No abstract

Objective To describe coronavirus disease-2019 (COVID-19) and pregnancy outcomes in patients with rheumatic disease who were pregnant at the time of infection. Methods Since March 2020 the COVID-19 Global Rheumatology Alliance (GRA) has collected cases of patients with rheumatic disease with COVID-19. We report details of pregnant women at the time of COVID-19 infection, including obstetric details separately ascertained from providers. Results We report on 39 patients, including 22 with obstetric detail available. The mean and median age was 33 years, range 24-45 years. Rheumatic disease diagnoses included: rheumatoid arthritis (n=9), systemic lupus erythematosus (n=9), psoriatic/other inflammatory arthritides (n=8) and anti-phospholipid antibody syndrome (n=6). Most had a term birth (16/22), with 3 pre-term births, one termination, one miscarriage and one woman yet to deliver at time of report. A quarter (n=10/39) of pregnant women were hospitalised following COVID-19 diagnosis. Two of 39 (5%) required supplemental oxygen (both hospitalised); no patient died. The majority did not receive specific medication treatment for their COVID-19 (n=32/39, 82%), seven patients received some combination of anti-malarials, colchicine, anti-IL-1beta, azithromycin, glucocorticoids, and lopinavir/ritonavir. Conclusion Women with rheumatic diseases who were pregnant at the time of COVID-19 had favourable outcomes. These data have limitations due to the small size and methodology, though they provide cautious optimism for pregnancy outcomes for women with rheumatic disease given the increased risk of poor outcomes that have been reported in other series of pregnant women with COVID-19.

No abstract

his transaminases fell rapidly, normalizing by day 12. The HAGMA persisted until day six. Urine excretion of 5oxoproline halved by day nine and was normal on repeat testing on day 19. Plasma taurine, cystine and methionine fell and remained below the reference range after recovery and discharge from hospital. Plasma glycine was within the reference range. Review of previous investigations found that two years prior to this admission he had very low levels of some of the sulphur-containing amino acids (Table 2). The child was given methionine supplementation (250 mg/day) and his plasma amino acids have returned to normal values. On presentation, this child had evidence for several of the proposed precipitating risk factors for paracetamol-induced 5-oxoprolinuria, including chronic ketosis, low plasma protein intake, liver failure and lactic acidosis. In addition, he had evidence of long-term depletion of sulphurcontaining amino acids. N-acetyl-P-benzoquinoneimine, a toxic intermediate of paracetamol metabolism, is stabilized and excreted by conjugation with glutathione. Glutathione is synthesized from glutamate, cysteine and glycine; deficiency of this tripeptide alters the g-glutamyl cycle, resulting in increased 5-oxoproline synthesis. 6 It is possible that deficiency of sulphur-containing amino acids in this patient resulted in low glutathione stores, precipitating 5oxoprolinuria in following paracetamol ingestion. In conclusion, we have described a child who presented with severe illness, HAGMA and 5-oxoprolinuria following a standard dose of paracetamol. His long-term ketogenic diet, while successful in controlling his severe epilepsy, appears to have been deficient in methionine, causing impaired synthesis of sulphur-containing amino acids and possible depletion of glutathione stores. This adds evidence to the hypothesis that nutritional deficiency, in particular of essential amino acids, may be a contributing factor to the abnormal metabolic response to paracetamol of HAGMA and 5-oxoprolinuria.