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Patients with autoimmune rheumatic diseases have an increased risk of viral infections that can be attributed to the underlying immunological abnormalities, comorbidities and immunosuppressive therapy. Moreover, immunocompromised patients with influenza had more severe disease, longer viral shedding and more antiviral resistance while demonstrating less clinical symptoms and signs.1 COVID-19 in patients with autoimmune rheumatic diseases, particularly treated with immunosuppressive agents, is also likely to follow the deleterious course previously reported in the other respiratory viral infections.2
Surprisingly, little is known about the association of COVID-19 and inflammatory rheumatic diseases, although the number of patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has already exceeded two millions and continues to rise in many countries, including Russia. In a recent article, Monti et al suggested that patients with chronic arthritis treated with biological and targeted synthetic disease modifying antirheumatic drugs (DMARDs) do not seem to be at increased risk of respiratory or life-threatening complications from COVID-19 compared with the general population.3 However, more data about the prevalence, severity and outcomes of COVID-19 in patients with rheumatic disease are urgently needed to identify patients at higher risk and to inform management guidelines.4
In a retrospective nationwide study, we evaluated the prevalence of autoimmune rheumatic diseases among 902 intensive care unit (ICU) patients with SARS-CoV-2 pneumonia who required noninvasive or invasive lung ventilation with or without inotropic support. According to the government’s decision, medical records were submitted via Internet by all local COVID-19 hospitals across Russia to the Federal Center at the Sechenov University (Moscow) that provided advice on the antiviral therapy and critical care management. Diagnosis of the SARS-CoV-2 pneumonia suspected clinically was confirmed both by PCR and CT. In patients with inconclusive or pending results of PCR, SARS-CoV-2 pneumonia was defined as severe acute respiratory infection with typical CT findings (bilateral multilobar ground-glass opacification with a peripheral or posterior distribution, or multifocal consolidative opacities superimposed on ground-glass opacification, septal thickening and development of a crazy paving pattern)5 and no other obvious aetiology.
Four hundred and fifty records (49.9%) were received from the Moscow hospitals, 123 records (13.6%) from the Moscow province and 329 records (36.5%) from the hospitals located in fifty two geographical regions of the Russian Federation. Autoimmune rheumatic diseases, including rheumatoid arthritis, systemic sclerosis, psoriatic arthritis, systemic lupus erythematosus and ankylosing spondylitis, as reported by the local physicians, were identified in 10 (1.1%) of 902 ICU patients with COVID-19 (table 1). Diagnoses were reported by the local physicians and could not be definitely ascertained. As expected, rheumatoid arthritis was the most common rheumatic disorder, given its higher prevalence in the general population. Six patients were older than 60 years of age. Seven patients had concurrent cardiovascular diseases (arterial hypertension, atrial fibrillation, previous myocardial infarction or stroke), and three patients had type 2 or steroid diabetes. Five patients (50%) died.
We assumed that immunocompomised patients with autoimmune rheumatic diseases were likely to present with a more severe course of COVID-19 requiring oxygen support and admission to ICU. However, the total prevalence of inflammatory rheumatic diseases among ICU patients with SARS-CoV-2 pneumonia was low (1.1%) and did not exceed that in the general population (1%–2%). Moreover, most critically ill patients with rheumatic disease had predictors of unfavourable outcomes of SARS-CoV-2 pneumonia, such as cardiovascular diseases, diabetes mellitus and obesity, that could contribute to development of acute respiratory distress syndrome (ARDS). Apparently, we cannot make any definite conclusions regarding the risk of severe COVID-19 in rheumatic patients, since we do not know the total number of infected patients with autoimmune rheumatic diseases in Russia. Of note, patients with any chronic diseases are probably at increased risk of contracting respiratory infections due to more frequent visits to outpatient clinics or hospitals where they can have contacts with infected individuals.
Accumulating evidence suggests that a proportion of patients with severe SARS-CoV-2 pneumonia have a cytokine release syndrome or cytokine storm, underlying ARDS that is the leading cause of mortality.6 Various anti-inflammatory agents improve cytokine profile, suppress hyperinflammation and therefore may prevent virus-induced ARDS in patients with SARS-CoV-2 infection.2 Several antirheumatic medications, that is, hydroxychloroquine/chloroquine, tocilizumab, sarilumab, anakinra, colchicine, are currently under investigation in patients with COVID-19. Tocilizumab, a humanised monoclonal antibody against the interleukin-6 receptor, seems to be the most promising agent for prevention and treatment of SARS-CoV-2-induced ARDS, given its established efficacy in patients with cytokine release syndrome caused by overactive immune response to chimeric antigen T-cell therapy for cancer. However, it cannot be stated if certain drugs are helpful, not helpful or aggravating for COVID-19 due to the lack of controlled trials.
In summary, our findings suggested that patients with autoimmune rheumatic diseases were not over-represented in the large cohort of ICU patients with SARS-CoV-2 pneumonia who developed ARDS. These data indirectly support the current recommendation not to interrupt therapies used in rheumatic patients to avoid flares of autoimmune disease.7
Contributors All authors contributed to the manuscript.
Funding The Russian Academic Excellence Project 5–100.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.