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Correspondence on ‘Clinical course of coronavirus disease 2019 (COVID-19) in a series of 17 patients with systemic lupus erythematosus under long-term treatment with hydroxychloroquine’
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  1. Hercílio Martelli Júnior1,2,
  2. Nelson Pereira Marques3,
  3. Nádia Carolina Teixeira Marques2,4,
  4. Edson Gomes de Lucena5,
  5. Daniella Reis B Martelli1,
  6. Eduardo A Oliveira6
  1. 1Primary Care/Health Science Postgraduate Program, Montes Claros State University, Montes Claros, MG, Brazil
  2. 2Center for Rehabilitation of Craniofacial Anomalies, Universidade José do Rosário Vellano, Alfenas, MG, Brazil
  3. 3FOP-UNICAMP, State University of Campinas, Piracicaba, SP, Brazil
  4. 4Faculty of Dentistry, Universidade José do Rosário Vellano, Alfenas, MG, Brazil
  5. 5Clinical and Social Dentistry Department, Federal University of Paraiba, Joao Pessoa, Brazil
  6. 6Department of Pediatrics, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
  1. Correspondence to Dr Nelson Pereira Marques, FOP-UNICAMP, State University of Campinas, Piracicaba, SP 13414-018, Brazil; neomarques{at}hotmail.com

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The SARS-CoV-2 disease 2019 (COVID-19) pandemic deeply affected all Brazilian regions. Brazil has seen approximately 12 million cases of COVID-19 and over 294 042 deaths to date (21 March 2021) (https://COVID-19.saude.gov.br/), and the end of the pandemic cannot yet be predicted. The COVID-19 pandemic scenario represents a source of concern for the management of patients with chronic diseases and comorbidities, including autoimmune diseases, such as systemic lupus erythematosus (SLE).1 The new viral infection caused by SARS-CoV-2 seems to lead to the onset or exacerbation of autoimmune diseases in genetically predisposed patients.2–4 SLE is an autoimmune disease prone to flare-ups that are linked to significant morbimortality. Immunosuppression-related infections are one of the leading causes of premature death in patients with SLE. However, there are currently no data to support a higher infection rate or an increased risk for fatal outcome related to COVID-19 in these patients.2–5 One could even speculate the SLE treatment can protect against the serious complications related to COVID-19.2

In this regard, we read the relevant paper by Mathian et al1 who evaluated the clinical course of COVID-19 in patients with SLE treated with hydroxychloroquine. Although these preliminary data have shown a lack of clarity about the incidence and severity of COVID-19 in patients with SLE, it is suggested that patients with comorbidities, such as chronic kidney disease and obesity, may suffer from severe forms of COVID-19, regardless of the chronic use of hydroxychloroquine. Similarly, Wallace et al6 suggests that patients with SLE may develop more severe manifestations of COVID-19 infection, especially when other comorbidities and predisposing factors are associated, including obesity, smoking and chronic use of medications, such as immunosuppressants. On the other hand, Favalli et al7 consider the impact of COVID-19 in patients with SLE very low, since most patients with chronic diseases are used to take measures in order to reduce infection risks, even before the outbreak of COVID-19. Accordingly, Caso et al5 claim that different strategies followed for the management of rheumatic diseases are currently included in the treatment protocol for SARS-CoV- 2 infection.

However, it is believed that autoinflammatory and autoimmune syndromes can have triggering factors, such as viruses, which stimulate the activation of an exacerbated immune response, with increased synthesis of proinflammatory cytokines. Due to similar pathogenic mechanisms and clinical–radiological aspects in hyperinflammatory diseases and COVID-19, it can be suggested that SARS-CoV-2 could act as a triggering factor for the development of rapid autoimmune and/or autoinflammatory dysregulation.5 In order to ascertain this issue further, we evaluated the number of cases of SLE diagnosed from January 2017 to December 2020 over all the five Brazilian macroregions and compared the prepandemic and transpandemic period of COVID-19.

Over the triennium 2017–2019, the average number of new diagnosed cases of SLE was 23 422, while in 2020 this figure reached 36 549, an increment of about 56% during the time frame analysed. The increment was consistent across all five Brazilian macroregions, ranged from +23.4% in Southeast to +108.9% in the Northeast region. The increase in the overall Brazilian cases reached +13 107 (+55.9%) cases, corresponding an addition of an average of 1092 cases per month during the COVID-19 pandemic (table 1). Table 2 shows a significant increase in the incident cases of SLE per million population in Brazil (p<0.001).

Table 1

The average number of diagnosed systemic lupus erythematosus cases, across Brazilian geographical macroregions, according to different periods (2017–2019 vs 2020)

Table 2

Incident cases of systemic lupus erythematosus per million population in Brazilian macroregions according to the periods 2017–2019 versus 2020

In conclusion, our findings have shown an increase in the number of new cases of SLE in Brazil during the pandemic period. Conversely, we recently reported that the pandemic period has dramatically reduced the diagnosis of new cases of cancer in Brazil, possibly by the limitation of consultations in public health services.8 Many aspects of the association between SLE and COVID-19 are not yet well established. Further prospective clinical studies are needed to define whether these conditions are really related.

Acknowledgments

The authors would like to thank State Research Foundation—FAPEMIG, Minas Gerais, Brazil, the National Council for Scientific and Technological Development—CNPq, Brazil, and the Coordination for the Improvement of Higher Education Personnel, CAPES, Brazil.

References

Footnotes

  • Handling editor Josef Smolen

  • Contributors HMJ: Conceptualisation, formal analysis, methodology, project administration, supervision, roles/writing—original draft and writing—review and editing. NPM: Conceptualisation, data curation, formal analysis, investigation, methodology, roles/writing—original draft and writing—review and editing. NCTM: Formal analysis, investigation, methodology and writing—review and editing. EGdL: Conceptualisation, data curation, formal analysis and methodology. DRBM: Conceptualisation, formal analysis and writing—review and editing. EAO: Formal analysis, investigation, methodology and writing—review and editing.

  • 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.

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

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