Rheumatologists' perspective on coronavirus disease 19 (COVID-19) and potential therapeutic targets

Long-Term Risk of Autoimmune and Autoinflammatory Connective Tissue Disorders Following COVID-19

Importance

Few studies have investigated the association between COVID-19 and autoimmune and autoinflammatory connective tissue disorders; however, research with long-term observation remains insufficient.

Objective

To investigate the long-term risk of autoimmune and autoinflammatory diseases after COVID-19 over an extended observation period.

Design, Setting, and Participants

This retrospective nationwide population-based study investigated the Korea Disease Control and Prevention Agency-COVID-19-National Health Insurance Service (K-COV-N) cohort. Individuals with confirmed COVID-19 from October 8, 2020, to December 31, 2022, and controls identified among individuals who participated in the general health examination in 2018 were included in the analysis.

Exposures

Confirmed COVID-19.

Main Outcomes and Measures

Incidence and risk of autoimmune and autoinflammatory connective tissue disorders in patients after COVID-19. Various covariates, such as demographic characteristics, general health data, socioeconomic status, and comorbidity profiles, were balanced using inverse probability weighting.

Results

A total of 6 912 427 participants (53.6% male; mean [SD] age, 53.39 [20.13] years) consisting of 3 145 388 with COVID-19 and 3 767 039 controls with an observational period of more than 180 days were included. Alopecia areata (adjusted hazard ratio [AHR], 1.11 [95% CI, 1.07-1.15]), alopecia totalis (AHR, 1.24 [95% CI, 1.09-1.42]), vitiligo (AHR, 1.11 [95% CI, 1.04-1.19]), Behçet disease (AHR, 1.45 [95% CI, 1.20-1.74]), Crohn disease (AHR, 1.35 [95% CI, 1.14-1.60]), ulcerative colitis (AHR, 1.15 [95% CI, 1.04-1.28]), rheumatoid arthritis (AHR, 1.09 [95% CI, 1.06-1.12]), systemic lupus erythematosus (AHR, 1.14 [95% CI, 1.01-1.28]), Sjögren syndrome (AHR, 1.13 [95% CI, 1.03-1.25]), ankylosing spondylitis (AHR, 1.11 [95% CI, 1.02-1.20]), and bullous pemphigoid (AHR, 1.62 [95% CI, 1.07-2.45]) were associated with higher risk in the COVID-19 group. Subgroup analyses revealed that demographic factors, including male and female sex, age younger than 40 years, and age 40 years and older, exhibited diverse associations with the risk of autoimmune and autoinflammatory outcomes. In addition, severe COVID-19 infection requiring intensive care unit admission, the Delta period, and not being vaccinated were associated with higher risk.

Conclusions and Relevance

This retrospective cohort study with an extended follow-up period found associations between COVID-19 and the long-term risk of various autoimmune and autoinflammatory connective tissue disorders. Long-term monitoring and care of patients is crucial after COVID-19, considering demographic factors, disease severity, and vaccination status, to mitigate these risks.

Effect of traditional therapeutics on prevalence and clinical outcomes of coronavirus disease 2019 in Chinese patients with autoimmune diseases

The impact of the Coronavirus disease 2019 (COVID-19) pandemic on autoimmune diseases (AID) patients has been an important focus. This study was undertaken to characterize the incidence, clinical manifestations and hospitalization among AID affected by COVID-19 and to analyze the association between immunomodulatory medication and these outcomes. Clinical, demographic, maintenance treatment, symptoms and disease course data and outcomes of AID patients with COVID-19 infection were assessed via an online survey tool and printed copy from 1 January till February 28, 2023. A total of 432 patients with AID were enrolled in the study. The results showed the most common conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) was hydroxychloroquine (HCQ). The usage of csDMARDs didn't increase the risk of COVID-19 infection. Patients who warranted hospitalization were significantly older. ILD was associated with higher hospitalization rate. No csDMARDs other than calcineurin inhibitor (CNI) was associated with increased risk of hospitalization. HCQ intake was associated with cough. Compared with no glucocorticoids (GCs) group, high doses of GCs were accompanied with higher proportion of gastrointestinal symptoms and tachycardia, lower proportion of sore throat and ageusia. GCs didn't provoke the COVID-19 infection in patients with AID, but chronic use of oral GCs was significantly more common in those requiring hospitalization, and higher dose of GCs were correlated with higher risk of hospitalization. 97 patients discontinued csDMARDs after infection, which resulted in an elevated risk of hospitalization. Meanwhile, withdrawal of csDMARDs was associated with higher odds of disease flare and lower proportion of remission than maintenance groups. Collectively, our analysis provides the evidence that maintenance treatment of csDMARDs may be more prudent for AID patients during COVID-19 pandemic.

An Update on SARS-CoV-2 Clinical Trial Results-What We Can Learn for the Next Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has claimed over 7 million lives worldwide, providing a stark reminder of the importance of pandemic preparedness. Due to the lack of approved antiviral drugs effective against coronaviruses at the start of the pandemic, the world largely relied on repurposed efforts. Here, we summarise results from randomised controlled trials to date, as well as selected in vitro data of directly acting antivirals, host-targeting antivirals, and immunomodulatory drugs. Overall, repurposing efforts evaluating directly acting antivirals targeting other viral families were largely unsuccessful, whereas several immunomodulatory drugs led to clinical improvement in hospitalised patients with severe disease. In addition, accelerated drug discovery efforts during the pandemic progressed to multiple novel directly acting antivirals with clinical efficacy, including small molecule inhibitors and monoclonal antibodies. We argue that large-scale investment is required to prepare for future pandemics; both to develop an arsenal of broad-spectrum antivirals beyond coronaviruses and build worldwide clinical trial networks that can be rapidly utilised.

COVID-19 prognosis in systemic lupus erythematosus compared with rheumatoid arthritis and spondyloarthritis: results from the CONTROL-19 Study by the Italian Society for Rheumatology

INTRODUCTION

Data concerning SARS-CoV-2 in patients affected by SLE are contradicting.The aim of this study was to investigate disease-related differences in COVID-19 prognosis of patients affected by rheumatic diseases before vaccination; we tested the hypothesis that patients with SLE may have a different outcome compared with those with rheumatoid arthritis (RA) or spondyloarthritis (SPA).

METHODS

We analysed data from the national CONTROL-19 Database with a retrospective, observational design, including rheumatic patients affected by COVID-19. The principal outcome measure was hospitalisation with death or mechanical ventilation. Differences between SLE, RA and SPA were analysed by univariable and multivariable logistic regression models.

RESULTS

We included 103 patients with SLE (88.2% female, mean age 48.9 years, 50.4% active disease), 524 patients with RA (74.4% female, mean age 60.6 years, 59.7% active disease) and 486 patients with SPA (58.1% female, mean age 53.2 years, 58% active disease).Outcome prevalence was not different between patients with SLE and those with RA (SLE 24.5%, RA 25.6%), while patients with SPA showed a more favourable outcome compared with those with SLE (SPA 15.9%); data from the multivariable analysis confirmed this result.In SLE, age >65 years (OR 17.3, CI 5.51 to 63.16, p<0.001), hypertension (OR 6.2, CI 2.37 to 17.04, p<0.001) and prednisone (PDN) use (OR 3.8, CI 1.43 to 11.39, p=0.01) were associated with severe outcomes, whereas hydroxychloroquine use was found to be protective (OR 0.3, CI 0.14 to 0.91, p=0.03).

CONCLUSION

Our data suggest that patients with SLE and RA do not show a different COVID-19 outcome, while patients with SPA have a more favourable disease course compared with those with SLE. Risk of hospitalisation with ventilation or death was associated with age >65 years, hypertension and PDN use in patients with SLE.

Featured immune characteristics of COVID-19 and systemic lupus erythematosus revealed by multidimensional integrated analyses

BACKGROUND

Coronavirus disease 2019 (COVID-19) shares similar immune characteristics with autoimmune diseases like systemic lupus erythematosus (SLE). However, such associations have not yet been investigated at the single-cell level.

