Statistics from Altmetric.com
We read with great interest the article by Mathian et al1 who first described COVID-19 in patients with systemic lupus erythematosus (SLE). Subsequent reports2 3 focused on the clinical course of COVID-19 among patients with SLE. We were interested in the impact of COVID-19 pandemic on hospitalisation of patients with SLE.
The first case of COVID-19 was reported in Malaysia on 25 January 2020. Cases spiked in early March 2020 until Malaysia recorded the highest cumulative number of confirmed COVID-19 infections in South-East Asia. Malaysia instituted lockdown from 18 March 2020 until 9 June 2020 (a 12-week period) as a public health measure to curb the pandemic.4
Recent studies5 6 have reported increased mortality in out-of-hospital acute coronary syndromes, not fully explained by COVID-19 cases alone, and potentially related to the patients’ reluctance to seek medical care out of fear of the infection threat. Bromage et al7 reported incident acute heart failure hospitalisation significantly declined in their centre during the COVID-19 pandemic, but hospitalised patients had more severe symptoms at admission. Monti et al8 reported higher percentage of irreversible bilateral visual loss due to giant cell arteritis induced by delayed referral during the COVID-19 pandemic. Our aim is to examine the impact of COVID-19 pandemic on SLE hospitalisation rates, clinical characteristics and management of patients admitted to a tertiary hospital during the peak of the pandemic.
We performed a detailed comparison of patients hospitalised during the lockdown (from 18 March 2020 to 9 June 2020) period and patients presenting in the same period in 2019 with respect to clinical characteristics and management during the index admission. Patient demographics, disease history and medication lists were obtained from hospitalisation and clinic visit notes. The primary cause for hospitalisation was determined by a physician based on review of hospitalisation records. In-hospital morbidity was determined by the length of hospitalisation and intensive care unit (ICU) requirement.
There were a total of 18 patients with SLE hospitalised during the lockdown period and six of them were newly diagnosed with SLE as illustrated in table 1. In contrast, the total SLE hospitalisations during the same period in 2019 were 52 admissions by 34 patients with SLE. We found a decline (65.4%) in SLE hospitalisation rate in our centre during the COVID-19 pandemic. There were increased numbers of new cases (6 vs 2) during the lockdown period. Five out of six new cases presented late to our hospital, during the eighth week of lockdown period. Among the six new cases, two patients had lupus myocarditis and one patient had severe lupus pancreatitis which required intravenous methylprednisolone, cyclophosphamide and immunoglobulin. Mean Systemic Lupus Erythematosus Disease Activity Index among patients with active lupus was higher (13 vs 10) during the COVID-19 pandemic as compared with the previous year.
The most common reason for hospitalisation was disease flare (38.9%) where haematological and mucocutaneous flares were the most frequent manifestations. Infection (22.2%) was the next most common cause. Only one patient with lupus had COVID-19 infection. There was no hospitalisation for renal biopsy and haemodialysis-related training, as compared with previous year. There was increased ICU admission during this period (4 vs 2). Of the 18 hospitalisations, there were 3 (16.7%) deaths reported. One died of severe pulmonary tuberculosis and two died of overwhelming sepsis. These three deaths occurred among our pre-existing patients with lupus. No death was reported in the same period of previous year.
This report highlights that SLE hospitalisation rate declined during the COVID-19 pandemic, but hospitalised patients had more severe symptoms needing more intensive treatment. Active disease and infection remain the main causes of admission in patients with SLE. Pattern of hospitalisation among our patient with lupus was consistent with other study,9 where disease flare and infection contributed the main reason of hospitalisation. Our data suggest that patients with SLE have avoided coming to hospital. The national lockdown and social distancing restrictions may have reduced respiratory tract infections, which are a common trigger for SLE flare. Mortality rate was higher because of the delayed presentation during COVID-19 pandemic.
The authors thank the Director-General of Health Malaysia for permission to publish this article.
Contributors All authors were involved in conception or design, or analysis and interpretation of data, or both. All authors approved the final version 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, 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.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.