élevée (p = 0,003) et une diminution du pourcentage de lymphocytes B (p = 0,04), de lymphocytes T (p = 0,009) et de lymphocytes T CD4+ (p = 0,004) circulants parmi les lymphocytes totaux comparativement aux patients dont l’évolution était favorable. Parmi les sous-populations lymphocytaires T étudiées (mémoires, naïfs, Th1, Th2, Th17, Treg, Tc1, Tc17, T CD8 cytotoxiques), il n’y avait pas de différence significative entre les deux groupes en dehors du pourcentage de lymphocytes Th17 à l’admission qui était deux fois plus élevé chez les patients dont l’infection évoluait vers une forme grave (0,44 vs 0,23 % des LT CD4 totaux ; p = 0,028). Chez les patients ayant une infection évoluant vers une forme grave, l’IL-6 plasmatique à l’admission était plus élevée (39 vs 13,1 pg/mL ; p = 0,018) et la CRP à l’admission avait tendance à être plus élevée sans atteindre le seuil de significativité (58 vs 18,5 mg/L ; p = 0,17). En analyse multivariée (régression logistique binaire comprenant les variables : âge, créatininémie, CRP, hémoglobine, lymphocytes T CD4, Th17, Treg activés (CD4 + CD45RA-FoxP3high), lymphocytes B, IL-6 sérique), la seule variable associée au risque d’évolution vers une forme grave de l’infection était le pourcentage de lymphocytes Th17 circulants (p = 0,034). L’aire sous la courbe de la courbe ROC évaluant la sensibilité et la spécificité du pourcentage de lymphocytes Th17 pour prédire une forme grave d’infection à SARS-CoV-2 chez un patient hospitalisé était de 0,75 (intervalle de confiance à 95 % : 0,56–0,95). Enfin, le fait d’avoir un pourcentage de lymphocytes Th17 > 0,435 % des lymphocytes T CD4 totaux au moment de l’admission en hospitalisation était associé à une moins bonne survie (p = 0,024).

Conclusion

Cette étude suggère qu’une élévation du pourcentage de lymphocytes Th17 chez des patients hospitalisés pour infection à SARS-CoV-2 augmente significativement le risque d’évolution vers une forme grave de la maladie. Ce résultat est cohérent avec le fait qu’il a été démontré que le tocilizumab, qui est efficace dans le traitement des formes graves de COVID-19 [2], inhibe la réponse lymphocytaire Th17 [3]. Ces données méritent d’être confirmées chez un plus grand nombre de patients afin de confirmer ce résultat car cette mesure pourrait permettre de mieux cibler la population de patients à qui proposer précocement un traitement par tocilizumab pour diminuer le risque d’évolution vers une forme grave d’infection à SARS-CoV-2.

Is there a need to widely prescribe antibiotics in patients hospitalized with COVID-19?

BACKGROUND

Debate continues regarding the usefulness and benefits of wide prescription of antibiotics in patients hospitalized with coronavirus disease 2019 (COVID-19).

METHODS

All patients hospitalized in the Infectious Diseases Department, Dijon University Hospital, Dijon, France between 27 February and 30 April 2020 with confirmed COVID-19 were included in this study. Clinical, biological and radiological data were collected, as well as treatment and outcome data. An unfavourable outcome was defined as death or transfer to the intensive care unit. Patient characteristics and outcomes were compared between patients who did and did not receive antibiotic therapy using propensity score matching.

FINDINGS

Among the 222 patients included, 174 (78%) received antibiotic therapy. The univariate analysis showed that patients who received antibiotic therapy were significantly older, frailer and had more severe presentation at admission compared with patients who did not receive antibiotic therapy. Unfavourable outcomes were more common in patients who received antibiotic therapy [hazard ratio (HR) 2.94, 95% confidence interval (CI) 1.07-8.11; P = 0.04]. Multi-variate analysis and propensity score matching indicated that antibiotic therapy was not significantly associated with outcome (HR 1.612, 95% CI 0.562-4.629; P = 0.37).

CONCLUSION

Antibiotics were frequently prescribed in this study and this was associated with more severe presentation at admission. However, antibiotic therapy was not associated with outcome, even after adjustment. In line with recent publications, such data support the need to streamline antibiotic therapy in patients with COVID-19.

COVID-19 ou non COVID-19 ? Comparaison des caractéristiques des patients hospitalisés pour une suspicion de COVID-19

Introduction

Matériels et méthodes

Résultats

Conclusion

[Clinical efficacy of eculizumab as treatment of gemcitabine-induced thrombotic microangiopathy: A case report]

INTRODUCTION

Gemcitabine-induced thrombotic microangiopathy is a rare event whose management is not yet consensual. The use of eculizumab could be of interest.

CASE REPORT

A 68-year-old woman was treated by gemcitabine as adjuvant chemotherapy of a pancreatic adenocarcinoma. Two months later, the patient presented with mechanical hemolytic anemia, thrombocytopenia and high blood pressure that led to the diagnosis of thrombotic microangiopathy. Gemcitabine was stopped. Plasma exchange therapy was introduced since hematological and renal parameters had worsened. As clinical efficacy was insufficient, eculizumab was introduced at a dose of 900 mg per week 4 times, then 1200 mg every 2 weeks. Symptoms along with hematological and nephrological analysis were back to physiological standards after 7 intravenous injections.

CONCLUSION

Eculizumab seems to be an effective treatment against gemcitabine-induced thrombotic microangiopathy in case of severe hematological and renal injuries associated with a lack of response to plasma exchange therapy.