Boston and Wuhan Report Rheum COVID Patients at Risk for Respiratory Failure Save

Two current reports from Boston and Wuhan describe cohorts of COVID-19 (+) rheumatic disease patients who generally do well but appear to have a higher risk of pulmonary involvement.

The Annals of Rheumatic Disease reports on 21 rheumatic patients infected with COVID-19 from Wujan China. This retrospective study of 2326 COVID-19 patients from the Tongji Hospital were between 13 January and 15 March 2020. Nearly 1% of these (21) COVID patients also had rheumatic disease (8 RA, 4 SLE, 3 Sjögren’s, 2 UCTD, 2 AS, 1 each with PMR and JIA.  Compared with non-rheumatic COVID patients, the rheumatic COVID patients had a higher ratio of female patients.

Hospitalization and mortality rates were similar between rheumatic and non-rheumatic patients, yet rheumatic patients were more likely to experience respiratory failure (38% vs 10%, p<0.001). Radiographically they presented with ground-glass opacities and consolidation. Patients with pre-existing interstitial lung disease showed massive fibrous stripes and crazy-paving signs at an early stage.

Common symptoms of COVID in rheumatic patients included fever (76%), fatigue (43%) and diarrhea (23%). Four of 21 rheumatic patients had a flare of rheumatic disease during hospitalization (manifest as myalgias, back pain, joint pain or rash).  Five patients were taking hydroxychloroquine before COVID-19; none progressed to critically ill stage.

The Wuhan experience has confirmed that rheumatic disease patients, including those on hydroxychloroquine, can be infected with COVID-19 and that they may be at higher risk for respiratory failure.  In the evaluation of respiratory failure, chest CT scan, COVID testing and disease-specific symptoms may aid in distinguishing between a rheumatic disease flare and the coronavirus infection. 

D’Silva and colleagues from Boston have reported their comparative cohort study of 52 patients with rheumatic disease and COVID-19 matched 1:2 with a nonrheumatic control group of patients diagnosed between 1 March and 8 April 2020.  These patients were older (mean 63 year), predominantly female (69%) and 75%were on immunosuppressive medications.

The two groups were similar in labs, symptoms,  hospitalization rates (44% vs 40%), p=0.50) and mortality (6% vs 4%), p=0.69).

But, rheumatic disease were more likely to require intensive care admission and mechanical ventilation (48% vs 18%; multivariable OR 3.11 [95% CI 1.07 to 9.05]).

It appears that patients with rheumatic disease and COVID-19 infection may be at higher risk for respiratory failure; suggesting the need for early diagnosis, monitoring and intervention in such patients.