ABSTRACT
Rationale: APECED is a life-threatening monogenic disorder characterized by multiorgan autoimmunity. Most patients harbor autoantibodies (auto-abs) to type-1 interferons (IFNs), which are important mediators of viral defense. Auto-abs to type-1 IFNs are associated with severe COVID-19 and may play a role in other viral infections including by varicella zoster virus (VZV). A recent study of 44 European APECED patients reported increased susceptibility to VZV, and a correlation between VZV recurrence and auto-abs to IFN-α. The clinical, immunophenotypic, and auto-ab characteristics of APECED patients in the USA with VZV are described. Methods: Data was obtained from 103 participants on a prospective, natural history study after informed consent. Auto-abs to IFN-α, IFN-β or IFN-ω were measured using a multiplex particle-based assay. Unpaired t tests or U Mann Whitney tests were used, with Holm correction for multiple comparisons, where appropriate. Results: Twenty-six patients reported childhood chickenpox (mean onset 5.6 years) and 2 (7.7%) required hospitalization for severe disease. Nineteen patients (18%) had at least one episode of shingles (median onset 13 years;range, 4-55 years) and 4 had >1 episode. Fifteen of the 19 patients with shingles (79%) were not receiving immunosuppressive medications during their first infection. VZV IgG levels;total and percent CD3, CD8, CD4, CD19, NK cells;and auto-abs to IFN-α, IFN-β and IFN-ω did not significantly differ between patients with or without recurrent shingles. Conclusions: A subset of APECED patients develop early-onset, recurrent VZV infections even in the absence of immunosuppression. The mechanisms underlying susceptibility to VZV in APECED require further study.
ABSTRACT
Objective Multisystem inflammatory syndrome in children (MIS-C), characterized by fever, inflammation, and multiorgan dysfunction, was newly defined after severe acute respiratory syndrome coronavirus 2 infection. The clinical spectrum of MIS-C can be classified as mild, moderate, and severe. We aimed to evaluate demographics, clinical presentations, laboratory findings, and treatment modalities of patients with MIS-C according to clinical severity. Methods We performed a retrospective study of patients who were diagnosed as having MIS-C between September 2020 and October 2021 in the Necmettin Erbakan University Meram Faculty of Medicine, Türkiye. Results A total of 48 patients (24 females and 24 males) with a median age at diagnosis of 10.3 years (range: 42 months-17 years) were enrolled, the most common clinical severity of MIS-C was moderate. The common presentations of patients were fever (97%), nonpurulent conjunctivitis (89.6%), rashes (81.3%), fatigue (81.3%), strawberry tongue (79.2%), and myalgia (68.8%). The most common laboratory findings were lymphopenia (81.2%), thrombocytopenia (54.1%), elevated D-dimer levels (89.5%), C-reactive protein (CRP;100%), procalcitonin (97%), erythrocyte sedimentation rate (87.5%), ferritin (95.8%), interleukin 6 (IL-6) (86.1%), and probrain natriuretic peptide (pro-BNP) (97%). High levels of CRP, procalcitonin, pro-BNP, and urea were associated with the severity of MIS-C (p < 0.05). Fifteen of the patients were found to have pulmonary involvement. Ascites were the most common finding on abdominal ultrasonography (11 patients) and were not seen in a mild form of the disease. During the study period, two patients died. Conclusion It is important to make patient-based decisions and apply a stepwise approach in treating patients with MIS-C due to the increased risk of complications and mortality. © 2022. Thieme. All rights reserved.
