COVID-19 and rheumatic autoimmune systemic diseases: report of a large Italian patients series

Abstract

Introduction Covid-19 infection poses a serious challenge for immune-compromised patients with inflammatory autoimmune systemic diseases. We investigated the clinical-epidemiological findings of 1641 autoimmune systemic disease Italian patients during the Covid-19 pandemic. Method This observational multicenter study included 1641 unselected patients with autoimmune systemic diseases from three Italian geographical areas with different prevalence of Covid-19 [high in north (Emilia Romagna), medium in central (Tuscany), and low in south (Calabria)] by means of telephone 6-week survey. Covid-19 was classified as (1) definite diagnosis of Covid-19 disease: presence of symptomatic Covid-19 infection, confirmed by positive oral/nasopharyngeal swabs; (2) highly suspected Covid-19 disease: presence of highly suggestive symptoms, in absence of a swab test. Results A significantly higher prevalence of patients with definite diagnosis of Covid-19 disease, or with highly suspected Covid-19 disease, or both the conditions together, was observed in the whole autoimmune systemic disease series, compared to “Italian general population” (p = .030, p = .001, p = .000, respectively); and for definite + highly suspected diagnosis of Covid-19 disease, in patients with autoimmune systemic diseases of the three regions (p = .000, for all comparisons with the respective regional general population). Moreover, significantly higher prevalence of definite + highly suspected diagnosis of Covid-19 disease was found either in patients with various “connective tissue diseases” compared to “inflammatory arthritis group” (p < .000), or in patients without ongoing conventional synthetic disease-modifying anti-rheumatic drugs treatments (p = .011). Conclusions The finding of a higher prevalence of Covid-19 in patients with autoimmune systemic diseases is particularly important, suggesting the need to develop valuable prevention/management strategies, and stimulates in-depth investigations to verify the possible interactions between Covid-19 infection and impaired immune-system of autoimmune systemic diseases. Key Points• Significantly higher prevalence of Covid-19 is observed in a large series of patients with autoimmune systemic diseases compared to the Italian general population, mainly due to patients’ increased susceptibility to infections and favored by the high exposure to the virus at medical facilities before the restriction measures on individual movement.• The actual prevalence of Covid-19 in autoimmune systemic diseases may be underestimated, possibly due to the wide clinical overlapping between the two conditions, the generally mild Covid-19 disease manifestations, and the limited availability of virological testing.• Patients with “connective tissue diseases” show a significantly higher prevalence of Covid-19, possibly due to deeper immune-system impairment, with respect to “inflammatory arthritis group”.• Covid-19 is more frequent in the subgroup of autoimmune systemic diseases patients without ongoing conventional synthetic disease-modifying anti-rheumatic drugs, mainly hydroxyl-chloroquine and methotrexate, which might play some protective role against the most harmful manifestations of Covid-19.

COVID-19 and systemic sclerosis: clinicopathological implications from Italian nationwide survey study

“… 3 , 4 , 5 These diseases affect a non-negligible proportion of individuals worldwide and are characterised by profound immune system alterations and increased susceptibility to infections, frequently aggravated by immune-modulating therapies. 3 , 4 , 5 , 6 …”

“… 7 However, the literature on the impact of COVID-19 in patients with systemic sclerosis is limited to anecdotal reports or single-centre survey studies focusing on a miscellanea of rheumatic autoimmune disorders. 4 , 8 , 9 …”

COVID-19 Among Patients With Inflammatory Rheumatic Diseases

“…Interestingly, an observational multicenter study including 1641 IRD patients showed an increased prevalence of COVID-19 among IRD patients not on csDMARDs and suggested a protective role of csDMARDs [20]. But, this study did not elaborate on the severity of COVID-19 infection among patients who used csDMARDs and those who did not.…”

COVID-19 in Italian patients with rheumatic autoimmune systemic diseases

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] Given the heterogeneous distribution of pandemic infection within the same country, we investigated the impact of COVID-19 in ASD patients' populations from three distinct regions of Italy (northern, Emilia Romagna; central, Tuscany; and southern, Calabria), characterised by different spread of the COVID-19 pandemic, prevalent in northern Italy with a marked gradient north-south. 16 Our 6-week multicentre telephone survey of 1641 unselected patients with ASD confirmed the quite benign clinical course of COVID-19 in ASD, along with the safety of baseline use of either bDMARD or tsDMARD [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] ; however, the survey revealed a significantly higher prevalence of (1) either definite COVID-19 (always confirmed by positive oral/nasopharyngeal swabs at PCR testing) or highly suspected COVID-19 (presence of fever and/or known contact with infected subject, and at least 4 out of 12 typical signs/symptoms of COVID-19) in patients with ASD compared with the Italian, or regional, general population; (2) definite COVID-19 plus highly suspected COVID-19 in connective tissue diseases (CTD)/vasculitis (703 patients) compared with the subgroup of chronic arthritis (938 patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis); and (3) definite COVID-19 plus highly suspected COVID-19 in ASD patients without ongoing csDMARD. 16 Although a number of issues still remain to be better investigated, we can draw some provisional considerations based on the whole of currently available data: ► The actual prevalence of COVID-19 in patients with ASD might be underestimated, possibly due to concurrent factors, mainly the high rate of mild COVID-19 variants, the frequent clinical overl...…”

“…16 Our 6-week multicentre telephone survey of 1641 unselected patients with ASD confirmed the quite benign clinical course of COVID-19 in ASD, along with the safety of baseline use of either bDMARD or tsDMARD [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] ; however, the survey revealed a significantly higher prevalence of (1) either definite COVID-19 (always confirmed by positive oral/nasopharyngeal swabs at PCR testing) or highly suspected COVID-19 (presence of fever and/or known contact with infected subject, and at least 4 out of 12 typical signs/symptoms of COVID-19) in patients with ASD compared with the Italian, or regional, general population; (2) definite COVID-19 plus highly suspected COVID-19 in connective tissue diseases (CTD)/vasculitis (703 patients) compared with the subgroup of chronic arthritis (938 patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis); and (3) definite COVID-19 plus highly suspected COVID-19 in ASD patients without ongoing csDMARD. 16 Although a number of issues still remain to be better investigated, we can draw some provisional considerations based on the whole of currently available data: ► The actual prevalence of COVID-19 in patients with ASD might be underestimated, possibly due to concurrent factors, mainly the high rate of mild COVID-19 variants, the frequent clinical overlapping between ASD and COVID-19, and the limited availability of virological test that may be critical for differential diagnosis in many individuals. ► Despite increased susceptibility to infections that characterise patients with ASD, the impact of the COVID-19 pandemic revealed less severe than initially feared, particularly in countries with well-organised healthcare systems.…”