De novo lupus nephritis after SARS-CoV-2 infection.

The relationship between viral infection and onset of autoimmune diseases such as systemic lupus erythematosus remains uncertain. During the COVID-19 pandemic, organ-specific and multisystemic autoimmune phenomena temporally related to the viral infection have been described. Immune dysregulation triggered by the SARS-CoV-2 virus leading to hyperactivation of both the innate and adaptive immune systems contributes to the excessive production of pro-inflammatory cytokines, autoantibodies, and subsequent autoimmune manifestations. We report two patients without known autoimmune diseases who developed lupus nephritis shortly after a documented mild SARS-CoV-2 infection. Together with other similar cases in the literature, the observation supports a viral trigger of the development of systemic lupus erythematosus in susceptible individuals.

Hesitancy for SARS-CoV-2 vaccines and post-vaccination flares in patients with systemic lupus erythematosus.

OBJECTIVES: To study the rate of SARS-CoV-2 vaccination and post-vaccination disease flares in patients with systemic lupus erythematosus (SLE). METHODS: Patients who fulfilled ≥ 4 of the ACR criteria for SLE were identified and their SARS-CoV-2 vaccination status was traced. Flares of SLE at 6-week post-vaccination were reviewed retrospectively. Clinical characteristics of patients with and without vaccination, and those who did or did not experience post-vaccination flares were compared by statistical analyses. RESULTS: 914 adult patients with SLE were studied (92.5 % women, age 48.6 ± 14.0 years; SLE duration 14.5 ± 8.6 years). Two doses of the SARS-Cov-2 vaccines (61.5 % BioNTech; 38.5 % CoronaVac) were received by 449 (49.1 %) patients. The vaccination rate in SLE was significantly lower than that of the adult general population (77.8 %; p < 0.001) at the time of data analysis. Patients who were hesitant for vaccination were more likely to be hypertensive, have a history of neuromuscular manifestations, and a significantly higher organ damage score (1.10 ± 1.45 vs 0.74 ± 1.15; p < 0.001). However, none of these factors were significantly associated with vaccine hesitancy on multivariate analysis. Among 449 vaccinated patients, 37(8.2 %) experienced SLE flares: mild/moderate in 34; severe in 3. In an equal number of unvaccinated SLE controls randomly matched for the post-vaccination observation period, 28(6.2 %) had SLE flares: mild/moderate in 17; severe in 11 (odds ratio [OR] for flare in vaccinated patients 1.40[0.81-2.43]; p = 0.23, adjusted for age, sex, active serology, SLE duration and prednisolone use). In vaccinated patients, logistic regression revealed that active lupus serology before vaccination (OR 2.63[1.05-6.62]; p = 0.04) and a history of arthritis (OR 2.71[1.05-7.00]; p = 0.04) or discoid skin lesion (OR 4.73[1.90-11.8]; p = 0.001) were associated with SLE flares following vaccination, adjusted for confounders. CONCLUSION: Hesitancy for COVID-19 vaccination is common in SLE patients. Vaccination against SARS-CoV-2 is not significantly associated with increased SLE flares. Patients with active SLE serology or a history of arthritis/discoid lesion are more likely to flare after vaccination.

Rheumatology Drugs and COVID-19

Glucocorticoids have been used to treat SARS-CoV in 2003 but were associated with considerable side effects such as avascular bone necrosis [24]. Glucocorticoids may also delay viral clearance and may lead to secondary infections in patients with MERS coronavirus infection [25]. In fact, randomized controlled trials did not show benefit of glucocorticoids and may even aggravate lung injury in MERS and H1N1 pneumonia [26,27]. With the availability of more targeted biological agents, glucocorticoids are currently out of favor for the treatment of severe COVID-19.The non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used by rheumatologists for pain related to arthritis and myalgia. Ibuprofen was commonly prescribed for early symptoms of COVID-19 in Italy and has been attributed to have caused the progression of infection because of its anti-inflammatory effects required for viral clearance [28]. Although the deleterious effect of NSAIDs has yet to be confirmed, some European authorities have advised against their use in COVID-19 infection.Several drugs commonly used by rheumatologists have been proposed to have potential efficacy in COVID-19. Rheumatologists may be consulted for the precautions and monitoring of these drugs should they be used in severe COVID-19. The optimal dosages of these agents in the treatment of COVID-19 have to be explored further. On the other hand, a linkage between micro-organisms and the onset of autoimmune diseases has long been suggested [29]. It is of intense interest to watch out for the incidence of rheumatic diseases in the next 12 to 24 months in our locality. The COVID-19 Global Rheumatology Alliance has created a registry to capture rheumatology patients who have been infected with COVID-19 [30].