ABSTRACT
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) directed great attention and anxiety all over the world. Epidemiologic models predict that the current COVID-19 pandemic will last several months or even several years, until the development of a vaccine and/or herd immunity. Although the course of the infection is often not severe in children, it can be life threatening especially in immunocompromised children with leukemia. Hematopoietic and lymphoid cancers are accounting for approximately 40% of all childhood cancers. The five-year survival rate for childhood cancer has approached to 70% and more than 80% for leukemia in our country. During COVID pandemic, children with leukemia may also have COVID-19 infection, especially when their bone marrow is depressed due to chemotherapy. It is observed that factors such as the underlying type of cancer, status of remission, or having stem cell transplantation may affect the prognosis. As well as standard and proven treatments for febrile neutropenia, all tests and treatments should be applied very quickly and properly for COVID 19 as is all suspected patients. These efforts may contribute to increase the survival of our children with cancer. Given the absence of data to address concerns related to SARS-CoV-2 infection while on chemotherapy, questions are increasing about the approach for management of systemic immunosuppressive therapies, i.e. ceasing or reducing the immunosuppressive medications in children with leukemia. The current rapid worldwide spread of COVID-19 necessitates identifying optimal preventive strategies and effective medical management. In this report, we tried to review appropriate literature-based approaches for prevention, diagnosis and management of treatment protocols for children with cancer during the pandemic period.
ABSTRACT
Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd
ABSTRACT
The problem of coronavirus disease 2019 (COVID-19) still remains relevant even now, after two years. As one of the methods of combating the current COVID-19 pandemic, most experts suggest the widespread use of vaccination. The use of anticovid vaccines in patients with rheumatic diseases raises a number of questions related to efficacy, immunogenicity (especially in patients receiving immunosuppressive therapy), as well as safety of immunization. With that in mind, it is very important to analyze the data on the above-mentioned aspects in real time. This review presents the results of studies on COVID-19 vaccination immunogenicity in rheumatology conducted over the past two years. The ability of a number of antirheumatic drugs to have a negative effect (to varying degrees) on the post-vaccination response has been demonstrated. Interpretation and comparison of the results of vaccine immunogenicity studies are complicated by a number of factors usually associated with the design of works. Within the framework of the problem under consideration, there are still a sufficient number of questions, the answers to which should be found in further research.
ABSTRACT
Acute exacerbations due to COVID-19 vaccination in patients with interstitial lung disease (ILD) have been reported, but their incidence is unknown. We investigated the incidence of exacerbations of ILD and respiratory symptoms due to the mRNA COVID-19 vaccines. A questionnaire survey was conducted on adverse reactions to the mRNA COVID-19 vaccination in 545 patients with ILD attending our hospital and retrospectively examined whether the eligible patients actually developed acute exacerbations of ILD induced by the vaccine. Of the 545 patients, 17 (3.1%) patients were aware of the exacerbation of respiratory symptoms, and four (0.7%) patients developed an acute ILD exacerbation after vaccination. Of the four patients who experienced exacerbations, two had collagen vascular disease-associated ILD, one had nonspecific interstitial pneumonia, another had unclassifiable idiopathic pneumonia, and none had idiopathic pulmonary fibrosis. Four patients were treated using steroid pulse therapy with a steroid taper, and two of the four also received intravenous cyclophosphamide pulse therapy. Tacrolimus was started in one patient with myositis-associated interstitial lung disease. Eventually, all patients exhibited improvement with immunosuppressive treatment and were discharged. COVID-19 vaccination for patients with ILD should be noted for developing acute exacerbations of ILD with low incidence, although manageable with early diagnosis and treatment. © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases
ABSTRACT
