The COVID-19 pandemic has spread across New York City, NY, USA, affecting more than 150 000 of its 8·5 million inhabitants as of April 26, 2020.1 Severe illness resulting in hypoxemic respiratory failure, believed to be the result of uncontrolled inflammation coupled with a reduced and dysfunctional lymphocyte response, occurs in 5% of cases.2 Systemic lupus erythematosus (SLE) is an autoimmune disease characterised by autoantibodies, inflammation, and lymphopenia. The condition is frequently treated with hydroxychloroquine or chloroquine, both of which are being tested in the treatment of COVID-19.3 It remains unclear whether patients with SLE are at increased risk of COVID-19 or if there is a paradoxical protective effect due to, in part, hydroxychloroquine use. Patients with SLE comprise 17% of the COVID-19 Global Rheumatology Alliance registry as of April 1, 2020.4 Although two series5, 6 reported that patients with chronic arthritis receiving immunosuppressants had low rates of severe disease from COVID-19 (0–2%), another series by Mathian and colleagues7 described 17 patients with SLE, of whom 7 (35%) required mechanical methods of ventilation or extracorporeal membrane oxygenation.
To our knowledge, this is the first case series to report the characteristics and clinical course of COVID-19 in patients with SLE in the USA. 18 patients diagnosed with SLE on the basis of the revised classification criteria by the American College of Rheumatology8 had confirmed or clinically suspected COVID-19 infection. 16 of these patients were identified from the Columbia Lupus Cohort consisting of 450 patients and the remaining two patients were from the New York Presbyterian–Columbia database of 835 patients who tested positive for COVID-19 up to April 1, 2020. All patients with SLE admitted for COVID-19 have a consultation with a rheumatologist and are cared for by our team (per hospital policy); therefore, the patients reported here are the total patient population reporting to our hospital with SLE until April 26, 2020. Additionally, we included patients with SLE from our cohort with clinically suspected COVID-19 infection, as assessed by the Lupus Center treating clinician. The clinical characteristics of the 18 patients are described in the appendix. Ten patients had COVID-19 infection confirmed by nasopharyngeal swab COVID-19 RT-PCR. The other eight patients had clinical symptoms highly suggestive of COVID-19 but were not tested. By contrast with most of the patients with COVID-19, but as expected for individuals with SLE, 16 (89%) of patients were young women (mean age 41 years [SD 11]). There was an over-representation of Hispanic patients (nine [50%]) and black patients (seven [39%]). Most patients (15 [83%]) were taking immunosuppressants, seven (39%) were taking steroids, 13 (72%) were taking hydroxychloroquine or chloroquine, and 11 (61%) had lupus nephritis (one patient had end-stage renal disease on haemodialysis and two patients were kidney transplant recipients). Six patients were essential health-care workers.
Of the seven hospitalised patients, three had severe hypoxemic respiratory failure. C-reactive protein concentration (median 200 mg/L [IQR 93–300]), erythrocyte sedimentation rate (68 mm/h [42–113]), ferritin concentration (572 ng/mL [173–2351]), or a combination of all three, were elevated in six (86%) of the hospitalised patients. The patients' mean absolute lymphocyte count appeared lower at the time of COVID-19 diagnosis than at baseline (0·79 × 103 cells per μL [SD 0·46] vs 1·58 × 103 [0·73] cells per μL). In three patients who had double-stranded DNA titres available both before and at the time of COVID-19 diagnosis, titres did not change; however, complement concentrations increased. Patients with severe hypoxaemia had higher serum interleukin (IL)-6 concentrations than did patients who did not require any supplemental oxygen (258 pg/mL [99] vs 39 pg/mL [44]), and chest x-rays showed multifocal opacities (three patients), compared with no opacities (one patient) or focal opacities (four patients) in the remaining patients with available chest x-ray results.
