SEPTAL PANNICULITIS AS A MANIFESTATION of COVID-19 INFECTION

Objectives: to study the clinical and laboratory features of septal panniculitis in the form of erythema nodosum (EN) in a cohort of patients with COVID-19 referred to a rheumatological center. Methods: In 2020-2021 we examined 21 patients (18 women and 3 men, average age 43.2±11.4 years) with EN and polyarthralgia/arthritis. Depending on the time of EN and articular syndrome associated with COVID-19 development, patients were divided into three groups: 1) up to 4 weeks-acute COVID (symptoms potentially associated with infection);2) from 4 to 12 weeks-ongoing symptomatic COVID and 3) more than 12 weeks-post-COVID syndrome (persistent symptoms not associated with an alternative diagnosis). All patients underwent a comprehensive clinical, laboratory and instrumental examination, including ultrasound of the joints and chest computed tomography (CT), as well as pathomorphological examination of skin and subcutaneous adipose tissue from the node area (in 9 cases). Results: Based on the history data, COVID-19 in the study cohort had mild (in 3 patients), moderate (12) and severe (6) severity. Two patients (21 and 23 years old) with a mild severity of the disease on the 2nd-3rd day of the development of the respiratory symptom for the frst time noted red painful (45 mm on a visual analogue scale) nodes on the legs and polyarthralgia. In 9 patients (52.3%), similar skin changes were detected 24.5 ± 7. 6 days after stopping active COVID-19, i.e. during the period of ongoing symptomatic COVID. In 8 patients (38%), including 6 with moderate severity of the disease, nodules appeared after 85.6 ± 12.3 days, which corresponded to post-COVID syndrome. At the time of examination, 100 and 71.4% of patients complained of skin rashes and joint pain, respectively. Shortness of breath, weakness, cough, sweating and myalgia disturbed 67% of patients. An increase in body temperature to subfebrile was observed in 43% of cases, mainly with ongoing symptomatic COVID. In the overwhelming majority of cases (86%), UE was located on the anterior and lateral surfaces of the legs, less often on the posterior and medial surfaces. It is noteworthy that the lesion of more than 50% of the surface of the lower and upper extremities was associated with the number of nodes (p <0.02), CRP level (p <0.03) and post-COVID syndrome (p <0.2). Sixteen patients (76.1%) had signs of arthralgia, mainly ankle (81%) and knee (56%) joints. In a laboratory study, the median ESR was 39 [14;62] mm/h, the level of CRP was 17 [2;79] mg/l. The results of the polymerase chain reaction for SARS-CoV-2 were negative in 90.4 % of patients. In 90.4 % of cases, IgG antibodies were detected and in 52.3%-IgM to the SARS-CoV-2 virus. At CT of the chest, ≤25% of lung lesions were detected in 51% of patients, from 25 to 50%-in 33% and from 50% to 75%-in 9.5 % of cases. Pathomorphological examination of the nodes showed signs of septal panniculitis. Conclusion: When EN associated with SARS-CoV-2 appears it is important to timely suspect a post-infectious manifestation, based on the clinical picture of the disease and to determine the scope of further examination and adequate treatment.

Vaccination in persons with systemic lupus erythematosus: the current state of the problem

Vaccination plays an important role in the prevention of infectious diseases in patients with immunoinflammatory diseases. When vaccinating patients with systemic lupus erythematosus (SLE), as with other immunoinflammatory rheumatic diseases, its safety is of great importance, including mitigating the risks of the primary disease or the development of new autoimmune phenomena. Many practitioners continue to consider autoimmune diseases as a contraindication for vaccination due to the perceived possibility of their exacerbation and reduced vaccine effectiveness during active immunosuppressive therapy. The lecture presents current data on the immunogenicity, efficacy and safety of vaccines against a number of infections caused by influenza viruses, hepatitis B, Herpes zoster, human papilloma viruses, COVID-19 and pneumococcus in patients with SLE. It has been shown that the benefits of vaccination in patients with SLE significantly outweigh the risk of adverse events or exacerbations of the disease. At the same time, it was noted that the problem of vaccination of such patients requires further study. © 2022, Ima-Press Publishing House. All rights reserved.

[Peculiarities of blood coagulation disorders in patients with COVID-19].