Background: COVID-19 vaccines are safe & effective, though patients with rheumatic diseases like idiopathic inflammatory myositis (IIMs), and those with multiple comorbidities continue to be hesitant. Adverse events after vaccination are not extensively studied in those with multiple coexisting autoimmune diseases. Patients with IIM often have multiple autoimmune rheumatic and autoimmune non-rheumatic comorbidities (IIM-AIDs), with potentially increased risk of AEs. The COVAD study aimed to assess COVID-19 vaccination-related AEs till 7 days post-vaccination in IIM-AIDs compared to IIMs and healthy controls (HCs) group. Method(s): T he C OVAD s tudy g roup c omprised > 110 c ollaborators across 94 countries. The study was conducted from March-December 2021. A survey monkey platform-based self-reported online survey captured data related to COVID-19 vaccination-related AEs in IIMs, AIDs, and HCs. We compared COVID-19 vaccination-related AEs among IIM-AID patients and IIM alone and HCs, adjusting for age, gender, ethnicity, vaccine type, immunosuppression, and numbers of AIDs, using binary logistic regression. Statistically significant results following multivariate regression are reported. Result(s): Among 6099 participants, 1387 (22.7%) IIM, 4712 (77.2%) HC, 66.3% females, were included from 18 882 respondents: 573 (41.0%) people with IIM-AIDs;814 (59.0%) with IIM without other AIDs;and 4712 HCs. People with IIM were older [median 54 (45-66) IIM-AIDs, 64 (50-73) IIM, 34 (26-47) HC years, P < 0.001]. BNT162b2 (Pfizer) (37.5%) and ChAdOx1nCoV-19 (Oxford) (11.1%) were the most common vaccines. When compared to IIM alone, IIM-AID patients reported higher overall AEs [OR 1.5 (1.1-2.1)], minor AE [OR 1.5 (1.1-2.1)] &major AE [OR 3 (1.5-5.8)]. IIM-AIDs patients also reported higher body ache, nausea, headache, & fatigue (OR ranging 1.3-2.3). After adjusting for the number of AIDs, the major AEs equalized but overall AEs, & minor AEs, such as fatigue remained higher. When compared to HCs, IIM-AIDs patients reported similar overall AEs, minor AEs but higher major AEs [OR 2 (1.2-3.3)] nausea/ vomiting [OR 1.4 (1.01-2)], headache [OR 1.2 (1.01-1.6)], and fatigue [OR 1.3 (1.03-1.6)]. Dermatomyositis with AIDs (n = 183) reported higher major AEs [OR 4.3 (1.5-12)] compared to DM alone (n = 293). Active IIM with AIDs (n = 482) reported higher overall AEs [OR 1.5 (1.1-2.2)], minor AEs [OR 1.5 (1.1-2.2)] and major AEs [OR 2.6 (1.2-5.2)] compared to active IIM alone (n = 643). Conclusion(s): COVID-19 vaccination is safe with minimal to no risks of short-term AEs in patients with IIM without other concomitant autoimmune diseases. The presence of autoimmune multimorbidity conferred higher self-reported short-term risks of overall, major, and minor COVID-19 vaccination-related AEs 7 days post-vaccination, particularly in those with active IIM.
ABSTRACT
Purpose of Study: Vaccinations are an essential part of preventative medicine and provide for the improvement of public health by preventing the spread of infectious diseases. Patients with autoimmune rheumatic diseases have chronic illnesses that often require prolonged or lifelong immunosuppression or immunomodulation therapy to promote both quality-of-life and survival. Less than half of these patients receive the most common vaccinations despite having a higher risk of vaccine-preventable infections than the general population. The evaluation of immunization status and discussion of vaccines have remained under-prioritized in the medical community due to a wide variety of factors. The use of smart phrases has been shown in previous studies to positively affect clinical outcomes. Improvement in the documentation rate with this method can prompt discussion of immunizations and reduce the rate of suboptimal vaccination coverage in this high-risk patient population. We aimed to increase documentation of vaccinations by ten percent over four weeks using a novel vaccine smart phrase. This will prompt the provider to discuss patient-specific vaccination strategies and has the potential to improve vaccination rates in UMMC rheumatology patients. Methods Used: A baseline assessment through chart review was performed for four weeks immediately prior to implementation (March 14, 2022). Then, educational material on dot phrase implementation was provided electronically to four rheumatology fellows and a two week adjustment period was allowed. The impact of the smart phrase intervention was defined as the difference in the frequency of discussion (via documentation) of vaccinations (COVID, influenza, pneumococcal, and zoster) per clinical in-person encounter four weeks before and four weeks after implementation. Inclusion criteria were any patient with a rheumatology fellow provider seen in adult rheumatology clinic at UMMC. A total of 345 patient encounters were evaluated. Summary of Results: Results showed that implementation of the dot phrase was unable to meet our goal of increased vaccination documentation by 10%. In fact, a 5% overall decrease in the frequency of vaccine documentation was observed. [Figure presented] Conclusion(s): We suspect that an increased patient-to-provider ratio may have pressured the system and led to decreased discussion of vaccinations. Additionally, while we were careful to choose a time for assessment which avoided COVID-19 peaks, proximity to a recent spike may have artificially increased baseline vaccination discussion relative to post-implementation. Lastly, patient charts were not reviewed from prior to the pre-intervention assessment period in an effort to prioritize sample size. It is possible that a discussion on vaccination status was not repeated in subsequent clinic visits. Future studies seek to increase the length of time of the assessment in order to minimize these effects. Additionally, fellow education should be provided in person with the opportunity for further discussion and fellow input. Copyright © 2023 Southern Society for Clinical Investigation.
