Covid-19 infection in patients with autoimmune rheumatic diseases: Patient’s perspective and descriptive analysis from a lower-middle-income country

Abstract

The study was conducted to determine the severity of Covid-19 in autoimmune inflammatory rheumatic disease (AIRDs) patients and knowing their perceptions. All AIRDs cases with Covid-19 infection between December 2020 and February 2021 were included. A cross-sectional phone survey was conducted for perceptions. Twenty-one patients were analysed for severity of illness and 16 (76.2%) for perceptions. Mean age was 44.8 ±14.8 years, with 11 (52.4%) females. Two (9.5%) patients had severe disease, six (28.6%) required hospitalisation, and none expired. Hypertension 7 (33.3%) was the commonest comorbidity. Low dose steroids were the most used drug 9 (42.9%). Regarding perceptions, 10 out of 16 (62.5%) felt that AIRD made them vulnerable to Covid-19 infection. The most common reason of delay in seeking medical advice from the rheumatologist was closure of services for chronic diseases during the pandemic. ---Continue

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2059
Open Access J Pak Med Assoc
Abstract
The study was conducted to determine the severity of
COVID-19 in autoimmune inammatory rheumatic disease
(AIRDs) patients and knowing their perceptions. All AIRDs
cases with COVID-19 infection between December 2020
and February 2021 were included. A cross-sectional
telephonic survey was conducted for perceptions. Twenty-
one patients were analysed for severity of illness and
16(76.2%) for perceptions. Mean age was 44.8±14.8 years,
with 11(52.4%) females. Two (9.5%) patients had severe
disease, 6(28.6%) required hospitalisation, and none
expired. Hypertension 7(33.3%) was the commonest
comorbidity. Low dose steroids were the most used drug
9 (42.9%). Regarding perceptions, 10 out of 16 (62.5%) felt
that AIRD made them vulnerable to COVID-19 infection.
The most common reason of delay in seeking medical
advice from the rheumatologist was closure of services for
chronic diseases during the pandemic. Patients with AIRDs,
receiving immunosuppressive treatment seem to be at a
lower risk of developing a severe form of COVID-19
pneumonia.
Keywords: COVID-19, Rheumatic diseases, Autoimmune
diseases, Immunosuppressive agents.
DOI: https://doi.org/10.47391/JPMA.7161
Submission completion date: 12-09-2022
Acceptance date: 09-02-2023
Introduction
The COVID-19 pandemic has resulted in more than 500
million infections and six million deaths.1During the early
phase of the pandemic it was noted that patients with
autoimmune inammatory rheumatic diseases (AIRDs) had
a higher preponderance for COVID-19 with worsening
outcomes.2This may be due to an increased simultaneous
presence of chronic diseases and use of various
immunosuppressants. Global Rheumatology Alliance, a
registry maintained by physicians, reported around 600
cases of rheumatologic diseases and COVID-19. Nearly half
of these required hospitalisation and 9% had fatal
outcome.3People with AIRDs logically argued with their
care providers about the risk of developing a severe
infection and inquired about the benecial effects of
reducing or stopping immunosuppressive drugs. Data
regarding COVID-19 infection in patients with AIRDs is
lacking from lower middle-income countries (LMICs). This
study was conducted to examine the severity of
SARS-CoV-2 infection in patients receiving immuno-
suppressive therapy for AIRDs from a single centre of
Karachi, and their perception as to how COVID-19 affected
their rheumatic disease and access to care.
Patients/Methods and Results
A combined retrospective observational study and cross-
sectional telephonic survey was conducted at the Aga
Khan University Hospital (AKUH), Karachi, Pakistan. The
study was granted approval by the Ethical Review
Committee of AKUH (ERC Number: 2020-5530-15347). All
adult patients with AIRDs and COVID-19 attending the
rheumatology clinic between December 1, 2020, and
February 28, 2021, were recruited. Information regarding
socio-demographics, risk factors for COVID-19, history of
potential exposure to a patient suffering from COVID-19,
symptoms and severity of infection, need for
hospitalisation, medication history, and outcome of COVID-
19 illness were recorded. The severity of illness was
categorised according to the National guidelines into
asymptomatic, non-severe, severe, and critical disease.4
Hospitalisations, ICU admissions, and death were measured
as outcomes.
Furthermore, a cross-sectional telephonic survey was
performed to evaluate patients’ perception regarding the
impact of COVID-19 illness on AIRD, patient’s global
assessment of the underlying AIRDs activity and the quality
of care provided during the pandemic. A standardised
questionnaire was used with patients who consented to
participate. IBM Statistical Package for Social Sciences
(SPSS) version 22.0 was used for data analysis. Qualitative
variables, like gender, comorbidities, rheumatic diseases,
treatment history, and perceptions were reported as
frequency and percentages.
A total of 21 patients reported to have SARS-CoV-2
infection. There were 11 (52.4%) women with mean age of
44.8±14.8 years. Eight (38.1%) patients had a history of
SHORT COMMUNICATION
COVID-19 infection in patients with autoimmune rheumatic diseases: Patient’s
perspective and descriptive analysis from a lower-middle-income country
Mehmood Riaz, Saliha Ishaq, Zaibunnisa, Huzefa Jibril, Saad Bin Zafar Mahmood
Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
Correspondence:
Saad Bin Zafar Mahmood. e-mail: saad_24689@hotmail.com
ORCID ID. 0000-0002-6840-0401

