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Background: Multiple sclerosis (MS) patients have been considered a higher-risk population for COVID-19 due to the high prevalence of disability and disease-modifying therapy use;however, there is little data in our Middle East and North Africa region (MENA) identifying clinical characteristics of MS associated with worse COVID-19 outcomes. Material(s) and Method(s): This a nationwide, multicenter, retrospective cohort study conducted between March 2020 and February 2021 and included MS patients with a suspected or confirmed COVID-19. Using data collected from the MENACTRIMS registry and local COVID-19 registries, the association of patient demographics, MS disease characteristics, and use of disease-modifying therapies with outcomes and severity of COVID-19 illness were evaluated by multivariate logistic models. Result(s): A total of 600 MS patients with suspected (n=58) or confirmed (n=542) COVID-19 (mean age: 36.4 +/- 10.16 years;414 (69%) females;mean disease duration: 8.3+/- 6.6 years) were analyzed. Seventy-three patients (12.2%) had a COVID-19 severity score of 3 or more, and 15 patients (2.5%) died of COVID-19. The median EDSS was 2.0 (range, 0-9.5), and 559 patients (93.2%) were receiving disease-modifying therapy (DMT). There was a higher proportion of patients with a COVID-19 severity score of 3 or more among patients treated with DMTs relative to untreated patients (82.9% vs 17.1%;P < .001), from whom the majority (n=117;19.7%) were maintained on anti-CD20 therapies such as ocrelizumab and rituximab. Comorbidities mainly hypertension and cardiovascular diseases, progressive MS, disease duration, and EDSS were associated with severe or worse COVID-19 disease outcome. Multivariate logistic regression analysis showed that older age (odds ratio per 10 years, 1.5 [95%CI, 1.1-2.0]), male gender (OR, 2.1 [95%CI. 1.2-3.8]), obesity (OR, 2.8 [95%CI, 1.3-5.8]), and treatment ocrelizumab/rituximab (OR for ocrelizumab, 4.6 [95%CI. 1.2-17.7], OR for rituximab, 14.1 [95%CI, 4.8-41.3]) or off-label immunosuppressive medications such as azathioprine or mycophenolate mofetil (OR, 8.8 [95%CI. 1.7-44.0]) were risk factors for moderate to severe COVID-19 requiring hospitalization. Surprisingly, smoking and diabetes were not identified as risk factors for severe COVID-19 disease in our cohort. Conclusion(s): In this registry-based cohort study of patients with MS, age, sex, EDSS, obesity, progressive MS were independent risk factors for severe COVID-19. Moreover, there was an association found between exposure to anti-CD20 DMTs and COVID-19 severity. Knowledge of these risk factors may help improve the clinical management of MS patients with COVID-19 infection.Copyright © 2022
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Background: National Multiple Sclerosis Society and other international guidelines suggest that full COVID-19 vaccination status should be completed two to four weeks before starting Year 2 of treatment with cladribine tablets (CladT). CladT is administered twice over two years, Year 1 and Year 2. There is a special interest in real-world evidence on whether vaccination status may affect initiation of CladT treatment in Year 2. The objective of this analysis was to describe the proportion of patients treated with CladT who received COVID-19 vaccination, and whether this influenced the timing of initiating treatment with CladT in Year 2. Material(s) and Method(s): A vaccination questionnaire-based survey was sent to patients treated with CladT who were enrolled in the ADVEVA patient support program (PSP), upon their consent. The survey was carried out in the Gulf region (GULF) from Jun 2021 to Sept 2021, and in the Latin American region (LATAM) from Jan 2022 to Mar 2022. Demographics, COVID-19 vaccination status, type of vaccine(s), number of doses received, and dates of vaccination were collected. In each region, patient data from the survey were linked to data routinely collected by the PSP, with cut-off dates as mentioned. Fully vaccinated status was defined as having received 2 doses of mRNA vaccine, 1 dose of Johnson & Johnson vaccine or other vaccines approved by the World Health Organization, plus 14 days. Descriptive analyses were performed and time to Year 2 treatment initiation among those with at least 18 months' follow-up was estimated by vaccination status. Result(s): The survey participation rate in GULF was 87% (91 out of 105) and 19% in LATAM (152 out of 789). In total, 62 (68%) patients in GULF and 144 (95%) in LATAM were fully vaccinated against COVID-19. In both regions, among those with at least 18 months' follow-up (GULF, n=59;LATAM, n=81), all patients initiated Year 2 of treatment with CladT, regardless of vaccination status. In GULF, the mean (standard deviation) time to treatment initiation in Year 2 was 13.8(1.6) months among fully vaccinated patients (44%) and 13.3(3.5) months among those not fully vaccinated (21%). In LATAM, the mean time was 12.8(1.4) months among those fully vaccinated (52%) and 12.4(0.02) months among those not fully vaccinated (1.3%). In each region, only 1 patient initiated Year 2 treatment after at least 18 months from the start of Year 1. Conclusion(s): Most patients were fully vaccinated against COVID-19 in GULF and in LATAM, which was consistent with vaccination coverage and guidelines in both regions. In LATAM, low participation rates might lead to selection bias which limits interpretation of results. In these regions, with limited data, COVID-19 vaccination status did not appear to alter the time of treatment initiation with CladT in Year 2. Almost all patients followed the label recommendations in terms of timing of Year 2 treatment initiation.Copyright © 2022