METHODS

We integrated and analyzed RNA sequencing results from different patients and normal controls from the GEO database and identified subsets of immune cells that might involve in the pathogenesis of SLE and COVID- 19. We also disentangled the characteristic alterations in cell and molecular subset proportions as well as gene expression patterns in SLE patients compared with COVID-19 patients.

RESULTS

Key immune characteristic genes (such as CXCL10 and RACK1) and multiple immune-related pathways (such as the coronavirus disease-COVID-19, T-cell receptor signaling, and MIF-related signaling pathways) were identified. We also highlighted the differences in peripheral blood mononuclear cells (PBMCs) between SLE and COVID-19 patients. Moreover, we provided an opportunity to comprehensively probe underlying B-cell‒cell communication with multiple ligand-receptor pairs (MIF-CD74+CXCR4, MIF-CD74+CD44) and the differentiation trajectory of B-cell clusters that is deemed to promote cell state transitions in COVID-19 and SLE.

CONCLUSIONS

Our results demonstrate the immune response differences and immune characteristic similarities, such as the cytokine storm, between COVID-19 and SLE, which might pivotally function in the pathogenesis of the two diseases and provide potential intervention targets for both diseases.

The role of TLR7 agonists in modulating COVID-19 severity in subjects with loss-of-function TLR7 variants

We investigate the mechanism associated with the severity of COVID-19 in men with TLR7 mutation. Men with loss-of-function (LOF) mutations in TLR7 had severe COVID-19. LOF mutations in TLR7 increased the risk of critical COVID by 16.00-fold (95% confidence interval 2.40-106.73). The deleterious mutations affect the binding of SARS-CoV2 RNA (- 328.66 ± 26.03 vs. - 354.08 ± 27.70, p = 0.03) and MYD88 (β: 40.279, p = 0.003) to TLR7 resulting in the disruption of TLR7-MyD88-TIRAP complex. In certain hypofunctional variants and all neutral/benign variants, there is no disruption of TLR7-MyD88-TIRAP complex and four TLR7 agonists showed binding affinity comparable to that of wild protein. N-acetylcysteine (NAC) also showed a higher binding affinity for the LOF variants (p = 0.03). To conclude, TLR7 LOF mutations increase the risk of critical COVID-19 due to loss of viral RNA sensing ability and disrupted MyD88 signaling. Majority of hypofunctional and neutral variants of TLR7 are capable of carrying MyD88 signaling by binding to different TLR7 agonists and NAC.

Exploring the potential common denominator pathogenesis of system lupus erythematosus with COVID-19 based on comprehensive bioinformatics analysis

Objective

Evidences show that there may be a link between SLE and COVID-19. The purpose of this study is to screen out the diagnostic biomarkers of systemic lupus erythematosus (SLE) with COVID-19 and explore the possible related mechanisms by the bioinformatics approach.

Methods

SLE and COVID-19 datasets were extracted separately from the NCBI Gene Expression Omnibus (GEO) database. The limma package in R was used to obtain the differential genes (DEGs). The protein interaction network information (PPI) and core functional modules were constructed in the STRING database using Cytoscape software. The hub genes were identified by the Cytohubba plugin, and TF-gene together with TF-miRNA regulatory networks were constructed via utilizing the Networkanalyst platform. Subsequently, we generated subject operating characteristic curves (ROC) to verify the diagnostic capabilities of these hub genes to predict the risk of SLE with COVID-19 infection. Finally, a single-sample gene set enrichment (ssGSEA) algorithm was used to analyze immune cell infiltration.

Results

A total of 6 common hub genes (CDC6, PLCG1, KIF15, LCK, CDC25C, and RASGRP1) were identified with high diagnostic validity. These gene functional enrichments were mainly involved in cell cycle, and inflammation-related pathways. Compared to the healthy controls, abnormal infiltration of immune cells was found in SLE and COVID-19, and the proportion of immune cells linked to the 6 hub genes.

Conclusion

Our research logically identified 6 candidate hub genes that could predict SLE complicated with COVID-19. This work provides a foothold for further study of potential pathogenesis in SLE and COVID-19.

New-onset acute psychosis as a manifestation of lupus cerebritis following concomitant COVID-19 infection and vaccination: a rare case report

BACKGROUND

Rare cases of COVID-19 infection- and vaccine-triggered autoimmune diseases have been separately reported in the literature. In this paper, we report the first and unique case of new onset acute psychosis as a manifestation of lupus cerebritis following concomitant COVID-19 infection and vaccination in a previously healthy 26-year-old Tunisian female.

CASE PRESENTATION

A 26-years old female with a family history of a mother diagnosed with schizophrenia, and no personal medical or psychiatric history, was diagnosed with mild COVID-19 infection four days after receiving the second dose of Pfizer-BioNTech COVID-19 vaccine. One month after receiving the vaccine, she presented to the psychiatric emergency department with acute psychomotor agitation, incoherent speech and total insomnia evolving for five days. She was firstly diagnosed with a brief psychotic disorder according to the DSM-5, and was prescribed risperidone (2 mg/day). On the seventh day of admission, she reported the onset of severe asthenia with dysphagia. Physical examination found fever, tachycardia, and multiple mouth ulcers. Neurological evaluation revealed a dysarthria with left hemiparesis. On laboratory tests, she had severe acute kidney failure, proteinuria, high CRP values, and pancytopenia. Immune tests identified the presence of antinuclear antibodies. Brain magnetic resonance imaging (MRI) revealed hyperintense signals in the left fronto-parietal lobes and the cerebellum. The patient was diagnosed with systemic lupus erythematosus (SLE) and put on anti-SLE drugs and antipsychotics, with a favorable evolution.

CONCLUSIONS

The chronological relationship between COVID-19 infection, vaccination and the first lupus cerebritis manifestations is highly suggestive, albeit with no certainty, of the potential causal link. We suggest that precautionary measures should be taken to decrease the risk of SLE onset or exacerbation after COVID-19 vaccination, including a systematic COVID-19 testing before vaccination in individuals with specific predisposition.

Comorbidities in the COVID-19 Pandemic: Scopus-Based Bibliometric Analysis

BACKGROUND

Comorbidities attract enormous attention amid the coronavirus disease 2019 (COVID-19) pandemic. Mapping knowledge based on these clinical conditions is increasingly important since the pandemic is still raging and primarily affecting subjects with chronic diseases and comorbidities. Clinical presentation and complications of COVID-19 are still hot topics which are explored in numerous evidence-based publications. The aim of this study was to analyze Scopus-indexed COVID-19 papers covering comorbidities.

METHODS

Searches through the Scopus database were performed on September 19, 2022 using the following keywords: "Diabetes mellitus" OR "Cardiovascular Diseases" OR "Rheumatic Diseases" OR "Obesity" OR "Malignancies" AND "COVID-19." All retrieved articles were analyzed using the following categories: document type, authorship, keywords, journal, citation score, country of origin, and language. Using the software tool VOSviewer version 1.6.18, we visualized the network of authors and keywords co-occurrence of the most prevalent comorbidities reported in connection with COVID-19.

RESULTS

Reports on COVID-19 and diabetes mellitus (DM) were most frequently published (n = 12,282). The US was the most productive country (n = 3,005) in the field of COVID-19 and comorbidities. There were 1,314 documents on COVID-19 and rheumatic diseases which is the least number in comparison with other comorbidities (COVID-19 and DM: 12,282, COVID-19 and cardiovascular disease: 9,911, COVID-19 and obesity: 7,070, and COVID-19 and malignancies: 1,758).

CONCLUSION

This mapping of COVID-19-related documents in connection with comorbidities may prioritize future research directions.

