Autoimmune inflammatory rheumatic diseases post-COVID-19 vaccination

Vaccination against COVID-19 is one of the critical tools to provide herd immunity, reduce mortality, and control the pandemic worldwide. Despite the safety of vaccination against SARS-CoV-2 in the healthy population, a minority of people may develop rare post-vaccine adverse reactions such as autoimmune syndromes. The current study aimed to identify and present a series of patients with de-novo autoimmune rheumatic diseases (ARDs) associated with COVID-19 vaccines. Inclusion criteria were the onset of ARDs symptoms at ∼ 3-4 weeks post-vaccination, age ≥ 16, no previous history of ARDs, meeting the classification criteria for one of the ARDs, and staying in the follow-up. The most commonly used vaccines in patients were Sinopharm [7 cases (50%)] and AstraZeneca [6 cases (42.9%)]. ARDs were significantly more common in subjects who received the AstraZeneca vaccine than in those who received other vaccines. Based on the results, patients were diagnosed with rheumatoid arthritis or one of its subtypes (5 cases), vasculitis (4 cases), systemic lupus erythematosus (3 cases), and peripheral seronegative spondyloarthritis (2 cases). Except for one patient with self-limitation of ARD, others were treated with disease-modifying antirheumatic drugs, and one case developed irreversible neurological complications. Indeed, our data can warn physicians about the possibility of ARDs post-vaccination, lead to faster diagnosis, prevent loss of window of opportunity for treatment, and prevent irreversible organ damage. Based on the published literature, autoimmune phenomena post-COVID-19 vaccination may be related to the overstimulation of mediators and cytokines due to complicated antigen-specific/non-specific immunological responses and mechanisms.

Inflammatory reflex disruption in COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified in Wuhan, China, in late 2019 and caused coronavirus disease 2019 (COVID-19), which is still a global pandemic. In most infected people, SARS-CoV-2 can only cause moderate symptoms, while in other patients, it leads to severe illness and eventually death. Although the main clinical manifestation of COVID-19 is often seen in the lungs, this disease affects almost all body organs. The excessive and prolonged release of inflammatory cytokines that may occur in COVID-19 patients, known as cytokine storms, stimulates undesired immune responses and can cause various tissues damage. In the current review article, we focus on the potential advantages of the intrinsic cholinergic anti-inflammatory pathway (CAP) as the efferent arm of inflammatory reflex in COVID-19 management. Considering this endogenous protective mechanism against chronic inflammation, we focused on the effects of SARS-CoV-2 in the destruction of this anti-inflammatory system. Several studies indicated the interaction of SARS-CoV-2 with the alpha7 subtype of the nicotinic acetylcholine receptor as the effector molecule of the inflammatory reflex. On the other hand, neurological manifestations have increasingly been identified as significant extrapulmonary manifestations of COVID-19. The rational connection between these findings and COVID-19 pathogenesis may be an important issue in both our understanding and dealing with this disease. COVID-19 is deeply rooted in our daily life and requires an urgent need for the establishment of effective therapeutic options, and all the possible treatments must be considered for the control of such inflammatory conditions.

Clinical course, chest computed tomography severity score and outcome of coronavirus disease 2019 (COVID-19) in patients with rheumatic diseases

Aim of the work To assess the clinical manifestations, imaging findings and outcomes of corona virus disease 2019 (COVID-19) in patients with rheumatic diseases. Patients and methods: In a three-center study, patients with rheumatic diseases who developed COVID-19 were included. Patients were classified into two groups, i) inflammatory arthritis including rheumatoid arthritis (RA), spondyloarthritis (SpA) and undifferentiated arthritis, ii) connective tissue diseases (CTDs) including systemic lupus erythematosus (SLE), vasculitis and others. COVID-19 outcomes were assessed based on chest computed tomography severity score (CT-ss), the level of care, the number of patients who died and flare of underlying rheumatic disease. Results: One hundred ninety-six patients with a mean age of 47.9±15.1 years, 73.5% female, were included. Underlying rheumatic diseases were RA (57.7%), SLE and other CTDs (17.9%), SpA (11.2%), vasculitis (11.2%) and undifferentiated arthritis (2%). Myalgia, malaise and fever were the most common clinical manifestations of COVID-19. Pneumonia on computerized tomography (CT), hospitalization, admission in intensive care unit and need to mechanical ventilation were observed in 75.5, 37.2%, 10.7% and 6.6% of patients, respectively. Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids, diabetes and underlying pulmonary disease were predictors of moderate to severe pneumonia and hospitalization. Fifteen (7.6%) patients died. Flare of underlying rheumatic disease occurred in 16.3% of patients. Flare of disease in patients with CTDs was significantly more than other rheumatic diseases. Conclusions: In rheumatic patients, treatment with NSAIDs or prednisolone, diabetes and pulmonary disease are risk factors of moderate to high CT-ss and hospitalization during COVID-19.

