Clinical features of rheumatic patients infected with COVID-19 in Wuhan, China

Abstract

Objective: The clinical features of rheumatic patients with coronavirus disease 2019 (COVID-19) have not been reported. This study aimed to describe the clinical features of COVID-19 in rheumatic patients and provide information for handling this situation in clinical practice.

Methods: This is a retrospective case series study. Deidentified data, including gender, age, laboratory and radiological results, symptoms, signs, and medication history, were collected from 2326 patients diagnosed with COVID-19, including 21 cases in combination with rheumatic disease, in Tongji Hospital between 13 January and 15 March 2020.

Results: Length of hospital stay and mortality rate were similar between rheumatic and non-rheumatic groups, while the presence of respiratory failure was more common in rheumatic cases (38% vs 10%, p<0.001). Symptoms of fever, fatigue and diarrhoea were seen in 76%, 43% and 23% of patients, respectively. There were four rheumatic patients who experienced a flare of rheumatic disease during hospital stay, with symptoms of muscle aches, back pain, joint pain or rash. While lymphocytopaenia was seen in 57% of rheumatic patients, only one patient (5%) presented with leucopenia in rheumatic cases. Rheumatic patients presented with similar radiological features of ground-glass opacity and consolidation. Patients with pre-existing interstitial lung disease showed massive fibrous stripes and crazy-paving signs at an early stage. Five rheumatic cases used hydroxychloroquine before the diagnosis of COVID-19 and none progressed to critically ill stage.

Conclusions: Respiratory failure was more common in rheumatic patients infected with COVID-19. Differential diagnosis between COVID-19 and a flare of rheumatic disease should be considered.

Trial registration number: ChiCTR2000030795.

Keywords: autoimmune diseases; autoimmunity; inflammation.

Figure 1

Basic information on rheumatic cases enrolled in this study. Ratio of rheumatic cases to the total number of patients with COVID-19 admitted to Wuhan Tongji Hospital (China), from 13 January 2020 to 15 March 2020 (left). Our series in this study consisted of eight RA cases, four SLE, three pSS, two UCTD, two AS, one JIA and one PMR (A). Gender distribution (B), age distribution (C), ratio of respiratory failure (D), hospitalisation time distribution (E) and mortality rate (F) of patients with COVID-19 with and without rheumatic diseases. Comparison of ordered categorical variables between two different groups was done using Mann-Whitney U test, while comparison of proportions for unordered categorical variables was realised using χ² test. P<0.05 was regarded as statistically significant. AS, ankylosing spondylitis; JIA, juvenile idiopathic arthritis; PMR, polymyalgia rheumatica; pSS, primary Sjögren’s syndrome; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; UCTD, undifferentiated connective tissue disease.

Figure 2

Symptoms and signs of rheumatic patients with COVID-19. Ratio of symptoms and signs presented by rheumatic patients with COVID-19: the lower panel shows the composition structure, while the upper panel shows the concrete percentage of each component of the corresponding parameters (A). Structure of the highest temperature of patients with fever (B) and ratio of cases who presented with at least one respiratory symptom (C).

Figure 3

Laboratory indices of rheumatic patients with COVID-19. The middle panel shows the composition structure, the upper panel shows the concrete percentage of each component, while the lower panel shows the unit, upper/lower limit, median value and IQR of the corresponding parameters. ALT, alanine aminotransferase; APTT, activated partial thromboplastin time; AST, aspartate aminotransferase; CK, creatine kinase; Cr, creatinine; cTn-I, Cardiac troponin- I; DBil, direct bilirubin; ESR, erythrocyte sedimentation rate; Hb, hemoglobin; hsCRP, high-sensitivity C-reactive protein; IL-6, interleukin-6; Lym, lymphocyte; Neu, neutrophil; PCT, procalcitonin; PLT, platelet; PT, prothrombin time; TBil, total bilirubin; TNF-α, tumour necrosis factor-α; UA, uric acid; WBC, white blood cell.

Figure 4

Chest CT of a rheumatoid arthritis patient with COVID-19 and interstitial lung disease. (A) CT image on the day of diagnosis showing ground-glass opacity (GGO), consolidation and fibrous stripes in both lungs. There was crazy-paving sign in the left upper lobe. (B) CT scan image 20 days after diagnosis showed that the GGO was partially absorbed and the fibrous stripes/crazy-paving sign had no significant changes. (C) CT scan image 36 days after diagnosis showing a significant absorption of GGO, while the fibrous stripes and crazy-paving sign remained unchanged.

Figure 5

Medication of rheumatic patients with COVID-19 before and during the hospitalisation. Heatmap in the upper panel records the medication of each case before the diagnosis of COVID-19. Heatmap in the lower panel records the information during hospitalisation, including the flare condition of rheumatic disease, medication for flare, glucocorticoids usage (converted to the corresponding dosage of prednisone) during hospitalisation, and some other parameters recording the process of hospitalisation and outcome. Mean of different colours illustrated by legends located on the right side of each heatmap. Numbers shown in different units are concrete values of the corresponding indices of specific patients. ACI, atherosclerotic cerebral infarction; AS, ankylosing spondylitis; CEG, chronic erosive gastritis; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; EP, epilepsy; HBP, high blood pressure; HCQ, hydroxychloroquine; HCV, hepatitis C virus; JIA, juvenile idiopathic arthritis; MMF, mycophenolate mofetil; NSAIDs, non-steroidal anti-inflammatory drugs; PMR, polymyalgia rheumatica; pSS, primary Sjögren’s syndrome; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; UCTD, undifferentiated connective tissue disease.