ABSTRACT
Background: We report a 40-year- old female with co-existent lupus nephritis and thymoma who developed severe lupus flare (worsening nephritis, new onset hemolytic anemia) following SARS-CoV- 2 vaccine. Case: This 40 year old female has had stable lupus nephritis (LN) while maintained on mycophenolate mofetil and hydroxychloroquine for several years. A co-existent thymoma was likewise stable and did not require any added therapy apart from the management of the LN. She received the first dose of inactivated vaccine for SARS-CoV- 2 without event. Two weeks following the second dose, she developed Coombs positive hemolytic anemia (hemoglobin 64 g/L) with leukopenia (WBC 2.3 x 109/L), worsening nephritis (3+ proteinuria with uPCR 1.0, active urine sediments), hypocomplementemia, and elevated anti-dsDNA. She received methylprednisolone pulse therapy then maintained on prednisone 40mg/day with clinical improvement. Two weeks thereafter, she was admitted due to severe COVID-19 pneumonia accompanied by severe anemia requiring blood transfusion;she received a regimen of bevacizumab, dexamethasone, and remdesivir and was discharged recovered, without overt sequelae at the time of this report. Discussion(s): Vaccines are highly effective in reducing hospitalization and death attributable to SARS-CoV- 2 infection. There are concerns however regarding autoimmune disease flares following SARS-CoV- 2 vaccine, reported to occur in about 4% patients with autoimmune disorders. It is also possible that this patient's reaction may have been further aggravated by the co-existent thymoma. While there was apparent sub-optimal protection of the vaccine against moderate to severe COVID-19 infection in this patient, it may be conjectured that her significant recovery and response to the anti-viral combined with immunosuppressive regimen may be due to the high dose steroid treatment given for the post-vaccine autoimmune reaction.
ABSTRACT
Background and Objective: This study describes the prevalence, characteristics, and outcomes of COVID-19 infection among patients with autoimmune rheumatic diseases (AIRD) seen in a tertiary hospital in Manila, Philippines. Method(s): This cross sectional study included patients diagnosed with AIRD seen over a 24-month period from March 2020 to February 2022 confirmed with COVID-19 infection. We collected data from patients' electronic records, clinic and hospital charts and analyzed underlying AIRD characteristics including disease activity, medications, severity, and outcomes including hospitalization and mortality. Result(s): Of the 565 patients with AIRD, 67 patients reported to be positive for COVID-19. The most common underlying AIRD was systemic lupus erythematosus (SLE) in 53 patients followed by rheumatoid arthritis and dermatomyositis. Cough, fever, dyspnea, diarrhea, anosmia, ageusia and sore throat were the common presenting symptoms. Three were asymptomatic, 52 had mild symptoms, 3 patients had moderate and 9 had severe COVID-19 infection. Nineteen patients (28%) were subjected to hospitalization and admission and 48 (72%) were confined at home or in an isolation facility. Use of methotrexate, mycophenolate mofetil, prednisone <10 mg/day and hydroxychloroquine did not affect the risk for moderate to severe COVID-19 infection, hospitalization and mortality. However, the use of azathioprine increases the risk for moderate to severe COVID-19 infection but not for hospitalization and mortality. Four (6%) patients died of severe COVID-19 pneumonia: an elderly rheumatoid arthritis patient with co-morbidity of asthma, a lupus nephritis patient with end stage renal disease on hemodialysis, another lupus nephritis patient with malignancy who underwent radiotherapy and lastly, a patient with overlap dermatomyositis and SLE with restrictive lung disease due to severe dextroscoliosis. Conclusion(s): This single-center experience on AIRD patients with COVID-19 infection showed that patients with active disease, co-morbidities, especially lung diseases, and use of high dose glucocorticoid had higher risk for moderate to severe COVID-19 infection, hospitalization and mortality.