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Background: The Gulf nations were among the first in the world to implement the COVID-19 vaccination. Regional guidelines like MENACTRIMS endorse that MS patients should be vaccinated against COVID-19. The vaccines being offered in the region include Sinopharm, Pfizer-BioNTech, Sputnik V, and Oxford-AstraZeneca. "Adveva™ Gulf is a Merck-sponsored health care provider (HCP) driven patient support program (PSP) for patients treated with cladribine tablets" Objectives: To describe the real-world experience on the use of COVID-19 vaccination in multiple sclerosis (MS) patients treated with cladribine tablets participating in the PSP. Methods: MS patients treated with cladribine tablets and participating in the PSP in the Gulf region were asked to participate in a questionnaire-based survey about their COVID-19 vaccination status. The interview was initiated by health educators over the phone, and they submitted the answers on the patient's behalf. Patient's verbal consent was required to start the questionnaire. Information collected included: Demographic, Treatment dates, Vaccination, and COVID-19 information. Results: Of the 106 MS patients, 92 (86%) patients provided consent to participate and completed the questionnaire. 77.5% of patients were females. All patients had been on cladribine tablets since 2018-till Sept 2021 (66% in Year 1, 15% in Year 2, and 19% in year 3 and 4). From the time of initiation of cladribine tablets, no switch to another disease modifying drugs (DMD) were observed. Overall, 74 (80.4%) of the cladribine tablets patients had received the COVID-19 vaccine. 51.4% and 41.9% of patients were vaccinated by the Pfizer and Sinopharm vaccines, respectively. Among those vaccinated in Year 1 and 2 (n=59), the mean time between the last dose of cladribine tablets and the first dose of the vaccine was 129 days. Of the patients who had not received the vaccine (n=18), 72.2% were planning to receive the vaccine. Only 2 patients were not willing to receive the vaccine for fear of complications. After completion of the COVID-19 vaccine regimen, 6 (8%) patients were infected with SARS-CoV-2, 5 of them confirmed by the RT-PCR test. All the cases were mild, and none of the patient's required hospitalization. No safety concerns were reported after the administration of the COVID-19 vaccine. The mean time from the completion of the vaccine series till the development of the SARS-CoV-2 infection was 79 days. Conclusions: The outcomes of this survey suggest that the use cladribine tablets didn't hinder the patients from receiving COVID-19 vaccinations. Few patients developed SARS-CoV-2 infection despite being vaccinated, but all had mild disease and did not require hospitalization. No safety concerns were observed. Continuous monitoring will be required to assess the safety and efficacy of the COVID-19 vaccine in this specific population. Meanwhile, MS patients should be encouraged to receive COVID-19 Vaccination.
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Background: CNS involvement in CLL is rare and it usually occurs in late-stage CLL disease. There is usual delay in the diagnosis due to its variable manifestations, challenging diagnosis process and possible misdiagnosis with a mimicker condition. I am sharing our relative successful experience with this challenging case that had satisfied outcome after going through comprehensive investigations and treatment journey treating his symptoms until arriving the final diagnosis and getting the best treatment option. Material(s) and Method(s): A 42 years old male, with recent COVID-19 infection, presented with multiple progressive neurologic symptoms over one month;started as numbness around the mouth, reduced facial sensation and a feeling of band like sensation below the costal margins. On exam, he had left abduction restriction, diplopia on left gaze and upbeat nystagmus, reduced facial sensation and hyperesthesia. The reflexes were 1+ in the upper limbs, 3+ in the lower limbs, up going planters, tingling from the feet up to T6 level and postural tremor bilaterally. His CSF showed high protein level. MRI brain/ spine revealed left frontal juxtacortical white matter and bilateral middle cerebral peduncles lesions with post-contrast enhancement and long segment spinal cord demyelinating plaques. He was initially treated as a case of Acute disseminated encephalomyelitis (ADEM) post viral infection in a background of CLL. The delayed diagnosis was due to temporal relation of neurological manifestation to viral infection, similar MRI lesions to ADEM and multiple negative CSF results of cytology and flow cytometry. He had persistent disabling symptoms and enhancing lesions in MRI despite being treated with IVMP, IVIG and PLEX. He was managed for ADEM based on responsiveness to the recommended therapy step by step. Firstly, he received a high-dose corticosteroids, secondly IV immunoglobulin but he was still progressing and considered as steroid-unresponsive ADEM. lastly, plasma exchange was done when he exhibited progressive symptoms with fair improvement. Interestingly, the patient showed significant improvement in the clinical and radiological parameters after starting him with a new anti-leukemia medication (Acalabrutinib) for his concurrent active condition. He run out of his medication for around 1 week and he experienced recurrent of the neurological manifestation and the previous lesions in the images. A repeated flow cytometry for the third time came positive for CLL cells and the final diagnosis of CNS involvement by CLL was established. The diagnosis was made after the exclusion of other etiologies. Result(s): The patient received Ibrutinib at a standard dose and as a monotherapy. It is an efficient chemotherapy that crosses the blood brain barrier and has showed a favorable clinical, biological and radiological outcome. The patient is back to his work and his daily activities have improved. Conclusion(s): In case of inconclusive work up, CSF analysis should be repeated testing for cytology and flow cytometry\immunophenotypes as the false negative results are common. Our patient had an active CLL proved in his investigations, and the fact that the patient responded very well to the new chemotherapy should alert the diagnosis of CNS involvement by CLL and directs towards repeating investigations and introducing aggressive treatment strategy to target both hematological and neurological complications of the condition.