Coronavirus disease 2019 in patients with Behcet's disease: a report of 59 cases in Iran.

OBJECTIVES: To present the clinical characteristics, disease course, management, and outcomes of COVID-19 infection in patients with Behcet's disease (BD). METHODS: In this retrospective cohort study, we retrieved BD patients with definite diagnosis of COVID-19 infection. Demographic data, comorbidities, features related both to BD and COVID-19 infection, treatments, and outcomes were collected. Comparisons between patients with or without hospitalization were performed. All statistical analyzes were performed using SPSS version 25. We considered p < 0.05 statistically significant. RESULTS: We identified 61 episodes of COVID-19 infection in 59 BD patients. The prevalence was 0.69%. The median age was 45 years (IQR = 20), and the median disease duration was 162 months (IQR = 195). BD features were similar except for higher rate of arterial involvement and positive pathergy test in infected patients. Thirty-five episodes (62.5%) happened in non-active patients; 39% had a comorbid disease. COVID manifestations were the same as the general population. Flu-like symptoms were the most common (85%), followed by fever (66%), ageusia/anosmia (56%), headache (51%), and pulmonary involvement (48%). There was no change in BD symptoms in 74%. Fifteen patients (25.4%) were hospitalized, and one patient (1.7%) died. Receiving glucocorticoids (p < 0.03) and cytotoxic drugs (p < 0.02) were associated with an increased rate of hospitalization. CONCLUSION: The incidence of COVID-19 infection in BD patients was not higher than general population in Iran. They showed milder form of disease with lower morbidity and mortality rate. Most were on immunosuppressive drugs, or had a comorbidity apart from BD. No significant effect on BD course was shown. Key Points • The incidence of COVID-19 infection in patients with Behcet's disease is not higher. • They showed milder form of infection with lower morbidity and mortality rate. • No significant effect on Behcet's disease course was shown with COVID19 infection. • BD patients can be managed according to the guidelines used for general population.

Factors associated with COVID-19 and its outcome in patients with rheumatoid arthritis.

OBJECTIVE: We assessed the factors associated with COVID-19, clinical manifestations, and a 30-day-prognosis of COVID-19 in a cohort of rheumatoid arthritis (RA) patients compared with the index population. METHODS: In a cross-sectional study, RA patients were followed in rheumatology clinics of Tabriz University of Medical Sciences, and a group of patients diagnosed with COVID-19 from index population were recruited. Outcomes of COVID-19 were assessed by the hospitalization rate and need to intensive care unit (ICU) and mortality. During a period of 12 weeks, 128 RA patients diagnosed with COVID-19, 760 RA control group, and 92 COVID-19 patients from index population were enrolled. RESULTS: Being female, obese, and diabetic, having pulmonary disease and chronic kidney disease (CKD), and treatment with prednisolone > 5 mg/d and TNFα inhibitors (TNFis) were independent predictors of COVID-19 in RA patients. Dyspnea, anosmia, and taste loss were more common in RA patients compared with the index population. Admission in hospital, need to ICU care, and mortality occurred in 38, 11.9, and 8.6 percent of RA patients, respectively. Although hospitalization rate in RA patients was more than the index population, there were no significant differences in need to ICU care and mortality between the two groups. CONCLUSIONS: Treatment with prednisolone and TNFis and having comorbidities including obesity, diabetes, pulmonary disease, and CKD increase the risk of COVID-19 in RA patients. Although some differences exist in the clinical manifestations of COVID-19 in RA patients and index population, prognosis of COVID-19 in RA patients is not any worse. Key Points • Being female, obese and diabetic, having pulmonary disease, chronic kidney disease (CKD), treatment with prednisolone > 5 mg/d and TNFα inhibitors (TNFis) were independent predictors of COVID-19 in RA patients. • Dyspnea, anosmia and taste loss were more common in RA patients compared with the index population. • Although COVID-19 related hospitalization was higher in RA patients than in the index population, there was no significant differences in the need to ICU care and mortality between the two groups.