AIM: To study the relationship of hemostatic disorders with inflammation and estimate their role in the course and outcomes of COVID-19. MATERIALS AND METHODS: We examined 215 consecutive patients with moderate and severe forms of acute COVID-19. The patients were on anticoagulants and immunosuppressive drugs. Hemostasis was assessed using the thrombodynamics assay, thromboelastography, fibrinogen and D-dimer levels, prothrombin time, and soluble fibrin-monomer complexes (ethanol gelation test). The hemostatic parameters were correlated with hematological and biochemical tests, including markers of inflammation (C-reactive protein, interleukins 6 and 8), as well as with the disease severity and outcomes. RESULTS: Laboratory signs of coagulopathy were revealed in the vast majority of the cases. Despite the use of low-molecular-weight heparins in the prophylactic and therapeutic doses, coagulopathy in COVID-19 manifested predominantly as hypercoagulability that correlated directly with the systemic inflammation and metabolic changes due to liver and kidney dysfunction. A direct relationship was found between the grade of coagulopathy and the severity of COVID-19, including comorbidities and the mortality. The chronometric hypocoagulability observed in about 1/4 cases was associated with a high level of C-reactive protein, which may decelerate coagulation in vitro and thereby mask the true inflammatory thrombophilia. Persistent hyperfibrinogenemia and high D-dimer in the absence of consumption coagulopathy suggest the predominance of local and/or regional microthrombosis over disseminated intravascular coagulation. CONCLUSION: The results obtained substantiate the need for laboratory monitoring of hemostasis and active prophylaxis and treatment of thrombotic complications in COVID-19.

Quantitative and qualitative changes in blood cells associated with COVID-19

Aim. To establish the relationship of hematological disorders with the pathogenesis, course and outcomes of COVID-19. Methods. We examined 235 hospitalized patients with moderate and severe forms of acute COVID-19 receiving anticoagulants and immunosuppressive drugs. We studied the full blood cell counts and morphology along with the platelet function by flow cytometry in comparison with the clinical features and synthesis of inflammatory markers. To assess platelet contractility, blood clot contraction (retraction) kinetics was used in combination with scanning electron microscopy of platelets and blood clots. Results. Hemolytic anemia, neutrophilia and lymphopenia were associated with immature erythrocytes and leukocytes, indicating activation of hematopoiesis. Contraction of blood clots in COVID-19 was impaired, especially in severe and lethal cases, as well as in the presence of comorbidities, including myeloproliferative and coronary heart diseases and acute cerebrovascular disease. In male patients, the changes in clot contraction were more pronounced. Suppression of clot contraction correlated directly with anemia and coagulopathy, including a high D-dimer level, which confirms the pathogenetic significance of blood clot contraction in COVID-19. A decrease in platelet contractility was due to moderate thrombocytopenia in combination with chronic platelet activation and secondary platelet dysfunction. The structure and cellular composition of blood clots depended on the extent of contraction;clots with impaired contraction were porous, had a low content of deformed polyhedral erythrocytes (polyhedrocytes) and an even distribution of fibrin. Conclusion. Blood cells undergoing both quantitative and qualitative changes are involved in the pathogenesis of COVID-19;the suppressed platelet-driven contraction of intravital blood clots may be a part of the prothrombotic mechanisms. © 2021 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/ licenses/by/4.0/.

Covid-19 and rheumatology: So far, so close

The disease caused by the new coronavirus COVID-19 is considered by the world community as an emergency of international importance. Along with the huge social importance, the COVID-19 pandemic has highlighted a number of principally new clinical and fundamental problems of immunopathology of human diseases. This problem is extremely urgent for patients suffering from immune-inflammatory rheumatic diseases (IIRD) due to their higher exposure to infectious complications. Achieving and maintaining control over the activity of IIRD plays an important role in reducing the incidence of comorbid infections in these patients. It has been shown that patients with IIRD undergoing active anti-rheumatic therapy are most likely not characterized by increased risk of respiratory or other life-threatening complications within COVID-19 compared to the general population. Given the need for continued monitoring of patients receiving these therapy, unjustified “prophylactic” cancellation should nevertheless be avoided, thereby increasing the risk of relapse of major IIRD. The article also discusses the issues related to the use of basic anti-rheumatic drugs in COVID-19. Currently there is no evidence to support the therapeutic and prophylactic efficacy of chloroquine or hydroxychloroquine in COVID-19. Tocilizumab can be considered as “lifesaving therapy” for patients with acute respiratory distress syndrome in COVID-19, if other treatments have failed or are unavailable. The use of baricitinib in hospitalized pneumonia patients as part of COVID-19 should be considered with extreme caution. The need for further research to assess the potential role of baricitinib for these patients is highlighted. In the absence of a COVID-19 vaccine in a continuing pandemic, vaccination against influenza and pneumococcal infection should be strongly recommended to the absolute majority of patients with IIRD. This is associated with a high risk of fatal respiratory infection in rheumatological patients, especially given the high respiratory tract involvement in COVID-19. © 2020, Remedium Group Ltd. All rights reserved.