COVID-19 signalome: Potential therapeutic interventions

The COVID-19 pandemic has triggered intensive research and development of drugs and vaccines against SARS-CoV-2 during the last two years. The major success was especially observed with development of vaccines based on viral vectors, nucleic acids and whole viral particles, which have received emergent authorization leading to global mass vaccinations. Although the vaccine programs have made a big impact on COVID-19 spread and severity, emerging novel variants have raised serious concerns about vaccine efficacy. Due to the urgent demand, drug development had originally to rely on repurposing of antiviral drugs developed against other infectious diseases. For both drug and vaccine development the focus has been mainly on SARS-CoV-2 surface proteins and host cell receptors involved in viral attachment and entry. In this review, we expand the spectrum of SARS-CoV-2 targets by investigating the COVID-19 signalome. In addition to the SARS-CoV-2 Spike protein, the envelope, membrane, and nucleoprotein targets have been subjected to research. Moreover, viral proteases have presented the possibility to develop different strategies for the inhibition of SARS-CoV-2 replication and spread. Several signaling pathways involving the renin-angiotensin system, angiotensin-converting enzymes, immune pathways, hypoxia, and calcium signaling have provided attractive alternative targets for more efficient drug development.

[Cardiohemodynamic Changes and Cardiac Arrhythmias After Coronavirus Infection]

Aim      To study changes in cardiohemodynamic alterations of the myocardium and heart rhythm disorders at 3 and 6 months following the coronavirus infection.Material and methods   EchoCG, ECG Holter monitoring, and Doppler ultrasonography of hepatolienal blood vessels were performed for 77 patients (mean age, 35.9 years) at 3 and 6 months after coronavirus infection. The patients were divided into the following groups: group 1, with injury of the upper respiratory tract; group 2, with bilateral pneumonia (CТ1, 2), and group 3, with severe pneumonia (CТ3, 4). Statistical analysis was performed with a SPSS Statistics Version 25.0 software package.Results At 6 months after the disease onset, the patients noted an improvement of their general condition. In patients with moderate pneumonia, early peak diastolic velocity (p=0.09), right ventricular isovolumic diastolic time (р=0.09), and pulmonary artery systolic pressure (р=0.005) where decreased, while tricuspid annular peak systolic velocity was, in contrast, increased (р=0.042). Both segmental systolic velocity of the LV mid-inferior segment (р=0.006) and the mitral annular Em / Am ratio were decreased. In patients with severe disease at 6 months, right atrial indexed volume was reduced (р=0.036), tricuspid annular Em / Am was decreased (р=0.046), portal and splenic vein flow velocities were decreased, and inferior vena cava diameter was reduced. Late diastolic transmitral flow velocity was increased (р=0.027), and LV basal inferolateral segmental systolic velocity was decreased (р=0.046). In all groups, the number of patients with heart rhythm disorders was decreased, and parasympathetic autonomic influences prevailed.Conclusion      At 6 months after coronavirus infection, practically all patients noted improvement of their general condition; incidence rate of arrhythmia and cases of pericardial effusion were decreased; and autonomic nervous system activity recovered. In patients with moderate and severe disease, morpho-functional parameters of the right heart and the hepatolienal blood flow were normalized, however, occult disorders of LV diastolic function remained, and LV segmental systolic velocity was reduced.

COVID-19: A trigger of autoimmune diseases

The SARS-coronavirus-2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19), has spread worldwide and caused a global health emergency. SARS-CoV-2 is a coronaviridae virus that infects target cells by interacting with the plasma membrane-expressed angiotensin-converting enzyme 2 (ACE2) via the S1 component of the S protein. Effective host immune response to SARS-CoV-2 infection, which includes both innate and adaptive immunity, is critical for virus management and elimination. The intensity and outcome of COVID-19 may be related to an overabundance of pro-inflammatory cytokines, which results in a "cytokine storm" and acute respiratory distress syndrome. After SARS-CoV-2 infection, the immune system's hyperactivity and production of autoantibodies may result in autoimmune diseases such as autoimmune hemolytic anemia, autoimmune thrombocytopenia, Guillain-Barré syndrome, vasculitis, multiple sclerosis, pro-thrombotic state, and diffuse coagulopathy, as well as certain autoinflammatory conditions such as Kawasaki disease in children. We have reviewed the association between COVID-19 and autoimmune disorders in this article.

Sociodemographic and clinical factors associated with poor COVID-19 outcomes in patients with rheumatic diseases: data from the SAR-COVID Registry

BACKGROUND/OBJECTIVE

This study aims to describe the course and to identify poor prognostic factors of SARS-CoV-2 infection in patients with rheumatic diseases.

METHODS

Patients ≥ 18 years of age, with a rheumatic disease, who had confirmed SARS-CoV-2 infection were consecutively included by major rheumatology centers from Argentina, in the national, observational SAR-COVID registry between August 13, 2020 and July 31, 2021. Hospitalization, oxygen requirement, and death were considered poor COVID-19 outcomes.

RESULTS

A total of 1915 patients were included. The most frequent rheumatic diseases were rheumatoid arthritis (42%) and systemic lupus erythematosus (16%). Comorbidities were reported in half of them (48%). Symptoms were reported by 95% of the patients, 28% were hospitalized, 8% were admitted to the intensive care unit (ICU), and 4% died due to COVID-19. During hospitalization, 9% required non-invasive mechanical ventilation (NIMV) or high flow oxygen devices and 17% invasive mechanical ventilation (IMV). In multivariate analysis models, using poor COVID-19 outcomes as dependent variables, older age, male gender, higher disease activity, treatment with glucocorticoids or rituximab, and the presence of at least one comorbidity and a greater number of them were associated with worse prognosis. In addition, patients with public health insurance and Mestizos were more likely to require hospitalization.

CONCLUSIONS

In addition to the known poor prognostic factors, in this cohort of patients with rheumatic diseases, high disease activity, and treatment with glucocorticoids and rituximab were associated with worse COVID-19 outcomes. Furthermore, patients with public health insurance and Mestizos were 44% and 39% more likely to be hospitalized, respectively.

STUDY REGISTRATION

This study has been registered in ClinicalTrials.gov under the number NCT04568421. Key Points • High disease activity, and treatment with glucocorticoids and rituximab were associated with poor COVID-19 outcome in patients with rheumatic diseases. • Some socioeconomic factors related to social inequality, including non-Caucasian ethnicity and public health insurance, were associated with hospitalization due to COVID-19.

Musculoskeletal system symptoms in patients with COVID-19 and the impact of these symptoms on quality of life

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a respiratory disease caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and also affects the musculoskeletal system.

OBJECTIVE

This study was conducted to investigate the musculoskeletal symptoms, type of pain and effect on quality of life in patients presenting with pain after COVID-19.

METHODS

This prospective, descriptive study included 97 patients aged 18 years or older who were diagnosed with COVID-19 based on a positive polymerase chain reaction test result, with or without musculoskeletal pain prior to COVID-19 infection. Patients who applied to the post-COVID-19 outpatient clinic with the complaint of pain at least 1 month and maximum 1 year after the diagnosis of COVID-19 were included. Patients' demographic characteristics and musculoskeletal examination findings were evaluated. The patients were examined, and the questionnaire forms were completed. The pain was assessed using the visual analog scale (VAS), the Douleur-Neuropathique-4 (DN-4) questionnaire, while the quality of life was assessed using the Short Form-36 (SF-36) survey. Patients were divided into groups in terms of gender, age, body mass index. Shapiro-Wilk's test, the independent samples t-test and the Mann-Whitney U test were used for statistical analyses.

RESULTS

The mean age of the patients was 46.5 ± 13.5 years, 30 of them were male. Pain increased in patients with pre-COVID-19 arthralgia and myalgia (p< 0.001). Post-COVID-19 VAS was significantly higher than pre-COVID-19 VAS (7 ± 1.2 vs. 3.2 ± 1.9, p< 0.05). Pre-COVID-19 patients with myalgia had significantly worse SF-36 physical function, social function, pain, general health perception (p< 0.05). The mean scores of females in the SF-36 physical function, pain were significantly worse than males (p< 0.05). According to DN-4, 41 (42.3%) patients had neuropathic pain. There was moderate negative correlation between VAS, DN-4 and SF-36 (p< 0.05).

CONCLUSIONS

Arthralgia, myalgia, and neuropathic pain, all of which negatively affect the quality of life, are often observed in the patients infected with COVID-19.

