Respiratory Failure More Common in COVID-19 Patients With Rheumatic Disease

By Marilynn Larkin

June 22, 2020

NEW YORK (Reuters Health) - COVID-19-infected patients with rheumatic disease were more likely to experience respiratory failure than those without rheumatic disease, according to a retrospective study in China.

"Immune dysregulation underlying rheumatic diseases may affect the disease manifestation of COVID-19," Dr. Jixin Zhong of Huazhong University of Science and Technology in Wuhan told Reuters Health by email. "Rheumatic disease-specific symptoms and tests may be useful to differentiate COVID-19-related symptoms and a flare of rheumatic disease or pre-existing interstitial lung disease caused by rheumatic disease."

Dr. Zhong and colleagues studied 2,326 COVID-19 patients in Tongji Hospital from January to March, including 21 with rheumatic disease. Eight had rheumatoid arthritis; four, systemic lupus erythematosus; three, primary Sjogren's syndrome; two, undifferentiated connective tissue disease; two, ankylosing spondylitis; one, polymyalgia rheumatica; and one, juvenile idiopathic arthritis.

As reported in Annals of Rheumatic Diseases, the length of hospital stay was similar between rheumatic and non-rheumatic groups, as were mortality rates (9.52% vs. 9.54%). Respiratory failure was more common in rheumatic cases, however (38% vs. 10%).

Among patients with rheumatic diseases, fever, fatigue and diarrhea were seen in 76%, 43% and 23%, respectively. Four patients had disease flares while hospitalized, with muscle aches, back pain, joint pain or rash.

Many clinical characteristics are similar between COVID-19 and a rheumatic disease flare, including fatigue, fever, and abnormalities in laboratory tests and on CT scans, the authors note. "The presence of these symptoms may lead to a misinterpretation of rheumatic disease flare and further delay the recognition of COVID-19."

Lymphocytopenia was seen in 57% of rheumatic patients; however, only one patient (5%) presented with leukopenia. Rheumatic patients also presented with similar radiological features of ground-glass opacity and consolidation, while those with pre-existing interstitial lung disease showed "massive fibrous stripes and crazy-paving signs at an early stage," according to the authors.

Dr. Bibi Ayesha, Director of the Vasculitis Clinic and Lead of the COVID-19 Cytokine Storm Task Force at Montefiore Health System in New York City, commented in an email to Reuters Health, "Patients with autoimmune rheumatic diseases have baseline immune dysregulation... Their response to COVID-19 infection is multifactorial, and depends on the type of rheumatic disease, severity of organ system involvement, use of immunosuppressive therapy, their baseline comorbidities and the disease activity of the underlying rheumatic disease."

"Dysregulated and excessive immune responses may result in multi-organ failure," she said. "Further analysis is needed to understand whether treatment with immunosuppressive therapy in patients with well controlled rheumatic diseases prior to COVID-19 infection could have possibly avoided the exaggerated immune response to COVID-19 infection."

Studies comparing the response to COVID-19 of patients with poorly controlled versus well-controlled rheumatic disease are also needed, she said.

"The findings (of this study) are not generalizable," she added, "as the sample size was small and there was no explanation about the baseline rheumatic disease activity of the patients."

"Rheumatologists should optimize management of rheumatic diseases and encourage patients to continue their treatment regimen even during the COVID-19 outbreak," she advised. "This strategy is reasonable as it aims to prevent rheumatic disease flares, thus avoiding intermittent use of high-dose corticosteroids which can further compromise immunity and predispose patients to a higher risk of secondary infection."

SOURCE: Annals of Rheumatic Diseases, online May 22, 2020.