key: cord-1025184-4symk0iy
authors: Bazmjoo, Ahmadreza; Aref Bagherzadeh, Mohammad; Farahmandpoor, Farida; Raoofi, Rahim; Abdoli, Amir
title: SARS‐CoV‐2 infection in an advanced Rheumatoid Arthritis patient
date: 2020-09-18
journal: APMIS
DOI: 10.1111/apm.13080
sha: 0309fafcba07cb24d8f793f9cc9d865c390cdac0
doc_id: 1025184
cord_uid: 4symk0iy

In late 2019, pneumonia due to the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) emerged in Wuhan, China, which has immediately spread around the world. The major clinical manifestations of COVID‐19 include a range from asymptomatic presentation to acute respiratory distress syndrome (ARDS) [1]. Rheumatoid Arthritis (RA) patients usually managed with immunosuppressive agents, hence, they are at a higher risk of infections [2]. However, limited data are available about the severe case of COVID‐19 in RA patients [3‐7]. Here we present a complicated case of SARS‐CoV‐2 infection in a female RA patient.

In late 2019, pneumonia due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, which has immediately spread around the world. The major clinical manifestations of COVID-19 include a range from asymptomatic presentation to acute respiratory distress syndrome (ARDS) [1] . Rheumatoid Arthritis (RA) patients usually managed with immunosuppressive agents, hence, they are at a higher risk of infections [2] . However, limited data are available about the severe case of COVID-19 in RA patients [3] [4] [5] [6] [7] . Here we present a complicated case of SARS-CoV-2 infection in a female RA patient. She admitted to the hospital (Valiye Asr hospital, Fasa, Iran) at 11, March 2020 with a dry cough, fever, myalgia, respiratory distress, dizziness and nausea. Though O2 Saturation (SPO2%) was low (64%) on the admission, the O2 nebulizer administered (O2 5 lit/min) which resulted in the correction of O2 Saturation (87%). Four days before admission, she had only dry cough without other symptoms. She declared no sign of reduced smell and taste senses. Before admission, she had a history of contact with her two daughters, her husband, and 1-year-old grandchildren, that all of them were positive for COVID-19 by real-time PCR test. She was the only member of her family with severe respiratory problems that needed to be hospitalized (and also the only person with RA in her family), whiles the rest of the family showed mild symptoms and quarantined at home. The Chest x-rays on the first day of hospitalization showed pneumonia signs alongside with

This article is protected by copyright. All rights reserved bilateral ground-glass pattern, vascular dilation, and traction bronchiectasis in the middle and secondary lobes (Figure 1 ). Positive real-time PCR tests confirmed the SARS-CoV-2 infection.

Laboratory findings on admission was a very low WBC count and reduced number of platelets, elevated ESR and PT.

Therapy with Hydroxychloroquine was started on the 1 st day and continued for 10 days.

Oseltamivir was added on the 2 nd day and continued for 6 days. The patient's nausea was controlled by Ranitidine, Ondansetron, and Pantoprazole. Kaletra (Lopinavir/Ritonavir 200-50 mg/day and night 2 tab each) was added to the antiviral regimen on the 4 th day, continued as the main antiviral medication for 7 days until symptoms relieved. A cluster of antibiotics was prescribed for the first week because of low WBC count and suppressed immunity to prevent secondary infection. In the following, she was treated with a period of Levofloxacin medication in home quarantine (day 14 till 27). Theophylline G and O2 Nebulizer treatment helped to support the airway and reduce the respiratory symptoms. As laboratory findings and symptoms demonstrate, the patient's condition was by the end of 1st week worsened. The WBC and RBC count were reduced. Chest CT scans at the 2 nd week revealed the destructive effects of inflammation of the infection (Figure 1 ). Due to the laboratory findings and symptoms were more similar to the COVID-19 cytopenia, we decided to redesign the treatment. So, the DMARDs and immunosuppressant treatment were omitted. We then discontinued the Ebtrex and Nisopred at the 2 nd week by dose reduction, only Sulfasalazine was continued. This strategy led to increased WBC count and altered hematologic factors (Supplementary table 1) . By reducing the symptoms, the patient was discharged with a stable condition and quarantined for 14 days at home. Her real-time PCR was negative on day 27. The last chest CT scans and X rays showed a significant reduction in GGO on day 35 (Figure 1 ).

Immunosuppressive medication in RA patients (e.g., csDMARDs and corticosteroids) in the course of SARS-CoV-2 infection may be as a double-edged sword [8] . Managing the RA disease with the lowest possible dose of csDMARDs besides treatment of SARS-CoV-2 could be an effective strategy for treatment of COVID-19 in RA patients. The results of this case have shown that a gradual reduction of immunosuppressive drugs could helped to decline the disease severity.

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All datasets generated for this study are available.

Funding: This study was not receiving any founding.

The authors declare no competing interests.

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Rheumatic disease and COVID-19: initial data from the COVID-19 Global Rheumatology Alliance provider registries

Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies

Rheumatic diseases in intensive care unit patients with COVID-19

Case series of acute arthritis during COVID-19 admission

Hydroxychloroquine shortages during the COVID-19 pandemic. Annals of the Rheumatic Diseases

COVID-19 infection and rheumatoid arthritis: Faraway, so close

The authors sincerely appreciate doctors, nurses, and laboratory personals of Jahrom and Fasa Universities of Medical Sciences for their tireless efforts in this crisis. We also thank the patient for her participation.

AB, MAB and AA designed the study. AB and MAB wrote the draft of the manuscript. AB and FF collected data and performed analyses. RR, FF, and AA supervised the study. AA revised the manuscript for submission.

This article is protected by copyright. All rights reserved