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Semin Arthritis Rheum ; 50(5): 885-889, 2020 10.
Article in English | MEDLINE | ID: covidwho-665551


OBJECTIVES: Patients with rheumatologic diseases might be more susceptible to COVID-19 and carry a poorer prognosis. The aim of this study is to examine the incidence and outcomes of all COVID-19 patients with rheumatologic conditions in Hong Kong. METHODS: This is a population-based retrospective study. All patients tested positive for SARS-CoV-2 by PCR with a previous diagnosis of rheumatologic diseases were reviewed. The incidence of COVID-19 in patients with rheumatologic conditions was calculated and compared to the general population in Hong Kong. Descriptive data of those rheumatologic patients with COVID-19 and the clinical course of the index infection were presented. RESULTS: Up till 27 May 2020, there were 1067 cases of COVID-19 diagnosed in Hong Kong which had a population of 7.5 million. Out of the 39,835 patients with underlying rheumatologic diseases, we identified 5 PCR confirmed COVID-19 cases. The estimated incidence of COVID-19 was 0.0126% patients with rheumatologic diseases, compared to 0.0142% in the general population. All 5 patients had inflammatory arthropathies. One patient was on hydroxychloroquine and sulphasalazine, and one was on methotrexate. None of the 3534 patients on b/tsDMARDs was infected. Four patients had leucopenia/lymphopenia and stool viral PCR was positive in 3 patients. All patients made uneventful recovery without complications or flare of underlying diseases. CONCLUSIONS: We found no alarming signals of increased frequency or severity of COVID-19 in patients with rheumatologic diseases, although extrapolation of the results to other populations with different infection control strategies should be made with caution.

Antirheumatic Agents , Betacoronavirus/isolation & purification , Clinical Laboratory Techniques , Coronavirus Infections , Joint Diseases , Pandemics , Pneumonia, Viral , Rheumatic Diseases , Adult , Antirheumatic Agents/classification , Antirheumatic Agents/therapeutic use , COVID-19 , COVID-19 Testing , Clinical Laboratory Techniques/methods , Clinical Laboratory Techniques/statistics & numerical data , Comorbidity , Coronavirus Infections/diagnosis , Coronavirus Infections/epidemiology , Female , Hong Kong/epidemiology , Humans , Incidence , Joint Diseases/drug therapy , Joint Diseases/epidemiology , Joint Diseases/etiology , Male , Middle Aged , Outcome Assessment, Health Care , Pneumonia, Viral/diagnosis , Pneumonia, Viral/epidemiology , Prognosis , Retrospective Studies , Rheumatic Diseases/diagnosis , Rheumatic Diseases/epidemiology , Risk Assessment , Risk Factors , SARS-CoV-2
Clin Rheumatol ; 39(7): 2085-2094, 2020 Jul.
Article in English | MEDLINE | ID: covidwho-436778


COVID-19 infection has a heterogenous disease course; it may be asymptomatic or causes only mild symptoms in the majority of the cases, while immunologic complications such as macrophage activation syndrome also known as secondary hemophagocytic lymphohistiocytosis, resulting in cytokine storm syndrome and acute respiratory distress syndrome, may also occur in some patients. According to current literature, impairment of SARS-CoV-2 clearance due to genetic and viral features, lower levels of interferons, increased neutrophil extracellular traps, and increased pyroptosis and probable other unknown mechanisms create a background for severe disease course complicated by macrophage activation syndrome and cytokine storm. Various genetic mutations may also constitute a risk factor for severe disease course and occurrence of cytokine storm in COVID-19. Once, immunologic complications like cytokine storm occur, anti-viral treatment alone is not enough and should be combined with appropriate anti-inflammatory treatment. Anti-rheumatic drugs, which are tried for managing immunologic complications of COVID-19 infection, will also be discussed including chloroquine, hydroxychloroquine, JAK inhibitors, IL-6 inhibitors, IL-1 inhibitors, anti-TNF-α agents, corticosteroids, intravenous immunoglobulin (IVIG), and colchicine. Early recognition and appropriate treatment of immunologic complications will decrease the morbidity and mortality in COVID-19 infection, which requires the collaboration of infectious disease, lung, and intensive care unit specialists with other experts such as immunologists, rheumatologists, and hematologists.