ABSTRACT
Corticosteroids, more specifically glucocorticoids are one of the most prescribed drugs. Corticosteroids are adrenal hormones that serve significant physiologic activities such as modulating glucose metabolism, protein catabolism, calcium metabolism, bone turnover control, immunosuppression, and down-regulation of inflammatory cascade. Corticosteroids are regarded life-saving due to their various effects and have been used therapeutically to treat broad range of auto-immune, rheumatologic, inflammatory, neoplastic, and viral illnesses.However, the therapeutic benefits of glucocorticoids are restricted by the adverse effects. The most serious side effects of corticosteroids are associated with the use of higher doses for longer periods and OTC availability in specific pharmacies, which leads to dependency, as well as its usage in mild and moderate server instances, which is contrary to guidelines. In the recent times the use of corticosteroids has been multiplied with the emergence of the Covid -19 pandemic. WHO and the standard guidelines has recommended the usage of corticosteroids in critically ill covid-19 patients but their usage in mild and moderate cases caused more harm than benefit. This illicit usage has resulted in the development of opportunistic fungal illnesses such as mucormycosis, posing an extra risk to patients in terms of quality of life and finances. Other adverse effects of systemic corticosteroids include morphological changes, increased blood sugar levels, delayed wound healing, infections, decreased bone density, truncal obesity, cataracts, glaucoma, blood pressure abnormalities, and muscle fibre atrophy.In this review we want to discuss the significance and detrimental effects of corticosteroids emphasizing on the recent times i.e., COVID-19.
ABSTRACT
Purpose: To evaluate the SARS-CoV- 2 infection rate among vaccinated RMD patients in a tertiary hospital and its associations. Methodology: This cross-sectional study was performed among adult rheumatology patients who attended follow up at our centre from 1st April 2022 to 30th April 2022. Demographics and clinical data were compared between the vaccinated patients with SARS-CoV- 2 infection, Group 1 (G1) and without SARS-CoV- 2 infection, Group 2 (G2). Descriptive and inferential statistics were conducted using SPSS version 26. Result(s): We enrolled a total of 212 patients with underlying diagnosis of rheumatoid arthritis (94 patients, 44.3%), systemic lupus erythematosus (59 patients, 27.8%), spondyloarthropathies (30 patients, 14.2%) and others (29 patients, 13.7%). Of all these patients, 57 (26.9%) had SARS-CoV- 2 infection (G1) with mean (SD) age of 45.2 (+/-14.65) years compared to 53.4 (+/-15.22) years in G2 (P = 0.001). In G1, 50 (87.7%) were female, 32 (56.1%) were Malay and 26 (45.6%) with >= 1 comorbidity. Most patients in G1 received 3 doses of vaccine (n = 36, 63.2%) while 21 (36.8%) completed 2 doses of vaccine. Majority in G1 (n = 46, 80.7%) had clinical stage 2 SARS-CoV- 2 infection. Seven required admission to health care facilities with median stay of 6 +/- 2 days. Twenty-three patients (32.9%) in G1 received more than one immunosuppressive drug. Twenty-one out of 63 patients (33.3%) who had 2 doses of SARS-CoV- 2 vaccine had SARS-CoV- 2 infection compared to 36 out of 149 patients (24.2%) who received 3 doses of vaccine, albeit not significant. Conclusion(s): Despite a quarter of the cohort acquired SARS-CoV- 2 infection, the disease was notably less severe, attributed to younger age, less comorbidity and vaccine effectiveness. Type of immunosuppression and use of more than one immunosuppressive drugs were not associated with SARS-CoV- 2 infection.
