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We read with interest the letter by Mathian A et al 1 describing the clinical course of COVID-19 in a series of 17 patients with systemic lupus erythematosus under long-term treatment with hydroxychloroquine. The COVID-19 Global Rheumatology Alliance registry2 shows that 19 (17%) of 110 patients with rheumatic diseases who have been diagnosed with COVID-19 as of 1 April 2020 were patients with lupus. Bozzalla Cassione et al,3 Romão et al 4 and Ye et al,5 respectively, described patients with SLE in their papers. The latest paper by D’Silva et al reported ten cases of lupus in their cohort.6 We would like to share the clinical course of COVID-19 among patients with SLE in Malaysia.
As of 30 March 2020, there were five cases of SLE from a total of 2626 cases of COVID-19 in Malaysia. Clinical data were obtained through a review of medical records. COVID-19 was diagnosed in the patients based on a positive result on a reverse transcriptase PCR testing that detected severe acute respiratory syndrome coronavirus 2 from nasopharygeal swab specimen. All five patients were women with a mean age of 52.80±4.46 years and a mean disease duration of 13.20±3.92 years. All the patients were on long-term hydroxycholoroquine at baseline. Two patients were on conventional disease modifying antirheumatic drugs (DMARDs) (sulfasalazine and azathioprine), and one patient was on biological DMARDs (belimumab). Only one patient was on prednisolone during the diagnosis of COVID-19 infection. Majority of the patients were hypertensive and obese; 60% of them were on ACE inhibitor or angiotensin II receptor blocker treatment. The most common presentations were fever and cough. One patient was having active lupus shortly before COVID-19 diagnosis, while two patients were having flares of disease concurrently with COVID-19. Most patients have lymphopenia (lymphocyte count <1500 mm3). Radiologically, all the patients had pneumonia in the chest X-rays. Demographic characteristics, clinical features, treatments and outcomes of five cases are illustrated in tables 1 and 2.
The ongoing, rapidly evolving COVID-19 pandemic poses a real threat to patients with SLE. As illustrated in the cases, COVID-19 is fast becoming a cause for morbidity and mortality in patients with SLE who are immunosuppressed. COVID-19 might mimic SLE flare as well as occur concurrently with SLE flare as demonstrated by cases 2 (arthritis) and 3 (autoimmune haemolytic anaemia).
Early diagnosis and treatment of COVID-19 is of paramount importance to ensure a good outcome. As illustrated by the cases, all patients presented with moderately severe to severe COVID-19 but responded well to treatment except the first case, which presented very late and was diagnosed posthumously. Only case 4 needed invasive ventilation and this patient received intravenous belimumab 1 week prior to contracting COVID-19. She needed more intensive treatment compared with the others. The role of belimumab in the clinical course of COVID-19 awaits further research. Three of them were also received intravenous corticosteroids during their hospitalisations; two received intravenous hydrocortisone as treatment of their concurrent SLE flares. Interestingly, case 3 received intravenous methylprednisolone for severe haemolytic anaemia at a very early stage; her COVID-19 was not worsening with this early use of corticosteroids but responded to standard treatment and she recovered well. The role of corticosteroids in the treatment of COVID-19 is controversial.
In summary, COVID-19 among our patients with SLE on hydroxychloroquine has a severe disease course needing aggressive therapy. Background hydroxychloroquine treatment for SLE did not prevent COVID-19 among our patients. Early diagnosis and treatment of COVID-19 resulted in good outcome in our patients with SLE.
The authors thank the Director General of Health, Malaysia, for technical support for this research paper.
Contributors CLT and SCG: study conception and design. YKC, WRWM, SAWMA and NMH: data acquisition and data analysis. CLT, YKC and SCG: manuscript preparation and critical revision. All authors read and approved the final version.
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.
Provenance and peer review Not commissioned; internally peer reviewed.