Antirheumatic Agents , Coronavirus Infections , Cytokine Release Syndrome , Lymphohistiocytosis, Hemophagocytic , Macrophage Activation Syndrome , Pandemics , Pneumonia, Viral , Antirheumatic Agents/classification , Antirheumatic Agents/immunology , Antirheumatic Agents/pharmacology , Betacoronavirus/isolation & purification , COVID-19 , Coronavirus Infections/complications , Coronavirus Infections/drug therapy , Coronavirus Infections/immunology , Cytokine Release Syndrome/etiology , Cytokine Release Syndrome/immunology , Cytokine Release Syndrome/therapy , Humans , Lymphohistiocytosis, Hemophagocytic/etiology , Lymphohistiocytosis, Hemophagocytic/immunology , Lymphohistiocytosis, Hemophagocytic/therapy , Macrophage Activation Syndrome/etiology , Macrophage Activation Syndrome/immunology , Macrophage Activation Syndrome/therapy , Patient Selection , Pneumonia, Viral/complications , Pneumonia, Viral/drug therapy , Pneumonia, Viral/immunology , SARS-CoV-2 , Time-to-Treatment
Semin Arthritis Rheum ; 50(4): 680-686, 2020 08.
Article in English | MEDLINE | ID: covidwho-343219


OBJECTIVE: To analyze clinical characteristics and outcome of COVID-19 patients with underlying rheumatic diseases (RD) on immunosuppressive agents. METHOD: A case series of COVID-19 patients with RD on disease modifying anti-rheumatic drugs (DMARDs) were studied by a retrospective chart review. A literature search identified 9 similar studies of single cases and case series, which were also included. RESULTS: There were 4 COVID-19 inpatients with RD from our hospital, and the mean age was 57 ± 21 years. Two patients had a mild infection, and 2 developed severe COVID-19 related respiratory complications, including 1 patient on secukinumab requiring mechanical ventilation and 1 patient on rituximab developing viral pneumonia requiring supplemental oxygenation. All 4 patients had elevated acute phase reactants, 2 patients had mild COVID-19 with lymphopenia, and 2 patients had severe COVID-19 with normal lymphocyte counts, and high levels of IL-6. None of the patients exhibited an exacerbation of their underlying RD. In the literature, there were 9 studies of COVID-19 involving 197 cases of various inflammatory RD. Most patients were on DMARDs or biologics, of which TNFα inhibitors were most frequently used. Two tocilizumab users had a mild infection. Two patients were on rituximab with 1 severe COVID-19 requiring mechanical ventilation. Six patients were on secukinumab with 1 hospitalization. Of the total 201 cases, 12 died, with an estimated mortality of 5.9% CONCLUSION: Patients with RD are susceptible to COVID-19. Various DMARDs or biologics may affect the viral disease course differently. Patients on hydroxychloroquine, TNFα antagonists or tocilizumab may have a mild viral illness. Rituximab or secukinumab could worsen the viral disease. Further study is warranted.

Antirheumatic Agents , Biological Products/therapeutic use , Coronavirus Infections , Pandemics , Pneumonia, Viral , Rheumatic Diseases , Antirheumatic Agents/classification , Antirheumatic Agents/therapeutic use , Betacoronavirus/isolation & purification , COVID-19 , Coronavirus Infections/immunology , Coronavirus Infections/mortality , Coronavirus Infections/therapy , Female , Humans , Immunosuppressive Agents/therapeutic use , Lymphocyte Count/methods , Lymphocyte Count/statistics & numerical data , Male , Middle Aged , Mortality , Outcome and Process Assessment, Health Care , Pneumonia, Viral/immunology , Pneumonia, Viral/mortality , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Respiration, Artificial/statistics & numerical data , Retrospective Studies , Rheumatic Diseases/drug therapy , Rheumatic Diseases/epidemiology , Rheumatic Diseases/immunology , SARS-CoV-2 , Severity of Illness Index , United States/epidemiology