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Rheumatic disease and COVID-19
  1. Jean W Liew1,
  2. Elizabeth R Graef2
  1. 1 Division of Rheumatology, Department of Medicine, University of Washington, Seattle, Washington, USA
  2. 2 Department of Rheumatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Jean W Liew, Division of Rheumatology, Department of Medicine, University of Washington, Seattle, WA 98195, USA; liew.jw{at}

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We appreciated the letter from Monti et al, which was the first dedicated report of patients with rheumatic disease who have been diagnosed with COVID-19.1 We have also reviewed the response from Joob and Wiwanitkit,2 which unfortunately perpetuates the notion that individuals with systemic lupus erythematosus (SLE) or other rheumatic disease may be protected from COVID-19 infection via hydroxychloroquine use. Although the origins of this claim are not entirely clear, they may arise from the fact that rheumatic or autoimmune diseases were not initially reported among other comorbidities in the first large Chinese case series.3–5 Some of the subsequent publications have also not reported these conditions in their tables of baseline characteristics.6–8

However, as the aphorism goes, ‘the absence of evidence is not evidence of absence’. Instead, we have to consider the following: Were these comorbidities searched for, but not found? Or were they not included in the search at all? The latter is understandable and should not automatically be discounted as a methodological oversight. While the prospective collection of granular data would have been ideal, this was likely precluded by the sheer volume and urgency of medical care delivered during the early stages of the pandemic. With the global medical and scientific community awaiting clinical data, those first publications were eagerly welcomed for the information that they could provide on the exploding crisis.

It is worth noting that this paucity of data on the rheumatic disease population ultimately prompted the rheumatology community to form a global case registry.9 In a report of the initial 110 patients from this registry, there were 19 with SLE who had been diagnosed with COVID-19.10 In the USA especially, widespread testing has been delayed and has likely resulted in lower counts of COVID-19 cases.11 Disparities in healthcare access, which are well documented in US patients with SLE,12 may have further potentiated this under-reporting. Further data from rheumatology-specific registries are forthcoming, especially as confirmed case numbers continue to rise. We expect that we will learn more about the impact of COVID-19 on people living with rheumatic disease in due course.



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  • Correction notice This article has been corrected since it published Online First. The second affiliation has been corrected.

  • Contributors Both authors contributed to this work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.