ABSTRACT
Case report - Introduction: This case highlights the dilemma of keeping rheumatoid arthritis disease under control in active cancer cases and establishing a consistent multidisciplinary dialogue during a pandemic and staffing crises. During chemotherapy and active cancer treatment, disease-modifying therapies (conventional and biologic) are often stopped. In some cases, the potential benefits versus risks of restarting usual therapies have to be balanced against risks of suppressing disease activity with highdose steroids. Risks of infection (common and atypical) need to be considered. Case report - Case description: A is a 67-year-old female nonsmoker diagnosed with seropositive rheumatoid arthritis (RF, anti - CCP positive) in 2008. Other conditions include type 2 diabetes, atrial fibrillation (on warfarin), hypothyroidism and obstructive sleep apnoea. Due to active disease, despite triple therapy (methotrexate, sulphasalazine and hydroxychloroquine), anti-TNF therapy (etanercept) commenced in 2009 with primary non-response. However, she responded well to B-cell therapy (rituximab) in conjunction with oral methotrexate (25mg weekly) receiving annual infusions from 2010 to 2016. In 2017, an elective sleeve gastrectomy procedure for high BMI was abandoned after peritoneal deposits of concern were noted. Histology and CT imaging were consistent with a primary peritoneal malignancy (Stage 3c low-grade serous adenocarcinoma). Treatment involved debulking surgery (total abdominal hysterectomy, bilateral salpinoophorectomy, omentectomy) and tamoxifen. Treatment for rheumatoid arthritis stalled during this period but as frequent steroids were required for active joint inflammation, in agreement with the oncologists, she had a rituximab cycle in 2018. Unfortunately, in 2019 she had signs of cancer progression (elevated tumour markers, CT imaging) and has subsequently started carboplatin chemotherapy. She has been unable to continue methotrexate or rituximab pending completion of the chemotherapy cycles (ongoing). However, her arthritis is now uncontrolled without increased steroids. Due to recurrent flares, her maintenance dose has been increased from 5mg to 7.5-10mg prednisolone daily until we can establish if it is safe and appropriate to recommence her usual arthritis regime. Even without disease-modifying therapy like methotrexate and rituximab, risk of infection (including atypical ones) is still significant with the combination of chemotherapy and steroids. Risk of progressive joint damage and adverse quality of life with active arthritis also needs to be considered. Staffing crises, exacerbated by COVID pandemic issues, have added to complexity of decision making and coordination of regular multidisciplinary discussions regarding treatment. Case report - Discussion: Cancer is a known association in rheumatoid arthritis patients with a twofold higher risk of lymphoma compared to the general population. Whether condition or treatment affects risk remains unclear as immune dysregulation is relevant in both autoimmunity and cancer. Paraneoplastic, recent onset arthritis, chemotherapy- or immunotherapy-induced arthralgia/arthritis are also well documented. This case had a seropositive rheumatoid arthritis phenotype quite a few years prior to cancer diagnosis. Primary peritoneal cancer is uncommon, often presenting as in this case as an incidental finding. It is usually treated like ovarian cancer Whilst methotrexate has been implicated in lung cancer, melanoma and non-Hodgkin lymphoma, overall safety data suggest any risk is quite low (e.g., EBV-associated lymphoproliferative disorders usually