VACCINATION AGAINST COVID-19 IN PARAGUAYAN PATIENTS WITH RHEUMATOID ARTHRITIS

BackgroundIn February 2021, the first doses of COVID-19 vaccines were received in Paraguay, and rheumatic patients were the preferred population to get these vaccines. Up to December 2022 the vaccination coverage in Paraguay was 59.4%, with at least one vaccine dose. 52.4% accessed the primary scheme (two doses), while 28.6% had at least one booster dose. Only 7.1% completed the COVID-19 immunization scheme.ObjectivesTo describe vaccination against COVID-19 in Paraguayan patients with Rheumatoid Arthritis (RA).MethodsDescriptive, cross sectional, observational study, in a Paraguayan cohort of RA patients meeting ACR/EULAR2010 criteria, under follow-up in two Rheumatology reference centers, from October to December 2022. A standardized questionnaire according to the variables included (clinical, vaccination, vaccine type, number of doses) was made. Quantitative variables were presented as means and qualitative as frequencies.Results568 patients with RA were included, 84.1% were female, mean age 55.48±13.94 years old. 23.9% patients were from Hospital de Clínicas and 76.1% from Hospital Central del Instituto de Previsión Social. The average number of received vaccinations doses was 2.54±1.19. 88.7% of patients acquired at least one dose of COVID-19 vaccine, 85% obtained two doses;and, while 60.9% of patients received the first booster, 21.2% had the second one.ConclusionIn this series of Paraguayan RA patients, vaccination against COVID-19 is higher than the general population, perhaps due to priority of patients with rheumatic diseases receiving immunization, and frequent access to medical care with physician's prompt to receive vaccinations. While over 80% of patients have a complete primary schedule, and more than 60% received the first booster;only 21% have a complete immunization schedule, which is still much higher than the general population in Paraguay.Table 1.Vaccines in Paraguayan patients with Reumatoid ArthritisVaccines against COVID-19First Dose n: 504Second Dose n: 483First booster n: 344Second booster n: 122Sputnik V(Gam--COVID-Vac) n (%)149 (26.2)137 (24.1)10 (1.8)0Astrazeneca (ChAdOx1 nCoV-19) n (%)172 (30.3)171 (30.1)110 (19.4)36 (29.5)Pfizer n (BNT162b2) (%)81 (14.3)80 (14.1)198 (34.9)68 (55.7)Moderna (mRNA-1273) n (%)41 (7.2)38 (6.7)22 (3.9)18 (14.8)Hayat Vax n (%)29 (5.1)28 (4.9)1 (0.2)0Sinopharm BBIBP n (%)2 (0.4)1 (0.2)00Covaxin n (%)28 (4.9)26 (4.6)3 (0.5)0CoronaVac n (%)2 (0.4)2 (0.4)00REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

DIFFERENCES IN HUMORAL RESPONSE AFTER SARS-COV-2 VACCINATION BETWEEN KIDNEY TRANSPLANT AND PERITONEAL DIALYSIS PATIENTS: WHAT IS THE IMPACT OF IMMUNOSUPPRESSION?

BACKGROUND AND AIMS: Patients on renal replacement therapy are reported to have altered humoral immunity, which is demonstrated by a decreased response to different vaccines. However, in kidney transplant (KT) patients, vaccines are even less immunogenic in terms of antibody response. Therefore, these patients have a higher risk of critical infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which makes them eligible for early vaccination. The aim of this study was to compare the humoral response after complete vaccination against SARS-CoV-2 between KT patients and peritoneal dialysis (PD) patients. METHOD: We conducted a single-center, retrospective study, which included 67 KT recipients and 49 prevalent PD patients. Patients were excluded if they had previously known SARS-CoV-2 infection or positive anti-nucleocapsid IgG or IgM antibodies. Completion of vaccination was defined as two doses of a messenger RNA vaccine (BNT162b2 messenger RNA vaccine [Pfizer-BioNTech] or messenger RNA- 1273 [Moderna]), two doses of viral vector vaccine ChadOx1 nCoV-19/AZD1222 (AstraZeneca) or one dose of JNJ-78 436 735 (Janssen) vaccine. Anti-spike (anti-S) IgG antibodies were measured, at least, 21 days after the completion of vaccination and before receiving a 'booster' dose. A value of anti-S >0.8 U/mL was considered positive. Immunogenicity of the vaccine, measured by anti-spike IgG antibodies, was compared between KT recipients and PD patients. RESULTS: The mean age of the population was 58.8 ± 13.6 years and 62.0% were males (similar between the two groups). The median interval between completion of vaccination and serologic analysis was 4.1 months in KT patients and 7.1 months in PD patients. In KT patients, the median anti-S level was 1.50 U/mL (IQR 0.0-27.3) versus 97.0 U/mL (IQR 34.5-447.0) in PD patients (P < .001). In the KT group, there were 31 (46.3%) non-responders (patients without detectable levels of anti-S), while in the second there were only two (4.1%). In KT patients, anti-S levels were not associated with time since transplant or immunosuppressive induction therapy. In PD patients, anti-S levels were not associated with time since the beginning of PD. In both groups, anti-S levels were not associated with age, gender, type of administered vaccine or interval between completion of vaccination and serologic analysis. CONCLUSION: We found a significant difference in humoral responses to the vaccine between PD and KT transplant patients with no previous exposure to SARSCoV- 2. In PD patients, the vaccine seemed to be effective. On the contrary, KT patients had a significantly weaker rising of anti-S titers, with a high proportion of patients not responding to the vaccine. This study emphasizes the negative impact of immunosuppression on humoral responses, reinforcing the need for a 'booster' dose in this group of patients.