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Vol. 73, No. 10, October 2023 Open Access
contact with a COVID-19 positive family member.
Hypertension was the commonest comorbidity 7 (38.9%),
followed by cardiovascular disease 3 (16.7%) and diabetes
mellitus 1 (5.6%). Seventeen (80.9 %) had a positive
nasopharyngeal RT-PCR test, two (9.5 %) had CT scan of the
chest (HRCT) which was highly suggestive of COVID-19
infection, while the remaining two (9.5%) had serological
diagnosis, i.e. positive IgG antibody test. Sixteen (76.2%) of
these patients participated in the telephonic survey, while
the remaining 5 (23.8%) could not be reached out. Nine
(24.3%) patients were on low dose steroids (≤ 5mg/d) at the
time of contracting SARS-CoV-2 infection. Demographic
characteristics, autoimmune rheumatic disease diagnosis,
comorbid conditions, history of exposure to a patient
infected with SARS-CoV-2, and treatment history are
summarised in Table 1. The common presenting symptoms
were cough 15 (71.4%), fever 12 (57.1%), and shortness of
breath 7 (33.3%). Nineteen (90.5%) patients had non-severe
COVID infection, while 2 (9.5%) developed severe disease
and required non-invasive ventilation for respiratory
distress. Six (28.6%) patients required hospitalisation due
to hypoxia requiring supplemental oxygenation. The mean
length of hospital stay for hospitalised patients was 5.3±3.3
days. No fatal outcome was observed. Treatment provided
during infection with COVID-19 has been summarised in
Table 2.
Of the 16 (76.2%) patients who participated in the
telephonic survey, 10 (62.5%) consulted their
rheumatologist and asked if they should continue or stop
immunosuppressive treatment, 2 (12.5%) stopped
DMARDs thinking that continuing such treatment might
be harmful during the pandemic. The most common
reason cited for delay in seeking health care was
suspension of services to patients with chronic diseases by
most hospitals. Twelve (75.0%) believed having an AIRD
made them more susceptible for SARS-CoV-2 infection,
while 9 (56.3%) felt that immunosuppressive treatment was
an added risk for COVID-19 infection. Methotrexate was the
commonest DMARD to be put on hold by the
rheumatologist during COVID-19 course of illness. To assess
the activity of the underlying AIRDs during COVID-19
infection, participants were asked to rate how good or bad
their AIRD was over the last one week on a visual analogue
scale of 0–100, wherein 0 being the best and 100 the worst.
Nine (56.3%) patients rated their disease control as mildly
active (0-30), 3 (18.8%) moderately active (31-60), and 4
(25.0%) as severely active disease (61-100). All patients who
participated in the telephonic survey expressed full
satisfaction with the care that had been provided by the
treating rheumatologist(s) during the COVID-19 illness as
well as soon after recovery. They felt that all inquiries about
COVID-19 were answered to their level of satisfaction and
clear instructions were given to stop Methotrexate where
indicated. When they were asked about the most essential
measure that would have helped them in coping with
COVID-19 during the pandemic and treatment with
immunosuppressive drugs for AIRD, “regular follow up
whether physically or through Tele-health with the treating
rheumatologist” was the most common response.
COVID-19 infection in patients with autoimmune rheumatic diseases: Patient’s ……
Table-1: Demographics and disease characteristic of patients with rheumatic diseases
and diagnosed with COVID-19 (n=21).
n (%)
Gender
Female 11 (52.4)
Male 10 (47.6)
Mean Age (years) 44.8±14.8
Primary Rheumatic Disease
Systemic Lupus Erythematous 1 (4.8)
Rheumatoid Arthritis 3 (14.3)
Seronegative spondyloarthropathy 7 (33.3)
Mixed Connective Tissue Disease 2 (9.5)
Dermatomyositis/ polymyositis 1 (4.8)
Vasculitis 3 (14.3)
Sjogren syndrome 1 (4.8)
Juvenile Idiopathic Arthritis 1 (4.8)
Adult still disease 1 (4.8)
Sarcoidosis 1 (4.8)
Comorbid Condition
Hypertension 7 (38.9)
Cardiovascular disease 3 (16.7)
Diabetes 1 (5.6)
Lung disease 2 (11.1)
Medications before COVID-19 infection
Non-Steroidal Anti-inammatory Drugs 2 (5.4)
Steroids 9 (24.3)
Hydroxychloroquine 6 (16.2)
Methotrexate 7 (18.9)
Leunomide 2 (5.4)
Sulphasalazine 4 (10.8)
Non Interluekin-6 inhibitor 3 (8.1)
Mycophenolate Mofetil 1 (2.7)
Azathioprine 3 (8.1)
Table-2: Treatment for COVID-19.
n (%)
Antiviral 2 (8)
Hydroxychloroquine/ Chloroquine 2 (8)
Steroids 8 (32)
Azithromycin 3 (12)
Anticoagulation 1 (4)
Supplemental Oxygen 2 (8)
Proning 3 (12)
Non-invasive ventilation 2 (8)