resolve with drug discontinuation). It is also a known chemotherapeutic agent. Anti-TNF treatment algorithms generally exclude patients with recent cancer. Rituximab, originally developed as a cancer drug, is not thought to affect risk of cancer development or progression. Treatment with disease-modifying therapy (conventional and biologics) is often withheld in patients with active malignancy undergoing chemotherapy due to a theo etical risk of potentiated immunosuppression and toxicity, particularly cytopaenias. However, maintaining arthritis control with glucocorticoids also has short- and long-term risks. Combining chemotherapy agents like carboplatin with methotrexate has been used for urothelial carcinoma and can be well tolerated with close monitoring of haematological parameters. Thus, it could be argued this patient is at risk of infections whichever treatment approach is taken and regaining control of arthritis with recommencement of methotrexate and rituximab is much better for her quality of life. Regular multidisciplinary discussions are important to outline risks versus benefits of combined treatment. This may be difficult in practice during staffing crises. Covid risk in patients receiving rituximab and/or chemotherapy, timing and response to COVID vaccination are also important considerations. Case report - Key learning points: . Primary peritoneal cancer is uncommon and can present as an incidental finding . Whilst treatment for progressive cancer is important, withholding rheumatoid arthritis treatment can have a significant adverse impact on quality of life . Morbidity and mortality risks of stopping treatment versus combined treatment (cancer therapy and disease-modifying therapy) ideally needs to be fully discussed and agreed with the patient and all care providers - lack of "named" providers, restructuring, redeployment, multi-specialty care and a global pandemic can make coordination of this difficult.
ABSTRACT
Background/Purpose: To determine and compare the magnitude of humoral immune response after the first, second, and third and overall exposure to SARS-CoV- 2, either by natural infection or vaccination, between rheumatoid arthritis (RA) patients under various immunosuppressive treatments and healthy controls (HCs). Method(s): Blood samples from various time points before and after the COVID-19 pandemic and longitudinal data on exposure history were obtained from RA patients and HCs recruited for this study. Antibody levels were then determined using indirect ELISA and statistically analysed in relation to exposure history. Result(s): A significant rise in antibody levels after overall exposure to SARS-CoV- 2 in RA patients and HCs was found, with no significant difference between the two groups. Amongst RA patients, a progressive rise in antibodies following each exposure to SARS-CoV- 2 was found, with antibody levels rising above the cut-off for seropositivity following the second and third exposures. Incidentally, HCs, despite having high antibody levels following the first and second exposure, were found to have antibody levels below the cut-off for seropositivity upon their third exposure to SARS-CoV- 2. Conclusion(s): Contrary to popular belief, RA patients, despite under immunosuppressive treatments, are capable of eliciting a humoral response that is comparable to that of healthy individuals. The lower antibody levels found in HCs by third exposure could signify that more vaccine boosters may be required to increase the public's immunity against SARS-CoV- 2 for herd immunity and avoid creating a reservoir for the emergence of novel variants with persistent infections.
