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We read with great interest the paper published by D’Silva et al 1 regarding the main outcomes in rheumatic patients with COVID-19. According to this cohort, there was a mortality rate of 6%, slightly similar to the frequency observed in individuals without rheumatic diseases (RDs) (around 4%). On the other hand, there was a threefold higher risk of intensive care admission and mechanical ventilation in patients with RDs, suggesting some difficulties to handle this subgroup. More recently, Favalli et al 2 stated that the incidence of COVID-19 was also quite similar between patients with RD and individuals from the general population in Lombardia (0.62% vs 0.66%, respectively). Moreover, the disease activity was not worsened or triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in rheumatic patients.
Brazil had its first confirmed case of COVID-19 on 26 February, and, to date, it accounts for more than one million cases and more than 50 000 deaths. The lethality rate has been estimated in 4.7%.3 ReumaCoV Brasil is the official Brazilian Registry of Rheumatic Patients with COVID-19, supported by the Brazilian Society of Rheumatology. The inclusion phase started on 19 May with recruitment of 130 patients from 38 centres spread in five regions of the country. After the 4-week enrolment, we observed 12 deaths with a lethality rate of 9.2%, almost twice more than the general Brazilian population. Our data are more closely in accordance with the Global Rheumatology Alliance Global Registry4 than D'Silva’s cohort.1
Considering our 12 patients with RD, more than 83.3% were women with a mean age of 49.9 years (±17.2). Only three patients were older than 60 years. Four patients had systemic lupus erythematosus (SLE); two had rheumatoid arthritis; two had systemic sclerosis; one had systemic vasculitis; one had psoriatic arthritis; one had axial spondyloarthritis; and one had overlap syndrome. Oral corticosteroids were being used by 58.3% of cases, with daily dosages between 10 and 20 mg, and only four patients used hydroxychloroquine. The main symptoms related to COVID-19 were cough (91.7%), dyspnoea (83.3%) and fever (75.0%), quite similar to the previously published data.4 5 Another relevant thing to address is the lack of biological therapy, higher prevalence of active SLE and recent combined methylprednisolone and cyclophosphamide pulse among our hospitalised patients. All of them were hospitalised in the intensive care unit with severe hypoxia (table 1).
Interestingly, we did not found any pattern related to death caused by COVID-19, suggesting neither RD itself (remission, disease activity, years since the diagnosis) nor the current immunosuppression status was associated with poor outcome. Nonetheless, the frequency of comorbidities was high, including hypertension (63.6%), diabetes (27.3%), chronic interstitial lung disease (27.3%) and renal failure (36.4%). Also, it is worthy emphasising the low adherence to international measures to mitigate the viral contagion, including social distancing (around 50%) in our cases, differently of reporting by Favalli et al.2
Thus, several other aspects, including immunosenescence, epigenetic modifications, viral load, genetic background, changes in T-cell diversity, inflammaging and comorbidities,6 seem to be more involved with the uncontrolled inflammatory and immune response, as well as the cytokine storm, and higher mortality rate in patients with COVID-19 than the underlying RDs.
Although our data are preliminary, it is important to highlight the huge spectrum of RD, as well as the heterogeneity of these patients, regarding the risk of death, especially in those with recent use of corticosteroids, reinforcing that protective measures need to keep on being recommended, and the rheumatologists should weigh the peculiarities of each disease and the immunosuppression to better manage them.
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Collaborators Adriana Maria Kakehasi, Ana Paula Monteiro Gomides, Eduardo dos Santos Paiva, Gecilmara Cristina Salviato Pileggii, Gilda Aparecida Ferreira, Licia Maria Henrique da Mota, Ricardo Machado Xavier.
Contributors All authors have participated in the study to the conception or design of the work, or the acquisition, analysis or interpretation of cases; and subsequent revisions of the manuscript.
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.