ABSTRACT
TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is a rare but severe life-threatening condition characterized by widespread bleeding of the pulmonary vasculature into the alveolar space. DAH have a myriad of underlying etiologies. Rheumatic diseases have shown association with DAH. The Coronavirus disease 2019 (COVID-19) pandemic has increased the complexity associated with diagnosing DAH. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infects the endothelium using the angiotensin-converting enzyme 2 receptor causing a lymphocytic endotheliitis. The increased inflammatory state secondary to COVID-19 has been associated with development of vasculitis syndromes. Although systemic sclerosis (SSc) has been linked to recurrent DAH, there is scarce evidence associating COVID-19 and SSc with DAH. CASE PRESENTATION: A 61-year-old female with a past medical history of SSc, interstitial lung disease (ILD) and DAH presented with worsening shortness of breath of 2 days duration. She was found to have acute hypoxic respiratory failure. Computed tomography (CT) of thorax showed diffuse bilateral ground-glass opacities. SARS-Cov-2 polymerase chain reaction was positive. She was started on broad spectrum antibiotics, dexamethasone and received two units of COVID-19 convalescent plasma. Due to respiratory distress, she was intubated. A decline in her hemoglobin prompted a diagnostic bronchoscopy that showed increasing frank blood in the bronchoalveolar lavage. Antinuclear antibody with centromere pattern and rheumatoid factor were positive with low complement C3 and C4. Steroids were switched to high-dose IV methylprednisolone. Three cycles of plasmapheresis were given with no clinical improvement. DISCUSSION: COVID-19 pandemic has changed the traditional approach to dyspnea. This change in the paradigm, as a result of limited resources and increased occupational risk, may hinder the diagnosis of complex disorders like SSc-ILD and DAH. It's of paramount importance to test rapidly for SARS-CoV-2 infection. ILD is a common complication of SSc. The high-resolution CT similarities between the 2 diseases make it difficult to distinguish COVID-19-ILD superinfection from worsening of SSc-ILD. Bronchoscopy and surgical lung biopsy should always be weighed against their possible complications, occupational exposure and prognosis. CONCLUSIONS: COVID-19 may overlap and complicate the diagnosis of SSc-ILD. COVID-19 associated acute respiratory distress syndrome is attributed to cytokines release (cytokine storm). This likely worsens the underlying inflammatory process in SSc-ILD and could explain the development of DAH. Although there is limited evidence to guide specific treatment, steroid therapy has proven to have mortality benefit in severe COVID-19. The role of steroids, plasmapheresis, immunomodulators and antifibrotic therapy in COVID-19 with SSc-ILD complicated with DAH is unknown. REFERENCE #1: Colby TV, Fukuoka J, Ewaskow SP, Helmers R, Leslie KO. Pathologic approach to pulmonary hemorrhage. Annals of Diagnostic Pathology. 2001;5(5):309-19. REFERENCE #2: Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, et al. Endothelial cell infection and endotheliitis in COVID-19. The Lancet. 2020;395(10234):1417-8. REFERENCE #3: Wong AW, Fidler L, Marcoux V, Johannson KA, Assayag D, Fisher JH, et al. Practical Considerations for the Diagnosis and Treatment of Fibrotic Interstitial Lung Disease During the Coronavirus Disease 2019 Pandemic. Chest. 2020;158(3):1069-78. DISCLOSURES: No relevant relationships by Vedesh Babu, source=Web Response No relevant relationships by Alejandra Garcia Fernandez, source=Web Response No relevant relationships by ahmad hamdan, source=Web Response No relevant relationships by Carlos Matute Martinez, source=Web Response
ABSTRACT
Background: Patients with inflammatory rheumatic diseases (IRD) infected with SARS-CoV-2 may be at risk to develop a severe course of COVID-19 due to the immune dysregulation or the influence of immunomodulating drugs on the course of the infection. For a better understanding of SARS-CoV-2 infections in patients with IRD and due to the high incidence of COVID-19 in Madrid from the beginning of this pandemic infection in Spain, the Society of Rheumatology from Madrid (SORCOM) established a registry (REUMA-COVID SORCOM) shortly after the beginning of the pandemic in Spain. Objectives: To determine factors associated with severity of infection with SARS-CoV-2 in patients with inflammatory rheumatic diseases in Madrid Methods: The REUMA-COVID SORCOM registry is a multicenter, retrospective, observational cohort study conducted in Madrid, a SORCOM initiative. All rheumatology departments from Madrid were invited to participate. The study includes patients with IRD presenting with a confirmed or highly suspected diagnosis of COVID-19 between March 1, 2020, and November 10, 2020. We consider severe infection death or need of hospitalization. Inclusion criteria was having an IRD and at least 1 of the following 4 criteria: (1) a biologically confirmed COVID-19 diagnosis based on a positive result of a SARS-CoV-2 polymerase chain reaction (PCR) test on a nasopharyngeal swab;(2) Detection of IgM or IgG anti SARSCoV2 in a symptomatic or asymptomatic patients (3)typical thoracic computed tomography (CT) abnormalities (ground-glass opacities) in epidemic areas;(4) COVID19-typical symptoms in an epidemic zone of COVID-19. Results: As of November 10, 2020, 417 patients with IRD were included in the REUMA-COVID SORCOM registry. 