COVID-19 VARIANTS AMONG US? PATIENT WITH COVID-19 CLINICAL PHENOTYPE, NEGATIVE RT-PCR TESTING, BUT POSITIVE IGM ANTIBODIES

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: As the COVID-19 pandemic progresses, genetic variants have been identified globally, including the UK, South Africa, and Brazil strains. These variants exhibit genetic mutations in spike proteins and open reading frame regions. Rising cases of COVID-19 strains call to question the accuracy of current polymerase chain reaction (PCR) testing in detecting genetic variants. CASE PRESENTATION: A 76-year-old male nursing home resident was brought to the emergency department (ED) by ambulance due to progressively worsening dyspnea. His past medical history was remarkable for COPD and diabetes mellitus type II. On initial presentation, his respiratory rate was 30 breaths per minute, heart rate was 128 beats per minute, blood pressure was 135/64 mmHg, and oxygen saturation was 92% on supplemental oxygen via bilevel positive airway pressure (BIPAP). Physical exam was remarkable for bilateral rhonchi with accessory muscle use. Labs were remarkable for a white blood cell count of 16.5 109/L with lymphopenia, lactic acid of 2.2 mmol/L, and a d-dimer of 5250 ng/mL. Chest CT showed bilateral patchy ground glass infiltrates, fibrotic changes, and small bilateral pleural effusions (Image 1). He tested negative for influenza A and B, Mycoplasma pneumoniae, Streptococcus pneumonia, and Legionella. Sputum cultures showed no growth. The patient tested negative for COVID-19 twice by RT-PCR analysis (Abbott Laboratory, Chicago, IL). He was treated with intravenous steroids and broad-spectrum antibiotics. He was unable to be weaned from BIPAP to a lower level of supplemental oxygen. Eight days after hospital admission, the patient tested positive for COVID-19 IgM and IgG antibodies. After 12 days of treatment, the patient suffered a fatal cardiac arrest. DISCUSSION: We present an elderly man with a clinical symptoms and imaging findings highly suggestive of COVID-19, despite multiple negative RT-PCR tests. The patient did not improve despite treatment with broad spectrum antibiotic and intravenous corticosteroids. Patients had positive COVID-19 IgM antibodies, despite no known recent prior infection. Although the lab utilized for COVID-19 RT-PCR analysis asserts that testing is not impacted by genetic variants, these cases challenge the true sensitivity of this testing in detecting emerging strains. CONCLUSIONS: There are potentially many patients in the community hospitals presenting with COVID-19 variants that are not detected by existing RT-PCR testing. The genetic diversity of COVID-19 may diminish the sensitivity of RT-PCR testing, as labs across the country utilize different primers and probes with variable sensitivities in detecting variants. Clinicians should maintain a high suspicion for COVID-19, despite negative PCR testing. REFERENCE #1: Wang R, Hozumi Y, Yin C, Wei G-W. Mutations on COVID-19 diagnostic targets. Genomics. 2020;112(6):5204-5213. REFERENCE #2: Sapoval N, Mahmoud M, Jochum MD, et al. SARS-CoV-2 genomic diversity and the implications for qRT-PCR diagnostics and transmission. Genome Res. 2021;31(4):635-644. DISCLOSURES: No relevant relationships by Gustavo Avila, source=Web Response No relevant relationships by Jessica Baek, source=Web Response No relevant relationships by Renuka Reddy, source=Web Response No relevant relationships by Claudia Tejera Quesada, source=Web Response no disclosure on file for Adam Wellikoff;

Interesting case of post-COVID thromboprophylaxis failure

Introduction:Venous thromboembolism (VTE) is a leading cause of morbidity and mortality worldwide, with an annual incidence of 1 to 2 per 1000 per year in the US. Data support that this incidence is often secondary to thromboprophylaxis failure more than omission. Studies have demonstrated that an extensive pro-inflammatory and hypercoagulable state is present in COVID-19 patients, however the duration of this state post-infection is unclear. Early identification of additional risk factors for thromboprophylaxis failure warrants a closer follow up.Case Description:A 47-year-old man with obesity, recent COVID-19 pneumonia with ventilator dependent respiratory failure (VDRF) presents with one-day history of worsening abdominal pain and bloating due to pneumoperitoneum secondary to PEG tube placement 9 days prior. Patient was discharged after a prolonged admission for management of respiratory failure in the setting of COVID-19 infection that was complicated with severe hemodynamic compromising, subsequently managed with mechanical ventilation and V-V ECMO. Patient received DVT prophylaxis since admission. On presentation, patient was tachycardic in moderate respiratory distress and SpO2 of 94% on 75% FiO2. Further work-up revealed COVID PCR negative, elevated Ferritin of 1130 ng/mL, elevated NT-proB type Natriuretic peptide (NT-Pro BNP) of 467 pg/mL and elevated D-Dimer of 914 ng/mL. ABG revealed decreased PO2 and elevated A-a gradient. Computed tomography angiogram revealed moderate sized right upper lobe pulmonary embolism with no evidence of right heart strain. Patient was started on heparin drip.Discussion:The development of VTE despite prophylaxis is not uncommon. The rates of DVT in the absence of prophylaxis range between 40 and 60% and 2-5% in its presence. It is pertinent learning to identify high risk patients to develop VTE and consider anticoagulation at a higher dose or for a longer period of time even after discharge. Patients with COVID-19 infection possess and additional risk from the underlying hypercoagulable state and a worse outcome is expected. The high risk of thrombosis in COVID-19 is demonstrated by the increase in d-dimer, which was found to be the most significant change in coagulation parameters in these group, suggesting increased thrombin production and activation of fibrinolysis. There is therefore a need to identify the increased risk of VTE at an early stage and to prevent thrombotic events and organ damage as far as possible. More data is needed on how long this hypercoagulability period persist, but definite steps need to be taken to address this common complication in this special population.