Host genetics and gut microbiota composition: Baseline gut microbiota composition as a possible prognostic factor for the severity of COVID-19 in patients with familial Mediterranean fever disease

Background

It is known that the gut microbiome of a healthy person affects the process of COVID-19 after getting infected with SARS-CoV-2 virus. It is also believed that colchicine can alleviate the severity of COVID-19.

Objective

Current investigations aimed to evaluate the associations between the baseline gut microbiota composition of healthy and Familial Mediterranean fever (FMF) - carrier Armenian men populations, and the severity of the COVID-19 disease after their infection with the SARS-CoV-2. The study has a purpose of answering three core questions: i. Do the characteristics of gut microbiome of Armenians affect the course of COVID-19 severity? ii. How does the COVID-19 disease course on go for FMF patients who have been taking colchicine as a medication over the years after getting infected with SARS-CoV-2? iii. Is there an initial gut micribiota structure pattern for non-FMF and FMF patients in the cases when COVID-19 appears in mild form?

Methods

The gut microbiota composition in non-FMF and FMF patients before the first infection (mild and moderate course of COVID-19) was considered. COVID-19 was diagnosed by SARS-CoV-2 nucleic acid RT-PCR in nasopharyngeal swab and/or sputum.

Results

The number of patients with male FMF with mild COVID-19 was approximately two times higher than that of non-FMF male subjects with COVID-19. In addition, an association of COVID-19 disease severity with the baseline gut Prevotella, Clostridium hiranonis, Eubacterium biforme, Veillonellaceae, Coprococcus, and Blautia diversities in the non-FMF and FMF populations were revealed by us, which can be used as risk/prognostic factor for the severity of COVID-19.

A Review of Persistent Post-COVID Syndrome (PPCS)

Persistent post-COVID syndrome, also referred to as long COVID, is a pathologic entity, which involves persistent physical, medical, and cognitive sequelae following COVID-19, including persistent immunosuppression as well as pulmonary, cardiac, and vascular fibrosis. Pathologic fibrosis of organs and vasculature leads to increased mortality and severely worsened quality of life. Inhibiting transforming growth factor beta (TGF-β), an immuno- and a fibrosis modulator, may attenuate these post-COVID sequelae. Current preclinical and clinical efforts are centered on the mechanisms and manifestations of COVID-19 and its presymptomatic and prodromal periods; by comparison, the postdrome, which occurs in the aftermath of COVID-19, which we refer to as persistent post-COVID-syndrome, has received little attention. Potential long-term effects from post-COVID syndrome will assume increasing importance as a surge of treated patients are discharged from the hospital, placing a burden on healthcare systems, patients' families, and society in general to care for these medically devastated COVID-19 survivors. This review explores underlying mechanisms and possible manifestations of persistent post-COVID syndrome, and presents a framework of strategies for the diagnosis and management of patients with suspected or confirmed persistent post-COVID syndrome.

The Efficacious Benefit of 25-Hydroxy Vitamin D to Prevent COVID-19: An In-Silico Study Targeting SARS-CoV-2 Spike Protein

The environment has rapidly looked at proven specialist task forces in the aftermath of the COVID-19 pandemic to build public health policies and measures to mitigate the effects of emerging coronaviruses. According to the researchers, taking 10 μg of 25-hydroxy vitamin D daily is recommended to keep us safe. There have been several studies recently indicating that there is a reduced risk of contracting Coronavirus by 25-hydroxy vitamin D consumption, even though there is no scientific data to prove that one would not affect the COVID-19 viral infection by 25-hydroxy vitamin D consumption. In this regard, the present study investigates the important literature and the role of 25-hydroxy vitamin D to prevent COVID-19 infection by conducting an in-silico study with SARS-CoV-2 spike protein as a target. Lopinavir, a previously reported drug candidate, served as a reference standard for the study. MD simulations were carried out to improve predictions of receptor-ligand complexes which offer novelty and strength to the current study. MD simulation protocols were explored and subjected to 25-hydroxy vitamin D and a known drug, Lopinavir. Comparison of ligands at refined models to the crystal structure led to promising results. Appropriate timescale simulations have been used to understand the activation mechanism, the role of water networks for receptor function, and the ligand binding process. Furthermore, MD simulations in combination with free energy calculations have also been carried out for lead optimization, evaluation of ligand binding modes, and assessment of ligand selectivity. From the results, 25-hydroxy vitamin D was discovered to have the vital interaction and highest potency in LBE, lower RMSD, and lower inhibition intensity similar to the standard. The findings from the current study suggested that 25-hydroxy vitamin D would be more effective in treating COVID-19. Compared with Lopinavir, 25-hydroxy vitamin D had the most potent interaction with the putative binding sites of the SARS-CoV-2 spike protein of COVID-19.

Adipose-derived stem/stromal cells with heparin-enhanced anti-inflammatory and antifibrotic effects mitigate induced pulmonary fibrosis in mice

Interstitial lung disease (ILD) is a life-threatening pathological condition that causes respiratory failure and often presents as pulmonary fibrosis. Although it is treated using immunosuppressive and antifibrotic agents, the beneficial effects of these agents remain limited. Thus, the development of new therapeutic strategies for lung fibrosis is crucial. Mesenchymal stem/stromal cells (MSCs) have multilineage differentiation potential; additionally, they have anti-inflammatory and antifibrotic effects as well as the ability to modulate the immune response and modify the microenvironment at the site of engraftment. Numerous adipose-derived MSCs (ASCs) are present in the adipose tissue. Heparin and low-molecular-weight heparin (LMWH) mediate the secretion of several cytokines and growth factors with cell migratory and antifibrotic effects. This study aimed to confirm the therapeutic effect of LMWH-activated ASCs on ILD. Mouse ASCs (mASCs) were cultured in an LMWH-supplemented medium. LMWH significantly increased the number of mASC and enhanced their migratory, anti-inflammatory, and antifibrotic effects. Furthermore, mice with bleomycin-induced pulmonary fibrosis were intravenously administered LMWH-activated mASCs. The relative mRNA expression of inflammation-related genes in ILD lungs was significantly lower in the treatment group than in the pathological model group. Our findings suggest that LMWH-activated mASC administration reduces lung fibrosis.

Air pollution and public health in Latin America and the Caribbean (LAC): a systematic review with meta-analysis

Background

Over the years, air pollution has garnered increased attention from researchers who continue to provide studies and suggestive data that prove there is an ever-increasing risk of air pollution on the health of humans, terrestrial, and aquatic animals. A measurement involved in the quantity of certain traceable particles within the air, namely: Particulate Matter (PM) 2.5 and 10, ozone (O₃), Nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and carbon monoxide (CO) emissions, all converted to Air Quality Index. Most studies are predominantly from developed nations with limited research conducted in developing nations such as those in Latin America and the Caribbean.

Main body

In this systematic review, we examined the impact of air pollution on public health. A database search produced 1,118 studies, of which four were selected for a quantitative meta-analysis that explored hazard ratios concerning exposure to elevated levels of PM2.5. The meta-analysis results show that exposure to PM2.5 increases the risk of an adverse health event by as much as 2% five days after exposure. Results also indicated a consensus on the negative impacts of air pollution on public health. The results also suggest that more can be done within the region to combat or at the very least minimize the impact of air pollution to public health.

Conclusion

The pooled data from the studies reviewed show that there is an increased risk of an adverse health event on the day of exposure to PM2.5 and every subsequent day after exposure. A pattern exists between hospitalization and air pollution due to increased susceptibility to respiratory infections and asthma development. Combating the harmful effects of air pollution should be a top priority in Latin America and the Caribbean.

Lifting the Mask on Musculoskeletal Manifestations of COVID-19: Results of an Interview-Based Study

Background

Coronavirus disease of 2019 (COVID-19) is considered a multi-system disease that might present with or develop complications during the acute phase of illness. The aim of this study was to describe the characteristics of musculoskeletal (MSK) manifestations in patients with COVID-19 infection and investigate their clinical correlations.