5 patients were discharged for incomplete data. Of 412 patients (mean age 57 years, 87.4% Caucasian race, 66.3% female) 174 need hospitalization (42.2%) and 33 patients died (18.4% mortality in hospitalized patients). 82.3% had comorbidities. 234 (56.8%) patients were classified as inflammatory arthropathy, 133 (32.3%) had connective tissue diseases (CTD). 41.1% of the patients had a large history of IRD (≥ 10 years). 10.4% of patients had previously pulmonary involvement. The study includes 143 patients taking Methotrexate, 89 patients taking anti-TNFα therapy and 27 Rituximab. In the univariant analysis, no differences were seen in the severity of COVID-19 infection in patients taking methotrexate. 63% of the all patients taking Rituximab included in the registry need hospitalization and 22% of them died. Hypertension, COPD or cardiovascular disease was associated with hospitalization. Independent factors associated with COVID-19 hospitalization in the multivariate analysis was: age (≥62 years), male sex, IMC ≥30, previous cardiovascular comorbidities and the IRD disease duration (≥ 10 years). Independent factors associated with COVID-19 related death was: age (≥ 62 years), having a CTD diagnose, pulmonary involvement before infection and chronical GC treatment. Conclusion: Patients with IRD represent a population of particular interest in the pandemic context because the baseline immunological alteration and the treated with immunosuppressants agents they receive, comorbidities and the well-known risk of severe infection. Older age, male sex, cardiovascular comorbidities were factors associated with high risk of hospitalization in IRD patients. CTD diseases, previously pulmonary involvement and chronical GC treatment with more than 10mg/day were associated with high risk of death. Neither anti TNF-α treatment nor Methotrexate were risk factor for hospitalization or death COVID-19 related in IRD patients.
ABSTRACT
Background: Diagnosis of previous SARS-COV2 infection may be challenging in immunocompromised patients. Objectives: To analyze positivity rate to SARS-COV2 antibody tests (SC2AT) in patients diagnosed of rheumatic diseases (RMD) treated with Rituximab. Methods: We conducted a case-control study of patients diagnosed of RMD followed in a referral hospital in Madrid, Spain. Positivity rate to IgG-SC2AT were analyzed in Rituximab-treated patients (RTX) compared with patients treated with TNF inhibitors (TNFi) and/or conventional DMARDs (cDMARDs) (N-RTX). We included patients that received Rituximab in the previous year to a confirmed SARS-COV2 infection (defined as a positive polymerase chain reaction test (PCR) and/or compatible chest Xray), to a suspected SARS-COV2 infection (2 or more symptoms) or to SC2AT determination. Patients with RMD treated with other biological DMARDs (bDMARDs) rather than Rituximab or TNFi were excluded. Results: We included 152 patients with RMD who underwent a SC2AT. Main characteristics are reported in Table 1. Among RTX and N-RTX, 4/48 (8.3%) and 35/104 (33.7%) showed a positive IgG-SC2AT, respectively. Four out of 104 (38.5%) N-RTX tested positive without previous symptoms. No asymptomatic infection was diagnosed among RTX. Univariable analysis showed a lower rate of positivity to SC2AT in confirmed and suspected infection among RTX [Positive IgG-SC2AT in confirmed infection: RTX 4/10 (40%), N-RTX 16/20 (80%);p=0.045. Positive IgG-SC2AT in suspected infection: RTX 0/3 (0%), N-RTX 15/18 (83.3%);p=0.015]. A logistic binary regression identified previous symptoms [OR 61.2, 95CI(13.3-280.6) p=0.0001], male sex [OR 4.8, 95CI(1.3-17.8) p=0.02], non-rituximab treatment [OR 19.7, 95CI(3.6-106.3) p=0.001] as independent factors associated with a higher probability of positive IgG-SC2AT. Age, previous PCR status, corticosteroid and cDMARD use showed no statistical significance. This model accounted for 47.6% of positive cases. Conclusion: RTX had a lower rate of positivity to IgG-SC2AT compared to N-RTX. Previous symptoms, male sex and non-RTX treatment were independently associated with higher probability of positive IgG-SC2AT.