Conclusion
Literature does not show any evidence that patients with
AIRDs have a higher risk of acquiring COVID-19 infection,
nor does it report poorer outcomes as compared to general
population.5The effect of the COVID-19 pandemic on
individuals with AIRDs remains unclear. Factors like age >65
years, male gender, and prior comorbidities have been
known to cause severe and critical COVID-19 in general
population.6Likewise, people on immunosuppressive
treatment, including those with systemic rheumatic
diseases, are at increased risk of infection, including SARS-
CoV-2.7This study attempted to explore the inuence of
COVID-19 pandemic on the lives of people with AIRDs
living in a LMIC. The results showed that most patients
perceived themselves more vulnerable to SARS-CoV-2
infection in comparison to general population. The
proportion of individuals who attributed this to underlying
immune disease was higher than those who thought
immunosuppressive treatment might be a risk factor.
Consequently, most of them were taking preventative
measures such as social distancing and use of face masks.
Only two patients suspended immunosuppressive therapy
abruptly due to the worry of having more severe COVID-19
infection. Nearly 2/3 patients discussed this query with
their treating rheumatologist and continued with
treatment except Methotrexate. Therefore, a close follow
up of this special population by the rheumatologist using
innovative measures like telehealth, for monitoring of
immunosuppressive therapy and continued education, is
of paramount importance. Establishing Tele-health clinics
may prove to be a useful strategy in this regard.8
Due to the small sample size of the study population, the
risk factors for infection or the impact of DMARDs on the
risk of SARS-CoV-2 infection could not be analysed.
Different results have been reported in studies from across
the globe in patients of systemic rheumatic diseases taking
immunosuppressive treatments and suffering from COVID-
19.9,10 In a nationwide cohort study from South Korea, the
odds of testing positive for SARS-CoV-2, developing severe
COVID-19, and COVID-19-related death were not
associated with treatment with any dose of systemic
corticosteroids or DMARDs, except in the case of patients
receiving 10mg or more of systemic corticosteroids.10
Though this study is limited due to it being a single-centre
study with a small sample size and retrospective study
design, we believe it will be benecial for patients to
continue taking their rheumatological treatment regimens
to prevent worsening of disease symptoms. Health care
systems need to establish well organised tele-health
services along with physical consultation to improve access
to care for patients with AIRDs in unprecedented situation
of COVID-19 pandemic. Further multi-centre studies are
needed to conrm the results and help patients with
rheumatic diseases during the pandemic.
Disclaimer: None.
Conict of interest: None.
Funding disclosure: None.
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M. Riaz, S. Ishaq, Zaibunnisa, et al.