Methods

This study was carried out on 110 patients with a history of RT-PCR confirmed COVID-19 infection. They completed a questionnaire that covered detailed information on their sociodemographic characteristics, clinical data of COVID-19 infection in addition to MSK discomfort form based on the Nordic MSK Questionnaire.

Results

The mean age of the patients was 37.7 years (SD 12.9), 72.7% were females. The majority of patients (90.9%) reported MSK symptoms that occur during or shortly after the acute attack of COVID-19 infection. The median duration of onset of MSK symptoms was 2 days from the first day of COVID-19 infection (min-max: 0–45 days) with a median duration of MSK symptoms of 7 days. Myalgia was the main complaint (85.5%) followed by arthralgia 90 (81.8%). However, swollen joints were reported in only 9 patients (8.2%). According to the body areas, maximum number of patients felt pain at the lower back (60%), followed by neck (39.1%), and upper back (32.5%) followed by right and left shoulder (20.9%). Patients with MSK manifestations were associated higher severity of COVID-19 infection (p < 0.001), prolonged duration of COVID-19 symptoms (p < 0.001) and higher prevalence of fatigue (p < 0.001).

Conclusion

MSK manifestations are common in COVID-19 patients and related to disease severity, duration and fatigue.

SARS-CoV-2 and HIV-1: So Different yet so Alike. Immune Response at the Cellular and Molecular Level

In the past half century, humanity has experienced two devastating pandemics; the HIV-1 pandemic and the recent pandemic caused by SARS-CoV-2. Both emerged as zoonotic pathogens. Interestingly, SARS-CoV-2 has rapidly migrated all over the world in less than two years, much as HIV-1 did almost 40 years ago. Despite these two RNA viruses being different in their mode of transmission as well as the symptoms they generate, recent evidence suggests that they cause similar immune responses. In this mini review, we compare the molecular basis for CD4+ T cell lymphopenia and other effects on the immune system induced by SARS-CoV-2 and HIV-1 infections. We considered features of the host immune response that are shared with HIV-1 and could account for the lymphopenia and other immune effects observed in COVID-19. The information provided herein, may cast the virus-induced lymphopenia and cytokine storm associated with the acute SARS-CoV-2 infection and pathogenesis in a different light for further research on host immune responses. It can also provide opportunities for the identification of novel therapeutic targets for COVID-19. Furthermore, we provide some basic information to enable a comparative framework for considering the overlapping sets of immune responses caused by HIV-1 and SARS-CoV-2.

Dysregulation of immunity in COVID-19 and SLE

The immune response plays a crucial role in preventing diseases, such as infections. There are two types of immune responses, specific and innate immunity, each of which consists of two components: cellular immunity and humoral immunity. Dysfunction in any immune system component increases the risk of developing certain diseases. Systemic lupus erythematosus (SLE), an autoimmune disease in the human body, develops an immune response against its own components. In these patients, due to underlying immune system disorders and receipt of immunosuppressive drugs, the susceptibility to infections is higher than in the general population and is the single largest cause of mortality in this group. COVID-19 infection, which first appeared in late 2019, has caused several concerns in patients with SLE. However, there is no strong proof of additional risk of developing COVID-19 in patients with SLE, and in some cases, studies have shown less severity of the disease in these individuals. This review paper discusses the immune disorders in SLE and COVID-19.

Effectiveness and safety of COVID-19 vaccines in patients with diabetes as a factor for vaccine hesitancy

Diabetes mellitus is one of the most common comorbid conditions encountered in patients with severe acute respiratory syndrome coronavirus 2 infection accompanied by significantly increased mortality, prolonged hospital stay, and requirement of invasive mechanical ventilation. This review aims to present the effectiveness and safety profile of available coronavirus disease 2019 (COVID-19) vaccines in people with diabetes as a potential cause of hesitancy for vaccination. Data from published research proves a robust immune response following immunization for COVID-19 in diabetic patients with substantial production of virus-neutralizing antibodies; however, the observed immune response was unequivocally weaker than that in individuals without diabetes. This observation was further enhanced by the findings that worse glycemic control was associated with more suppressed antibody production. In contrast, individuals with optimal glycemic control performed similarly to healthy controls. In addition to the need for strict glucose monitoring and adequate diabetes treatment, those findings reinforce the concept of diabetes-induced secondary immune deficiency and necessitate the application of booster doses to diabetic patients with priority. Nevertheless, after vaccination, reported adverse events were not different from those in the general population. No increase in severe adverse events was documented. While single case reports detected transient increases in blood glucose post-vaccination, more extensive trials could not replicate such a relationship.

COVID-19 Global Pandemic Fight by Drugs: A Mini-Review on Hope and Hype

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Coronavirus disease 2019 (Covid-19), a serious disease caused by the Severe Acute Respiratory Syndrome-Corona Virus-2 (SARS-CoV-2), was firstly identified in the city of Wuhan of China in December 2019, which then spread and became a global issue due to its high transmission rate. To date, the outbreak of COVID-19 has resulted in infection to 230,868,745 people and the death of 4,732,669 patients. It has paralyzed the economy of all the countries worldwide. Considering the possible mutations of SARS-CoV-2, the current medical emergency requires a longer time for drug design and vaccine development. Drug repurposing is a promising option for potent therapeutics against the pandemic. The present review encompasses various drugs or appropriate combinations of already FDA-approved antimalarial, antiviral, anticancer, anti-inflammatory, and antibiotic therapeutic candidates for use in the clinical trials as a ray of hope against COVID-19. It is expected to deliver better clinical and laboratory outcomes of drugs as a prevention strategy for the eradication of the disease.

Identification of Diagnostic Gene Markers and Immune Infiltration in Systemic Lupus

Background

Systemic lupus erythematosus (SLE) is an autoimmune disease involving multiple organs, with atypical clinical manifestations and indefinite diagnosis and treatment. So far, the etiology of the disease is not completely clear. Current studies have known the interaction of genetic system, endocrine system, infection, environment, and other factors. Due to abnormal immune function, the human body, with the participation of various immune cells such as T cells and B cells, abnormally recognizes autoantigens, so as to produce a variety of autoantibodies and combine them to form immune complexes. These complexes will stay in the skin, kidney, serosa cavity, large joints, and even the central nervous system, resulting in multisystem damage of the body. The disease is heterogeneous, and it can show different symptoms in different populations and different disease stages; patients with systemic lupus erythematosus need individualized diagnosis and treatment. Therefore, we aimed to search for SLE immune-related hub genes and determine appropriate diagnostic genes to provide help for the detection and treatment of the disease.

Methods

Gene expression data of whole blood samples of SLE patients and healthy controls were downloaded from the GEO database. Firstly, we analyzed and identified the differentially expressed genes between SLE and the normal population. Meanwhile, the single-sample gene set enrichment analysis (ssGSEA) was used to identify the activation degree of immune-related pathways based on gene expression profile of different patients, and weighted gene coexpression network analysis (WGCNA) was used to search for coexpressed gene modules associated with immune cells. Then, key networks and corresponding genes were found in the protein-protein interaction (PPI) network. The above corresponding genes were hub genes. After that, this study used receiver operating characteristic (ROC) curve to evaluate hub gene in order to verify its ability to distinguish SLE from the healthy control group, and miRNA and transcription factor regulatory network analyses were performed for hub genes.

Results

Through bioinformatics technology, compared with the healthy control group, 2996 common differentially expressed genes (DEGs) were found in SLE patients, of which 1639 genes were upregulated and 1357 genes were downregulated. These differential genes were analyzed by ssGSEA to obtain the enrichment fraction of immune-related pathways. Next, the samples were selected by WGCNA analysis, and a total of 18 functional modules closely related to the pathogenesis of SLE were obtained. Thirdly, the correlation between the above modules and the enrichment fraction of immune-related pathways was analyzed, and the turquoise module with the highest correlation was selected. The 290 differential genes of this module were analyzed by GO and KEGG. The results showed that these genes were mainly enriched in coronavirus disease (COVID-19), ribosome, and human T cell leukemia virus 1 infection pathway. The 290 DEGs with PPI network and 28 genes of key networks were selected. ROC curve showed that 28 hub genes are potential biomarkers of SLE.