Intake of immunosuppressants when admitted to hospital (eg, methotrexate, azathioprine, cellcept, tacrolimus, and rituximab) were not different in patients with mild versus severe disease. Four (43%) of the seven patients that required hospitalisation were taking hydroxychloroquine or chloroquine at baseline; ten (91%) of the 11 patients who were not hospitalised were taking these drugs. Three patients not on antimalarials when diagnosed with COVID-19 were treated with a 5–7 day course of 400–600 mg/day hydroxychloroquine. All hospitalised patients received empiric antibiotics. Three patients with severe hypoxaemia (two patients required non-invasive ventilation and one patient required invasive mechanical intubation) also received high-dose intravenous methylprednisolone (two patients received 1 mg/kg for 5 days and one patient received 1000 mg for 3 days), and tocilizumab (1–2 doses of 6–8 mg/kg). One patient improved and two remain critically ill, despite decreasing inflammatory markers. The remaining patients who were hospitalised improved without any requirement for supplemental oxygen.
Our findings suggest that 16 (4%) of the 450 patients in the Colombia Lupus Cohort developed symptomatic COVID-19 infection, compared with the suggested 2% community risk in New York City,1 as estimated by the number of symptomatic patients tested by RT-PCR nasopharyngeal swabs up to April 26, 2020. By contrast with the low incidence suggested by RT-PCR testing, antibody testing has suggested that up to 25% of the general population of New York City could be positive for COVID-19 antibodies;9, 10 however, whether these COVID-19 seropositivity rates are accurate or hold true for patients with SLE is unknown. More severe COVID-19 manifestations, which affected 2 (0·4%) of the 450 patients in the Columbia Lupus Cohort, were associated with high IL-6 concentrations and multifocal opacities on chest x-ray. Previous intake of immunosuppressants before admission to hospital did not seem to influence the severity of infection.
Acknowledgments
We declare no competing interests.
Supplementary Material
References
- 1.The Official Website of the City of New York COVID-19: data. https://www1.nyc.gov/site/doh/covid/covid-19-data.page
- 2.Li H, Liu L, Zhang D. SARS-CoV-2 and viral sepsis: observations and hypotheses. Lancet. 2020;395:1517–1520. doi: 10.1016/S0140-6736(20)30920-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Askanase A, Khalili L, Buyon J. Thoughts on COVID-19 and autoimmune diseases. Lupus Sci Med. 2020;7 doi: 10.1136/lupus-2020-000396. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Gianfrancesco MA, Hyrich KL, Gossec L. Rheumatic disease and COVID-19: initial data from the COVID-19 Global Rheumatology Alliance provider registries. Lancet Rheumatol. 2020;2:e250–e253. doi: 10.1016/S2665-9913(20)30095-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Monti S, Balduzzi S, Delvino P. Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies. Ann Rheum Dis. 2020;79:667–668. doi: 10.1136/annrheumdis-2020-217424. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Haberman R, Axelrad J, Chen A. Covid-19 in immune-mediated inflammatory diseases–case series from New York. N Engl J Med. 2020 doi: 10.1056/NEJMc2009567. published online April 29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Mathian A, Mahevas M, Rohmer J. Clinical course of coronavirus disease 2019 (COVID-19) in a series of 17 patients with systemic lupus erythematosus under long-term treatment with hydroxychloroquine. Ann Rheum Dis. 2020 doi: 10.1136/annrheumdis-2020-217566. published online April 24. [DOI] [PubMed] [Google Scholar]
- 8.Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40 doi: 10.1002/art.1780400928. [DOI] [PubMed] [Google Scholar]
- 9.Cuomo GA. Governor Cuomo's Daily Presentation. https://newyork.cbslocal.com/wp-content/uploads/sites/14578484/2020/04/04.27.20-COVID19-Briefing-Deck.pdf
- 10.The New York Times 1 in 5 New Yorkers may have had Covid-19, antibody tests suggest. https://www.nytimes.com/2020/04/23/nyregion/coronavirus-antibodies-test-ny.html
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.