key: cord-0773935-7mr8f5fp
authors: Sagnelli, Caterina; Gentile, Valeria; Tirri, Rosella; Macera, Margherita; Cappabianca, Salvatore; Ciccia, Francesco
title: Chronic conventional disease-modifying anti-rheumatic drugs masking severe SARS-CoV-2 manifestations in an elderly rheumatic patient
date: 2020-05-29
journal: J Infect
DOI: 10.1016/j.jinf.2020.05.043
sha: 1994be324271fffc60bbe09f0295135503a600a3
doc_id: 773935
cord_uid: 7mr8f5fp

nan

In early 2020 a new beta-corona virus (SARS-CoV-2) spread all over the world, and with a high incidence in Europe, especially in Italy [1, 2] . SARS-CoV-2 infection may lead to a wide range of clinical presentations, from an asymptomatic form to a severe acute respiratory syndrome [3] .

The symptoms more frequently observed were fever, chills, myalgia or fatigue, followed by a dry cough and dyspnea 3-7 days later. The age and the presence of chronic comorbidities (hypertension, cardiovascular disease, diabetes, chronic lung, kidney or cerebrovascular disease or malignancy) have been considered as the major risk factors for acute respiratory distress syndrome (ARDS) and the need for intensive care in COVID-19 patients [4] . ARDS is an immunopathologic event with hyper-activity of the systemic inflammatory response that induces cytokine storm, that increase proinflammatory cytokines like interferons, interleukins (IL), tumor necrosis factor and chemokines, suggesting the use of anti-inflammatory agents for SARS-CoV-2 pulmonary symptoms [5] . Few data are available on SARS-CoV-2 infection in rheumatological patients chronically treated with immunosuppressive therapy.

We present a clinical case of an 82-year-old Caucasian woman with a history of rheumatoid arthritis (RA) and idiopathic arterial hypertension hospitalized for SARS-CoV-2 pneumonia. The diagnosis of RA was performed in 2007 for the appearance of rheumatoid factor and anticitrullinated protein antibody-positive symmetrical polyarthritis, without signs of pulmonary or systemic disease. She had been under methotrexate, 10 mg/weekly (cumulative dose 6080 mg) and methylprednisolone (4 mg/day) treatment for two years, with a low disease activity status (DAS 28 PCR 2.9).

A week before admission, the patient had low grade fever (37.5°C) and a dry cough; she had stopped methylprednisolone and had started antibiotic treatment, without improvement; on 27

March, she underwent nasopharyngeal SARS-CoV-2 swab, which resulted positive, and was hospitalized on 30 March. Despite the absence of any pulmonary symptoms, a lung CT scan 3 showed interstitial bilateral pneumonia (Figure 1) , and a thoracic ultrasound with lung ultrasound reaeration score (LUS) of four. Hydroxycloroquine, lopinavir/ritonavir, and low molecular weight heparin (LMWH, 4000 UI/die) were started. Two days later, although afebrile, she presented dyspnea (respiratory rate-RR 32) with SpO2 of 93% in FiO2 21% and PaO2 / FiO2 309 mmHg and Oxygen therapy was started. High values of D-dimer and C-reaction protein were observed, a CT angiography excluded embolism, but showed a worsening of pneumonia (Figure 1 Thus, close and continuous clinical, biochemical and imaging monitoring are needed to identify the initial signs of respiratory failure.

Our case shows a different course from that described by Mihan et al. [6] , who reported a peculiar SARS-CoV-2 with mild symptoms in a 57-year-old woman with systemic sclerosis (SSc) with interstitial lung disease as main organ manifestation of SSc and chronically treated with tocilizumab (8 mg/kg body weight every 4 weeks iv). A month after the last infusion of tocilizumab, the patient developed a SARS-Cov-2 infection. However, her symptoms remained mild and she was monitored from home, resulting negative at the nasal swab after 14 days since symptoms had started [6] . The authors hypothesized that IL-6 blocking treatment given for chronic autoimmune diseases, such as rheumatoid disease, may even prevent the development of severe COVID-19. [6] .

In our case, although the patient had negative prognostic factors (older age, chronic disease and arterial hypertension), the use of tocilizumab and corticosteroid was associated with the control of severe pneumonia, supporting the role of tocilizumab in controlling severe SARS-CoV-2-related life-threatening conditions. 

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