Conclusion

The 28 hub genes such as RPS7, RPL19, RPS17, and RPS19 may play key roles in the advancement of SLE. The results obtained in this study can provide a reference in a certain direction for the diagnosis and treatment of SLE in the future and can also be used as a new biomarker in clinical practice or drug research.

Flare of adult-onset Still's disease following mRNA COVID-19 vaccination: a case report and review of literature

The upheaval caused by the coronavirus disease 2019 (COVID-19) pandemic has allowed to large population to use new vaccines urgently. Although vaccine development programs and available epidemiological data reassure us, there are concerns about specific risks associated with vaccinations in patients with autoimmune-autoinflammatory diseases. These patients have the potential to decrease humoral and cellular immune responses caused by biologic agents and develop an acute flare of underlying disease following vaccination. We herein present a rare case of a 49-year-old female with a flare of adult-onset Still's disease (AOSD) after the first dose of BNT162b2 mRNA COVID-19 vaccination. She had been diagnosed with AOSD 7 years earlier and had achieved remission with tocilizumab. This patient came to the emergency room with fever and nausea that occurred 4 days after the first vaccination. Based on laboratory results and clinical manifestations, we suspected AOSD flare and was treated with steroid pulse therapy. In this report, we also discuss possible mechanisms linking vaccination with a flare of AOSD. Considering the close time relationship between COVID-19 vaccinations and a flare of AOSD, physicians should be aware of adverse events from this new vaccination and evaluate the benefits and risks of vaccination for each patient. KEY POINTS: • COVID-19 vaccination may cause an AOSD flare in patients who are in remission with tocilizumab.

Implications of SARS-CoV-2 Infection in Systemic Juvenile Idiopathic Arthritis

Systemic juvenile idiopathic arthritis (sJIA) is a serious multifactorial autoinflammatory disease with a significant mortality rate due to macrophage activation syndrome (MAS). Recent research has deepened the knowledge about the pathophysiological mechanisms of sJIA-MAS, facilitating new targeted treatments, and biological disease-modifying antirheumatic drugs (bDMARDs), which significantly changed the course of the disease and prognosis. This review highlights that children are less likely to suffer severe COVID-19 infection, but at approximately 2-4 weeks, some cases of multisystem inflammatory syndrome in children (MIS-C) have been reported, with a fulminant course. Previous established treatments for cytokine storm syndrome (CSS) have guided COVID-19 therapeutics. sJIA-MAS is different from severe cases of COVID-19, a unique immune process in which a huge release of cytokines will especially flood the lungs. In this context, MIS-C should be reinterpreted as a special MAS, and long-term protection against SARS-CoV-2 infection can only be provided by the vaccine, but we do not yet have sufficient data. COVID-19 does not appear to have a substantial impact on rheumatic and musculoskeletal diseases (RMDs) activity in children treated with bDMARDs, but the clinical features, severity and outcome in these patients under various drugs are not yet easy to predict. Multicenter randomized controlled trials are still needed to determine when and by what means immunoregulatory products should be administered to patients with sJIA-MAS with a negative corticosteroid response or contraindications, to optimize their health and safety in the COVID era.

Association of vitamin D status with COVID-19 disease severity in pediatric patients: A retrospective observational study

Background and Aims

Vitamin D deficiency is associated with increased vulnerability to respiratory infections. This study aimed to determine the potential relationships between coronavirus disease 2019 (COVID-19) severity, serum vitamin D concentrations, and some inflammatory markers among pediatric COVID-19 patients in Iran.

Methods

A retrospective study was conducted among hospitalized pediatric COVID-19 cases in Abuzar Hospital (Ahvaz, Iran) for 6 months. The COVID-19 diagnosis was based on the real-time reverse transcription-polymerase chain reaction technique. Demographic and clinical data of patients were recorded. Patients with serum vitamin D levels lower than 20 ng/ml were assigned as Group 1 and those with serum vitamin D concentrations equal to or more than 20 ng/ml were considered as Group 2.

Results

A total of 144 patients were enrolled. Their mean age was 80  ±  49 months (range: 1-16 years). Patients in Group 1 had significantly lower levels of serum vitamin D, calcium, and lymphocytes, as well as higher fibrinogen, d-dimer, and C-reactive protein (CRP) levels compared with those in Group 2 (p < 0.001). In addition, they had a significantly higher dry cough, fever, chest radiographic findings, respiratory rate, and longer hospital length of stay than patients in Group 2. Serum concentrations of vitamin D were positively correlated with levels of serum calcium, lymphocytes, and neutrophils but negatively correlated with CRP, fibrinogen, and d-dimer values. Furthermore, patients with moderate or severe courses of COVID-19 had significantly higher inflammatory markers (CRP, d-dimer, and fibrinogen), as well as lower levels of serum calcium, vitamin D, lymphocytes, and neutrophils than those with mild COVID-19 (p < 0.001). In the multivariate analysis, fibrinogen level on admission was detected as the independent predictor of severe COVD-19 (odds ratio = 1.06, 95% confidence interval: 1.03-1.09; p < 0.001).

Conclusion

This study indicated associations between the severity of COVID-19, serum vitamin D concentrations, and some inflammatory markers in pediatric COVID-19 patients.

Post-traumatic stress disorder in patients with rheumatic disease during the COVID-19 outbreak: a cross-sectional case-control study in China

OBJECTIVE

The COVID-19 pandemic is not only a traumatic event, but a collective stressor unfolding over time, causing devastating implications for the mental health. This study aimed to shed light on the mental health status of patients with rheumatic disease (RD) during the massive outbreak of COVID-19 in China, especially the prevalence and severity of post-traumatic stress disorder (PTSD) compared with healthy individuals.

METHODS

A total of 486 patients with RD and 486 age-matched and sex-matched healthy individuals were recruited into the study. For each participant, we collected demographic and clinical characteristics data. The PTSD Checklist for DSM-5 (PCL-5) and four items from the Pittsburgh Sleep Quality Index (PSQI) were used to investigate the prevalence and severity of PTSD and sleep quality, respectively.

RESULTS

Compared with healthy control subjects (n=486), patients with RD (n=486) had a higher prevalence of PTSD (12.1% vs 4.1%; p<0.001). Higher total scores on the PCL-5 and on all four items from the PSQI (p≤0.001) were also observed. Female, old age, poor sleep quality, long duration of RD, poor subjective evaluation of the disease and pessimistic subjective perception of the epidemic were identified as risk factors of PTSD in patients with RD during the COVID-19 epidemic.

CONCLUSION

During the COVID-19 outbreak, patients with RD presented a higher prevalence and severity of PTSD and showed more sleep disturbances. Our findings confirm the importance of psychological assessment and mental healthcare out of regular clinical care for patients with RD during the pandemic.

CYTOKINES AS POTENTIAL MARKERS OF COVID-19 SEVERITY AND OUTCOMES

The continual propagation of SARS-CoV-2 has changed health care systems globally. Ranging degrees of clinical severity in COVID-19 patients have been noted in numerous literature sources. Cytokines play a crucial role in the development of key immunological processes in COVID-19. SARS-CoV-2 causes imbalance of the immune system and might culminate in cytokine storm and multiple organ involvement. The prevailing role of some special cytokines might serve as indicators of disease severity. Further stratification of patients in the context of specific cytokines can be beneficial for diagnosing disease stages. It can prevent critical states owing to timely diagnosis and targeted therapy. Targeting peculiar cytokines can markedly reduce complications. The aim of this article is to comprehensively overview the role of the main cytokines in COVID-19 pathogenesis and distinguish prognostic factors. Insights into specific cytokine involvement in COVID-19 pathogenesis may open new avenues for diagnosing hyperinflammatory COVID-19, predicting its outcomes and providing individualized cytokine-targeted therapeutic approaches.