ABSTRACT
We present a case of long-term organ functioning (ca.10 years) after allografting of a cadaveric kidney without usage of immunosuppressing drugs. In 2005, a patient suffering from a hypertensive form of chronic glomerulonephritis, have received an allogeneic graft of cadaveric kidney compatible for AB0 system, HLA antigens (A19, B07, DR04), and negative results of cross-match test. The graft function was immediately restored, with normalization of creatinine levels achieved 4-5 days after surgery. Immunosuppression with cyclosporine, solumedrol, cellcept, metypred and simulect was performed in the hospital. Pulse therapy with solumedrol was performed on the day +20 due to the development of initial rejection signs. The postoperative period proceeded without infectious complications. The patient was discharged being recommended to take cyclosporine, Cell-Sept and Metypred. Within a year after transplantation, the patient claimed for pain in the hip joint, and, therefore, metypred was completely canceled. Subsequently, the Cellcept was replaced with a Mayfortic. In 2007, the signs of coxarthrosis were revealed at computed tomography, followed by aseptic necrosis of the the right femur head. Deforming osteoarthritis of the right hip joint was detected, and the hip replacement surgery was suggested. In 2010, due to risk of side effects from ongoing immunosuppressive therapy, e.g., joint damage, the Mayfortic was canceled. In 2012, being in fear of original Sandimmun Neoral replacement by a generic drug, the patient completely refused cyclosporine therapy. In 2021, the endoprosthetics of the right hip joint was performed, and the surgical wound healed initially. Since 2012, the patient has not completely taken immunosuppressive therapy. Over this time period, the patient has never been admitted to the hospital for impaired functioning of the organ graft. Meanwhile, he monitored his graft function on regular basis undergoing biochemical analyses, clinical examination, ultrasound studies of the graft and made regular visits to the outpatient department. In 2021, a week after hip replacement, there was a slight increase in serum creatinine, followed by further increase to 230 mmol/L in 2021, and to 310 mmol/L in March 2022. In February 2022, the patient suffered mild respiratory infection (confirmed COVID-19). In March 2022, the first clinical signs of increasing nephropathy appeared, i.e., swelling of both lower extremities, with leukocytes in urine upon routine analysis, increased blood flow resistance in the main artery of the transplant shown by ultrasound study. Due to worsening of the patient's condition, he resumed taking the prescribed immunosuppressants. Copyright © 2022, SPb RAACI.
ABSTRACT
Background: Patients with SLE are at high risk of COVID-19 infection due to the disease itself and to steroids and immunosuppressive treatments. COVID-19 vaccine is crucial for reducing the severity and spread of the virus. However, vaccine hesitancy is a significant barrier to infection control. Accurate vaccine information contributes to increased vaccine acceptance. There is a lack of research on vaccine hesitancy and educational interventions in patients with SLE. Objective(s): The current study determines the prevalence and reasons for vaccine hesitancy in patients with SLE. Additionally, we evaluate the effectiveness of educational interventions. Method(s): This prospective study enrolled 305 patients with SLE between July and December 2021. The data included demographics, disease activity as measured by the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K), and medication. A score of >4 on the SLEDAI-2 K or >3 on the modified SLEDAI-2 K indicated active disease. Each patient completed a vaccination questionnaire before receiving the COVID-19 vaccination. We identified vaccine hesitancy rate and three main concerns regarding efficacy, side effects, and disease interference. Vaccine information was then provided, including the risks and benefits of vaccination following a standardized guideline. During the follow-up, the first vaccination was documented as vaccination acceptance. The factors associated with vaccine hesitancy were investigated using multivariate analysis. A P-value of 0.05 was considered statistically significant. Result(s): The majority of patients (94.4%) were female, with an average age of 46.6 years and a disease duration of 13.5 years. A mean period between follow-ups was 18.8 weeks. Half of patients (50.2%) had a low level of education. Only 23% of patients had active disease. Steroids and immunosuppressive treatment were 57.4 and 42.0%, respectively. COVID-19 vaccine hesitancy was observed in 86 (28.2%) of patients, with 36 (11.8%) refusing vaccination and 50 (16.4%) remaining indecisive. Concerns regarding the vaccination's efficacy were stated by 24.3 percent of all patients, 70.2 percent concerning side effects, and 70.5 percent about the vaccine exacerbating SLE activity. The educational intervention boosted vaccination acceptance from 71.8% to 94.1% in patients who were previously hesitant to vaccination. Low level of education was the only factor associated with vaccine hesitancy (P = 0.018). Conclusion(s): COVID-19 vaccine hesitancy is low in Thai patients with SLE. Most individuals are concerned about the vaccine's adverse effects and negative impact on SLE activity. Patients with a low level of education are prone to exhibit vaccine hesitancy. Appropriate vaccine education significantly increases vaccination acceptability.