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Objective(s): To evaluate the incidence, severity, and outcomes of coronavirus disease (COVID-19) and to identify demographic and clinical risk factors in patients with multiple sclerosis (MS). Material(s) and Method(s): A cross-sectional hospital records-based study was conducted on MS patients from clinics in Oman, Kuwait, and the United Arab Emirates (UAE) between March 2020 and February 2021. Patients diagnosed with MS using the 2010 McDonald criteria or previously accepted diagnostic criteria and with a positive diagnosis of COVID-19 were included in the study. Association between patient demographics, disease characteristics, use of disease-modifying therapies, and outcome of COVID-19 illness was evaluated statistically using an odds ratio estimation. Result(s): A total of 134 MS patients with COVID-19 (overall incidence rate of 3.7%) were analyzed in the study (116 with relapsing-remitting MS [RRMS], 11 with progressive MS;and 7 with clinically isolated MS). The median age of patients was 35.5 years. Of the total cohort, 127 (94.8%) patients were on disease-modifying therapy (DMT). A majority of the patients (126 [94.0%]) had mild COVID 19 illness and 122 (91.0%) made a full recovery while 1 (0.7%) patient died. A total of 8 patients (6.0%) were hospitalized;3 (2.2%) required intensive care, while 2 (1.5%) reported ventilator requirement. The mean EDSS scores reported in the study were low (1.74) with 127 (94.8%) reporting a score between 0 – 4.5. Univariate logistic regression analysis identified a high EDSS score and progressive MS disease as a risk factor for moderate to severe COVID-19 requiring hospitalization. Rituximab use and anti CD20 therapy were also associated with a statistically significant higher risk of developing moderate/severe COVID-19. The presence of comorbidities was associated with a higher risk of non-recovery from the viral infection in both univariate and multivariate analyses. Conclusion(s): COVID-19 showed an incidence rate of 3.7% in the studied cohort of MS patients. The disease course and outcomes were mostly favorable with most patients not requiring hospitalization. A higher EDSS score, progressive disease, use of rituximab, and use of antiCD20 therapy were associated with statistically significant increased risk of developing moderate/severe COVID-19, while the presence of comorbidities was associated with a higher risk of non-recovery from COVID-19. Age, sex, smoking history, and duration of MS were not independent risk factors for increased severity or adverse COVID-19 disease outcomes.
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Objective: To assess symptoms, severity, outcome of Covid 9 in Multiple sclerosis patients ( including NeuroMyelitis Optica )and to assess the prognostic factors for severe Covid19 Background: Covid 19 pandemic came with its own challenges of novelty, lack of information uncertainty of treatment and its effect on chronic autoimmune diseases like Multiple sclerosis. The outcome of covid 19 with immunosuppressive and immunomodulatory treatment in multiple sclerosis was not known till this year. We share our observation of multiple sclerosis patients including neuromyelitis optics who contracted Covid 19 in Dubai UAE, during April 2020 to Sep 2021 in 2 major hospitals treating multiple sclerosis. Design/Methods: All Multiple sclerosis Patients following in Rashid hospital and Alzahra Hospital Neurology apartment who had Covid 19 were included in this observational study. Results: 55 MS patient with Covid 19 ( including 2 NMO) were studied. Age of the patients ranged from 19 to 58years. There were 39 females and 16 males. 43 were RRMS, 6 -SPMS,4- CIS, 1- PPMS and 2 NMOSD. 6 were on interferons, 2 on teriflunamide, 8 on dimethylfumarate, 12 on fingolimod, 3 on natalizumab, 1 on alemtuzumab, 1 on rituximab, 9 on cladribine, 12 on ocrelizumab and 1 on azathioprine. 47 had fever, 30 anosmia, 28 had fatigue and 42 had sorethroat and cough, 5/55 had pneumonia.39/55 had mild covid, 13/55 had moderate and 3 had severe covid 19. 3/55 needed ICU. There were 2 deaths, first with MS, EDSS 6.5 on ocrelizumab and second with NMO (EDSS 7.0)on rituximab Conclusions: The disease course and outcomes were mostly favorable with most patients not requiring hospitalization. A higher EDSS score, progressive disease, use of rituximab, and ocrelizumab(antiCD20 therapy) were associated with the mortality encountered. Age, sex, smoking history, and duration of MS were not independent risk factors for increased severity or adverse COVID-19 disease outcomes.