Of vascular defense, hemostasis, cancer, and platelet biology: an evolutionary perspective

We have established considerable expertise in studying the role of platelets in cancer biology. From this expertise, we were keen to recognize the numerous venous-, arterial-, microvascular-, and macrovascular thrombotic events and immunologic disorders are caused by severe, acute-respiratory-syndrome coronavirus 2 (SARS-CoV-2) infections. With this offering, we explore the evolutionary connections that place platelets at the center of hemostasis, immunity, and adaptive phylogeny. Coevolutionary changes have also occurred in vertebrate viruses and their vertebrate hosts that reflect their respective evolutionary interactions. As mammals adapted from aquatic to terrestrial life and the heavy blood loss associated with placentalization-based live birth, platelets evolved phylogenetically from thrombocytes toward higher megakaryocyte-blebbing-based production rates and the lack of nuclei. With no nuclei and robust RNA synthesis, this adaptation may have influenced viral replication to become less efficient after virus particles are engulfed. Human platelets express numerous receptors that bind viral particles, which developed from archetypal origins to initiate aggregation and exocytic-release of thrombo-, immuno-, angiogenic-, growth-, and repair-stimulatory granule contents. Whether by direct, evolutionary, selective pressure, or not, these responses may help to contain virus spread, attract immune cells for eradication, and stimulate angiogenesis, growth, and wound repair after viral damage. Because mammalian and marsupial platelets became smaller and more plate-like their biophysical properties improved in function, which facilitated distribution near vessel walls in fluid-shear fields. This adaptation increased the probability that platelets could then interact with and engulf shedding virus particles. Platelets also generate circulating microvesicles that increase membrane surface-area encounters and mark viral targets. In order to match virus-production rates, billions of platelets are generated and turned over per day to continually provide active defenses and adaptation to suppress the spectrum of evolving threats like SARS-CoV-2.

Promising Indicators in Probiotic-recommendations in COVID-19 and its Accompanying Diseases

Scientific data suggests the possible beneficial role of probiotics in treatments for COVID-19, but the species/strains-specificity and disease-specificity of probiotics need high attention in choosing the appropriate probiotic in diseases, in particularly in the COVID-19. We hope this review will raise awareness of the COVID-19 probiotic recommendations, highlighting the latest scientific information about virus/hydrogen peroxide/probiotics and the importance of finding out of a specific “criterion” for the probiotics’ recommendation in this disease.

A report of two cases of myocarditis following mRNA coronavirus disease 2019 vaccination

BACKGROUND

Vaccination is the most important measure to control the coronavirus disease 2019 (COVID-19) pandemic. Myocarditis has been reported as a rare adverse reaction to COVID-19 vaccines. The clinical presentation of myocarditis in such cases can range from mild general symptoms to acute heart failure.

CASE SUMMARY

We report the cases of two young men who presented with chest pain and dyspnoea following the administration of the mRNA COVID-19 vaccine. Cardiac investigations revealed findings typical of acute myocarditis.

DISCUSSION

Myocarditis is a rare complication following mRNA COVID-19 vaccination. In this case series, the temporal proximity of the development of acute myocarditis and the administration of the mRNA COVID-19 vaccine was acknowledged. In the absence of other causative factors, myocarditis in these patients potentially occurred due to an adverse reaction to the mRNA COVID-19 vaccine. However, a causal relationship remains speculative. Clinical suspicion of myocarditis should be high if patients present with chest pain or dyspnoea after receiving COVID-19 vaccination.

Formulating Hypotheses for Different Study Designs

Generating a testable working hypothesis is the first step towards conducting original research. Such research may prove or disprove the proposed hypothesis. Case reports, case series, online surveys and other observational studies, clinical trials, and narrative reviews help to generate hypotheses. Observational and interventional studies help to test hypotheses. A good hypothesis is usually based on previous evidence-based reports. Hypotheses without evidence-based justification and a priori ideas are not received favourably by the scientific community. Original research to test a hypothesis should be carefully planned to ensure appropriate methodology and adequate statistical power. While hypotheses can challenge conventional thinking and may be controversial, they should not be destructive. A hypothesis should be tested by ethically sound experiments with meaningful ethical and clinical implications. The coronavirus disease 2019 pandemic has brought into sharp focus numerous hypotheses, some of which were proven (e.g. effectiveness of corticosteroids in those with hypoxia) while others were disproven (e.g. ineffectiveness of hydroxychloroquine and ivermectin).

Impact of Anti-Type 2 Inflammation Biologic Therapy on COVID-19 Clinical Course and Outcome

SARS-CoV-2 pandemic had a general and deep impact on the clinical management of chronic diseases, including respiratory and allergic disorders. At the beginning of the pandemic, one of the main concerns was the potential impact of immunosuppressive/immunomodulatory drugs on COVID-19 clinical course. In this review, we aim to summarize and analyze the available clinical evidence from patients treated with anti-type 2 inflammation biologics (including anti-IgE, anti-IL-5 and anti-IL-4 agents), who developed COVID-19. Overall, the treatment with anti-Th2 biologics can be considered safe during COVID-19. It does not worsen the clinical course and outcome of COVID-19, and it may be actually protective somehow from developing severe forms. Moreover, patients treated with these biological agents do not seem to be more prone to get infected by SARS-CoV-2.

Treatment With 25-Hydroxyvitamin D3 (Calcifediol) Is Associated With a Reduction in the Blood Neutrophil-to-Lymphocyte Ratio Marker of Disease Severity in Hospitalized Patients With COVID-19: A Pilot Multicenter, Randomized, Placebo-Controlled, Double-Blinded Clinical Trial

OBJECTIVE

The goal of this randomized, double-blinded, placebo-controlled clinical trial was to investigate the therapeutic efficacy of oral 25-hydroxyvitamin D3 (25(OH)D3) in improving vitamin D status in vitamin D-deficient/vitamin D-insufficient patients infected with the SARS-CoV-2 (COVID-19) virus.

METHODS

This is a multicenter, randomized, double-blinded, placebo-controlled clinical trial. Participants were recruited from 3 hospitals that are affiliated to [Institution Blinded for Review] and [Institution Blinded for Review].

RESULTS

A total 106 hospitalized patients who had a circulating 25(OH)D3 concentration of <30 ng/mL were enrolled in this study. Within 30 and 60 days, 76.4% (26 of 34) and 100% (24 of 24) of the patients who received 25(OH)D3 had a sufficient circulating 25(OH)D3 concentration, whereas ≤12.5% of the patients in the placebo group had a sufficient circulating 25(OH)D3 concentration during the 2-month follow-up. We observed an overall lower trend for hospitalization, intensive care unit duration, need for ventilator assistance, and mortality in the 25(OH)D3 group compared with that in the placebo group, but differences were not statistically significant. Treatment with oral 25(OH)D3 was associated with a significant increase in the lymphocyte percentage and decrease in the neutrophil-to-lymphocyte ratio in the patients. The lower neutrophil-to-lymphocyte ratio was significantly associated with reduced intensive care unit admission days and mortality.

CONCLUSION

Our analysis indicated that oral 25(OH)D3 was able to correct vitamin D deficiency/insufficiency in patients with COVID-19 that resulted in improved immune function by increasing blood lymphocyte percentage. Randomized controlled trials with a larger sample size and higher dose of 25(OH)D3 may be needed to confirm the potential effect of 25(OH)D3 on reducing clinical outcomes in patients with COVID-19.

