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LETTER TO EDITOR
Ahead of print publication  

Hospital outcomes of severe acute respiratory syndrome corona virus 2 in rheumatoid arthritis: A case series observation


 Department of General Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission24-Oct-2020
Date of Acceptance10-Mar-2021

Correspondence Address:
Swathy Moorthy,
Department of General Medicine, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 116, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_299_20



How to cite this URL:
Moorthy S, Gopalan S, Bhaskar E. Hospital outcomes of severe acute respiratory syndrome corona virus 2 in rheumatoid arthritis: A case series observation. Indian J Rheumatol [Epub ahead of print] [cited 2021 Dec 9]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=328979



Dear Editor,

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes adverse outcomes in those with prior medical comorbidities such as diabetes mellitus, hypertension, obesity, chronic kidney disease, and in the elderly.[1] Global registries such as the EULAR–COVID-19 database and COVID-19 Global Rheumatology Alliance aim to share outcomes of SARS-CoV-2 infection in rheumatological disorders.[2] However, there is a lack of data from South Asia. Patients with rheumatoid arthritis (RA) have a higher infection risk, due to disease process and drug therapy, more so with biologicals than with conventional disease-modifying anti-rheumatic drugs (DMARDs).[3] We report a case series of patients with RA, hospitalized for SARS-CoV-2 infection.

We retrospectively analyzed 9 hospitalized patients with prior seropositive RA with confirmed SARS-CoV-2 infection (by reverse transcriptase-polymerase chain reaction of naso-pharyngeal swab) between June 11 and September 30, 2020. The severity of RA was assessed using Disease Activity Score 28 at initial hospitalization.[4] SARS-CoV-2 infection was classified as mild (peripheral oxygen saturation > 94%), moderate (90%–94%), and severe (<90%). Patient characteristics including age, gender, clinical features, investigations, treatment, and course in the hospital were obtained.

The mean age was 54.5 ± 10.8 years. [Table 1] describes baseline characteristics, the severity of illness, and the management of individual patients. The mean duration of RA was 14.8 ± 3.6 years. Symptoms on presentation were fever (n = 7), cough (n = 4), shortness of breath (n = 3), sore throat (n = 3), myalgias, fatigue, and vomiting were observed in one each. The mean C-reactive protein was 3.5 ± 4.6 mg/dl, lactate dehydrogenase was 288.6 ± 73.6 U/L, ferritin 103.91 ± 112.04 ng/ml, serum albumin 3.7 ± 0.4 g/dl, d-Dimer 0.86 ± 0.57 mg/L, neutrophil-lymphocyte ratio was 3.3 ± 2.5, absolute lymphocyte count was 1810.8 ± 944.57 cells/cu mm. Four received steroids (methylprednisolone-2, prednisolone-1, and 1-dexamethasone) along with Zinc and Vitamin C supplementation. None received Remdesivir. DMARDs at dose taken by the patient before hospitalization was continued during the hospital stay. However, two patients had discontinued DMARDs before current illness and two were only on hydroxychloroquine as they were in clinical remission. The mean duration of hospital stay was 7.4 ± 2.7 days. Prolonged hospital stay, defined as >10 days, was required for 2 patients on account of hypoxia, none developed thrombosis or organ dysfunction. All were discharged to home.
Table 1: Baseline characteristics of the study patients

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Our case series shows favorable outcomes despite a high prevalence of additional prior medical illness (8 of 9 had at least one additional illness). Data from Europe suggest that outcomes of COVID are not influenced by preexisting rheumatological diseases.[5] The infection is known to result in the release of interleukins (IL) such as IL-6, IL-1, IL-8, and chemokines which activate macrophages and help their homing to inflammatory areas.[6] This cascade leads to increase in the production of macrophage inflammatory protein 1 alpha, tumor necrosis factor which results in tissue destruction. Activation of T cells, production of effector cytokine, and the influx of neutrophils are features of both synovitis due to RA and lung damage due to SARS-CoV-2 infection and DMARDs target several of these mediators.[6]

A recent meta-analysis observed that hydroxychloroquine/chloroquine does not reduce short-term mortality in patients hospitalized with COVID-19.[7] However, whether long term intake of disease-modifying agents help in downregulation of the cytokine and chemokine surge resulting in benefit in patients with rheumatological disorders is yet to be studied.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Yi, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 1
    
2.
COVID-19 Global Rheumatology Alliance. The Global Rheumatology Community's Response to the Worldwide COVID-19 Pandemic. Healthcare Provider Entered Registries. Available from: https://rheum-covid.org/provider-registry-gate/. [Last accessed on 2020 Oct 31].  Back to cited text no. 2
    
3.
Atzeni F, Masala IF, Di Franco M, Sarzi-Puttini P. Infections in rheumatoid arthritis. Curr Opin Rheumatol 2017;29:323-30.  Back to cited text no. 3
    
4.
Prevoo ML, van 't Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum. 1995;38:44-8. doi: 10.1002/art.1780380107. PMID: 7818570.  Back to cited text no. 4
    
5.
Fredi M, Cavazzana I, Moschetti L, Andreoli L, Franceschini F, Brescia Rheumatology COVID-19 Study Group. COVID-19 in patients with rheumatic diseases in Northern Italy: A single-center observational and case control study. Lancet Rheumatol 2020;2:e549-56.  Back to cited text no. 5
    
6.
Schett G, Manger B, Simon D, Caporali R. COVID-19 revisiting inflammatory pathways of arthritis. Nat Rev Rheumatol 2020;16:465-70.  Back to cited text no. 6
    
7.
Kashour Z, Riaz M, Garbati MA, AlDosary O, Tlayjeh H, Gerberi D, et al. Efficacy of chloroquine or hydroxychloroquine in COVID-19 patients: a systematic review and meta-analysis. J Antimicrob Chemother. 2021;76:30-42. doi: 10.1093/jac/dkaa403. PMID: 33031488; PMCID: PMC7665543.  Back to cited text no. 7
    



 
 
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