COVID-19 in Patients With Rheumatic Diseases: Is There a Need to Worry?

BACKGROUND/OBJECTIVES: SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), first described in December 2019, has infected more than 33 million people and claimed more than 1 million deaths worldwide. Rheumatic diseases are chronic inflammatory diseases, the prevalence and impact of which in COVID-19 patients are poorly known. We performed a pooled analysis of published data intending to summarize clinical presentation and patient outcomes in those with established rheumatic disease diagnosis and concurrent COVID-19. METHODS: PubMed and Google Scholar were searched to identify studies reporting data about rheumatic disease patients who were diagnosed with SARS-CoV-2 infection and published until July 22, 2020. Random-effects models were used to estimate the pooled incidence and rates of hospitalization, intensive care unit admission, and mortality among these patients, and interstudy heterogeneity was identified using I2 statistics with greater than 75% value indicating substantial interstudy variation. RESULTS: Twenty studies were included, giving a total sample size of 49,099 patients positive for SARS-CoV-2. Of 49,099 COVID-19 patients, a total of 1382 were also diagnosed with a rheumatic disease in the past. The random-effects pooled prevalence of COVID-19 among rheumatic disease patients was found to be 0.9%. The rates of hospitalization, intensive care unit admission, and mortality were 70.7%, 11.6%, and 10.2%, respectively. CONCLUSIONS: Although the prevalence of SARS-CoV-2 infection is not dramatically high in rheumatic disease patients, concurrent COVID-19 does seem to play a role in determining disease severity and outcomes to some extent. Further studies are needed to give conclusive evidence about whether this subset of the population is at a higher risk of COVID-19 and related outcomes compared with the population at large.

COVID-19 and Tuberculosis: A Meeting of Two Pandemics!

Coronavirus disease 2019 (COVID-19), causes serious respiratory illness manifesting as pneumonia, adult respiratory distress syndrome and respiratory failure. Amidst the rising number of cases and deaths, it is imperative to not forget Tuberculosis (TB) which is another pandemic existing since centuries. There could be dire consequences for tuberculosis patients globally especially in low and middle income countries with a high burden of disease and overwhelmed health care systems. Tuberculosis is still the leading infectious killer worldwide, and therefore, it is crucial to reflect on the interaction between the two diseases. Evidence suggests that both COVID-19 and tuberculosis have a synergistic relationship, boosting detrimental effect of each other, disrupting existing health care models, and also worsening the clinical outcomes in terms of morbidity and mortality. This review aims to draw attention towards this pertinent clinical issue, and tries to unravel the intricate relationship between COVID-19 and tuberculosis, as also the role of BCG vaccination to combat the COVID-19 pandemic.

Metabolic dysfunction associated steatotic liver disease: Current practice, screening guidelines and management in the primary care setting.

Metabolic dysfunction associated steatotic liver disease, previously known as non-alcoholic fatty liver disease, is the most common cause of chronic liver disease in the United States with rapidly rising prevalence. There have been significant changes recently in the field with screening now recommended for patients at risk for significant liver fibrosis in primary care and endocrine settings, along with clear guidance for management of metabolic comorbidities and changes in nomenclature. This paper serves as a summary of recent guidance for the primary care physician focusing on identifying appropriate patients for screening, selecting suitable screening modalities, and determining when referral to specialty care is necessary. The hope is that providers will shift away from past practices of utilizing liver tests alone as a screening tool and shift towards fibrosis screening in patients at risk for significant fibrosis. This culture change will allow for earlier identification of patients at risk for end stage liver disease and serious liver related complications, and overall improved patient care.

Tumor lysis syndrome and infectious complications during treatment with venetoclax combined with azacitidine or decitabine in patients with acute myeloid leukemia.

Venetoclax (Ven) in combination with azacitidine or decitabine (hypomethylating agent; HMA) is the standard-of-care treatment for older (≥75 years) or intensive chemotherapy ineligible adults with newly diagnosed acute myeloid leukemia (AML). Tumor lysis syndrome (TLS) and infectious complications are two of the most concerning associated adverse events. We studied the real-world incidence and outcomes of these adverse events with HMA/Ven in AML patients. Our retrospective analysis included 106 patients (median age 70 years). Of these, 61 (58%) received HMA/Ven in frontline setting while 45 (42%) received in salvage setting. 19 (18%) met laboratory criteria for TLS, five (5%) developed clinical TLS (acute kidney injury). The median time to develop TLS was 2 days (range -2 to 4). During cycle 1, 29 patients (27%) were diagnosed with febrile neutropenia while 26 (25%) developed new infections. Median time to development of new infection was 10 days (1-25). Pneumonia was the most common infection (8%). Febrile neutropenia and/or new infection during cycle 1 was associated with poorer median overall survival compared to those without these complications (4.9 months vs 11.6 months; p = 0.03). In conclusion, incidence of TLS and infections was high in our cohort during initiation of HMA/Ven therapy. This data emphasizes the need for closer monitoring in these patients, especially during the first 7-10 days of treatment, which is often achieved in the inpatient setting.

Admission Hyperglycemia in Non-diabetics Predicts Mortality and Disease Severity in COVID-19: a Pooled Analysis and Meta-summary of Literature.

In the latter part of 2019, a cluster of unexplained pneumonia cases were reported in Wuhan, China. In less than a year, SARS-CoV-2 has infected over 27 million people and claimed more than 800,000 deaths worldwide. Diabetes is a highly prevalent chronic metabolic disease, and recent reports have suggested a possible existence of COVID-19 related new-onset diabetes. Hyperglycemia induces an inflammatory state in the body, which coupled with coronavirus associated immune response is a possible explanation for clinical worsening of patients. We present a summary and pooled analysis of available evidence to ascertain the relationship between hyperglycemia in undiagnosed diabetics and outcomes of COVID-19 disease. Our results showed that hyperglycemia in non-diabetics was associated with higher risk of severe/critical illness (OR 1.837 (95% CI 1.368-2.465, P < 0.001) and mortality (2.822, 95% CI 1.587-5.019, P < 0.001) compared with those with normal values of blood glucose. The management of hyperglycemia in COVID-19 poses significant challenges in clinical practice, and the need to develop strategies for optimal glucose control in these patients cannot be overlooked.

Complex regional pain syndrome-A forgotten entity.

Complex Regional Pain Syndrome (CRPS) is a painful condition characterized by regional pain that is disproportionate temporality and severity to the usual course of any known cause. The pain is regional which is not in a specific nerve territory or dermatomal distribution. Judicious clinical suspicion and targeted investigations are necessary for correct diagnosis and appropriate treatment. We hereby report a case of a young lady with CRPS who presented to us with unilateral upper limb pain, swelling, discoloration and muscle atrophy without any history of inciting injury.