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A 61-year old female was presented to the hospital with complaints of muscle pain and fever from the past four days. Her daughter was confirmed with COVID-19 two days before she visited the hospital. She was diagnosed with rheumatoid arthritis three years ago. Treatment with hydroxychloroquine (200 mg per day), meloxicam (7.5 mg/day), leflunomide (20 mg/day), famotidine (20 mg/day), methylprednisolone (2 mg/day) and folic acid (1 mg/day) helped in achieving clinical remission. The lady had no drinking and smoking habits.
What could be the most likely diagnosis of this case presentation?
Introduction:
COVID-19, which began in December 2019 in Wuhan city of China, has now become a public health emergency due to its worldwide spread. Fever, cough and vomiting are the symptoms observed in most of the people infected with the coronavirus. Some of the COVID-19 individuals may not show any sign of disease. At the same time, some patients may suffer from acute respiratory distress syndrome or dysfunction of multiple organs, requiring admission to ICU for mechanical ventilation.
Rheumatoid arthritis (RA) is a joint disease which significantly raises the risk of infections, thereby contributing to increased mortality and morbidity in affected individuals as compared to healthy individuals. There could be many reasons which explain the increased susceptibility of RA patients to infections, e.g. the presence of other immunocompromised diseases, dysregulation of the immune system by RA itself, use of disease-modifying antirheumatic drugs (DMARDs). There are only a few reports of COVID-19 in RA patients. The present case reported coronavirus infected patient on DMARDs for RA.
A 61
year old lady with RA was diagnosed with COVID-19 pneumonia. After treatment
with lopinavir/ritonavir, she recovered and discharged from the hospital.
The patient reported no
medical history. He was diagnosed with RA 3 years ago and was taking DMARDs for
the same.
At the time of
admission, the lady reported no respiratory symptoms. Her vitals were checked,
which revealed a low-grade fever of 99.6 °F. Her blood pressure was 169/79 mm
Hg; the respiratory rate was 20 breaths per min, and heart rate was 80 beats
per min. The physical examination showed clear lung sounds with no signs of
pharyngeal infection. Initial laboratory findings of liver function markers,
complete blood count and C-reactive protein levels were found to be within the
normal range. No abnormalities were observed in the chest X-ray. Negative
results were seen for the blood cultures tested for S. pneumoniae, Chlamydia
pneumonia, Mycoplasma pneumonia,
HIV and M. tuberculosis. Polymerase
chain reaction (PCR) confirmed the diagnosis of COVID-19. The patient complained of dry cough, little
sputum and sore throat without any chest pain or breathlessness, post three
days of admission. Increase in C-reactive protein levels with haziness on the
chest X-ray (right lower lung area) confirmed the progression to COVID-19
pneumonia.
The lady received
treatment with two tablets of lopinavir 200mg/ritonavir 50 mg b.i.d for ten
days. The use of leflunomide and methylprednisolone for RA was stopped;
however, hydroxychloroquine, famotidine and meloxicam were continued. A
significant improvement in her symptoms was noted post-antiviral therapy.
C-reactive protein levels came back to normal after ten days of hospital
admission. The real-time PCR failed to show positive results for SARS-CoV-2
post 24 days of hospitalization. The patient was discharged in a healthy state.
The present case reported the clinical characteristics of the RA patient diagnosed with COVID-19. The patient recovered completely after cessation of DMARDs and initiation of antiviral therapy with lopinavir 200 mg/ritonavir 50 mg.
The selection of an appropriate treatment plan for COVID-19 patients with RA could be extremely challenging for physicians as COVID-19 infection may further worsen due to the use of immunosuppressive drugs by RA patients. Temporary discontinuation of RA drugs is suggested for hospitalized COVID-19 patients to avoid complications and to develop considerable immunity. However, cessation of DMARDs could result in increased inflammation in RA patients which can only be controlled with the use of immunosuppressive medications. In COVID-19 patients, the effect of steroids has not been studied. Hypothetically, the use of steroids can further weaken the immune system, thereby making it more prone to infections. Also, it could block the inflammatory cascade of pneumonia. The previous research has indicated higher mortality with steroid use in patients with influenza pneumonia. The study also reported late clearance of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).
In the present case, leflunomide and steroids were discontinued while the use of hydroxychloroquine was continued due to its significant antirheumatic and antiviral properties. The condition of the patient deteriorated post three days of admission. Still, after treatment with antiviral therapy (lopinavir/ritonavir) for one week, a significant improvement in inflammatory markers and clinical symptoms were noted. The use of protease inhibitors in COVID-19 individuals has been backed up by its considerable therapeutic efficacy established in HIV patients. The RA patients with COVID-19 should be closely monitored for timely detection of the disease progression.
The patient in this study was administered with cDMARDs, but the risk of infection could also be with biological as well as targeted DMARDs. Previous studies have suggested the risk of infections with bDMARDs and tsDMARDs use in patients with bacterial or viral infections. The discontinuation of bDMARDs or tsDMARDs in COVID-19 individuals is recommended due to the absence of any concrete evidence regarding the safe use of bDMARDs or tsDMARDs in patients with COVID-19 infection.
The findings of this
case could be used as a reference for managing COVID-19 patients suffering from
RA. The initiation of antiviral therapy with the discontinuation of DMARDs and
other drugs for RA except hydroxychloroquine offered significant improvement in
the COVID-19 patient.
However, more robust
clinical data is required to design the most optimal treatment for COVID-19
patients suffering from RA and administering immunosuppressive drugs.
Rheumatol Int. 2020 Apr 20.
Coronavirus Disease 19 (COVID‑19) complicated with pneumonia in a patient with rheumatoid arthritis receiving conventional disease‑modifying antirheumatic drugs
Song J et al.
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