COVID-19 from a rheumatology perspective: bibliometric and altmetric analysis

The Coronavirus disease 2019 (COVID-19) outbreak turned out the greatest pandemic for decades. It challenged enormously the global health system, forcing it to adjust to the new realities. We aimed to analyze articles covering COVID-19 papers in the rheumatological field and outline emerging topics raising within this frame. We applied the bibliometric database Scopus for our literature search and conducted it on the 5th of June using the following keywords: "rheumatic" OR "rheumatology" OR "rheumatoid arthritis" OR "systemic lupus erythematosus" OR "myositis" OR "systemic sclerosis" OR "vasculitis" OR "arthritis" OR "ankylosing spondylitis" AND "COVID-19". We analyzed all selected articles according to various aspects: type of document, authorship, journal, citations score, rheumatology field, country of origin, language, and keywords. With the help of the software tool VOSviewer version 1.6.15, we have built the visualizing network of authors and keywords co-occurrence. The measurement of the social impact of articles was made using Altmetric data. This study included 1430 retrieved articles with open access mostly. The top five journals in this field were Annals of the Rheumatic Diseases (n = 65), Rheumatology International (n = 51), Clinical Rheumatology (n = 50), Lancet Rheumatology (n = 50), and Frontiers In Immunology (n = 33). Most studies originate from countries with a high incidence of COVID-19 among the general population (the USA-387; Italy-268; UK-184; France-114; Germany-110; India-98 and Spain-96, China-94, Canada-73 Turkey-66). Original Articles (42.1%) were the most common articles' type, following by Letters (24.4%), Reviews (21.7%), Notes (6%), Editorials (4.8%), Erratum (1%). According to the citations scores, articles dedicated to the clinical course of COVID-19 in patients with rheumatic diseases were of the highest importance for the scientific rheumatologic community. Rheumatoid arthritis (n = 527), systemic lupus erythematosus (n = 393), vasculitis (n = 267), myositis (n = 71), systemic sclerosis (n = 68), and psoriatic arthritis (n = 68) were the most widely discussed rheumatic diseases in the view of COVID-19. The analysis of Altmetric and citations scores revealed a moderate correlation between them. This article provides a comprehensive bibliometric and altmetric analysis of COVID-19 related articles in the rheumatology field and summarizes data about features of rheumatology service in the time of the pandemic.

Axial spondyloarthritis may protect against poor outcomes in COVID-19: propensity score matched analysis of 9766 patients from a nationwide multi-centric research network

Introduction

The outcomes of COVID-19 in patients with axial spondyloarthritis (ax-SpA) have not been explored in detail. Tumour necrosis factor inhibitors (TNFi) are commonly used for ax-SpA patients, and how they influence outcomes may have implications on COVID-19 management.

Methods

A nationwide multi-centric research network was queried for patients with ax-SpA, including ankylosing spondylitis (AS) and non-radiographic SpA (nr-SpA) who had developed COVID-19. An equal number of propensity score(PS) matched controls were extracted from the database amongst patients with COVID-19 who did not have any inflammatory arthritis. Outcomes included mortality and others including hospitalization, intensive care unit, ventilation, acute kidney injury (AKI), renal replacement therapy, acute respiratory distress syndrome, cerebral infarction, venous thromboembolism (VTE), and sepsis.

Results

We identified 9766 patients with ax-SpA (924 AS and 8842 nr-SpA) and 691,862 without SpA who had COVID-19. In the unmatched comparison, patients with ax-SpA had higher risk ratios (RR) for all outcomes. After matching for demographics and comorbidities, patients with ax-SpA had lower RR for mortality [RR: 0.707 (95% CI: 0.598–0.836), p < 0.0001], severe COVID-19 [RR: 0.791 (0.69–0.906), p = 0.0007], hospitalization [RR: 0.872 (0.826–0.921), p < 0.0001], and AKI [RR: 0.902 (0.816–0.997), p = 0.044]. Only the risk of VTE was higher in ax-SpA patients [RR: 1.219 (1.037–1.433), p = 0.016]. Amongst the ax-SpA group, males had worse outcomes in 9 out of the 11 domains except for VTE and cerebral infarction, while blacks had worse outcomes in all except for mortality and the need for renal replacement therapy. AS had similar risk ratios for all outcomes compared with nr-SpA except hospitalization [RR: 1.457 (1.03–2.06), p = 0.0318]. There was no difference in outcomes in patients who had received TNFi in the year previous to COVID-19 infection. Ax-SpA patients who had been prescribed non-steroidal anti-inflammatory drugs in the 3 months prior to COVID-19 had poorer outcomes.

Conclusion

In conclusion, COVID-19 outcomes were better in patients with ax-SpA as compared with PS matched controls except for increased risk for VTE. The use of TNFi is not associated with better or worse outcomes. These apparently protective effects observed need to be validated and explored further.

Key Points • Patients with axial spondyloarthritis have lower mortality and morbidity during COVID-19 infections as compared with propensity score matched controls. • Axial spondyloarthritis is associated with higher risks for venous thromboembolism during COVID-19. • There is no difference in outcomes between ankylosing spondylitis and non-radiographic spondyloarthritis except in rates of hospitalization, which were higher in ankylosing spondylitis. • Use of tumour necrosis factor inhibitors did not influence COVID-19 outcomes.

Why Females Do Better: The X Chromosomal TLR7 Gene-Dose Effect in COVID-19

A male sex bias has emerged in the COVID-19 pandemic, fitting to the sex-biased pattern in other viral infections. Males are 2.84 times more often admitted to the ICU and mortality is 1.39 times higher as a result of COVID-19. Various factors play a role in this, and novel studies suggest that the gene-dose of Toll-Like Receptor (TLR) 7 could contribute to the sex-skewed severity. TLR7 is one of the crucial pattern recognition receptors for SARS-CoV-2 ssRNA and the gene-dose effect is caused by X chromosome inactivation (XCI) escape. Female immune cells with TLR7 XCI escape have biallelic TLR7 expression and produce more type 1 interferon (IFN) upon TLR7 stimulation. In COVID-19, TLR7 in plasmacytoid dendritic cells is one of the pattern recognition receptors responsible for IFN production and a delayed IFN response has been associated with immunopathogenesis and mortality. Here, we provide a hypothesis that females may be protected to some extend against severe COVID-19, due to the biallelic TLR7 expression, allowing them to mount a stronger and more protective IFN response early after infection. Studies exploring COVID-19 treatment via the TLR7-mediated IFN pathway should consider this sex difference. Various factors such as age, sex hormones and escape modulation remain to be investigated concerning the TLR7 gene-dose effect.

Potential Novel Thioether-Amide or Guanidine-Linker Class of SARS-CoV-2 Virus RNA-Dependent RNA Polymerase Inhibitors Identified by High-Throughput Virtual Screening Coupled to Free-Energy Calculations

SARS-CoV-2, or severe acute respiratory syndrome coronavirus 2, represents a new pathogen from the family of Coronaviridae that caused a global pandemic of COVID-19 disease. In the absence of effective antiviral drugs, research of novel therapeutic targets such as SARS-CoV-2 RNA-dependent RNA polymerase (RdRp) becomes essential. This viral protein is without a human counterpart and thus represents a unique prospective drug target. However, in vitro biological evaluation testing on RdRp remains difficult and is not widely available. Therefore, we prepared a database of commercial small-molecule compounds and performed an in silico high-throughput virtual screening on the active site of the SARS-CoV-2 RdRp using ensemble docking. We identified a novel thioether-amide or guanidine-linker class of potential RdRp inhibitors and calculated favorable binding free energies of representative hits by molecular dynamics simulations coupled with Linear Interaction Energy calculations. This innovative procedure maximized the respective phase-space sampling and yielded non-covalent inhibitors representing small optimizable molecules that are synthetically readily accessible, commercially available as well as suitable for further biological evaluation and mode of action studies.

Post-COVID-19 Syndrome

BACKGROUND

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many individuals have reported persistent symptoms and/or complications lasting beyond 4 weeks that is now called post-COVID-19 syndrome. SARS-CoV-2 is a respiratory coronavirus that causes COVID-19, and injury to the lungs is expected; however, there is often damage to numerous other cells and organs, leading to an array of symptoms. These long-term symptoms occur in patients with mild to severe COVID-19; currently, there is limited literature on the potential pathophysiologic mechanisms of this syndrome.

OBJECTIVES

The purpose of this integrative review is to summarize and evaluate post-COVID-19 syndrome from a biological perspective.

METHODS

An integrative review was conducted using Whittemore and Knafl's methodology literature published through August 30, 2021. The PubMed, CINAHL, and Web of Science databases were searched for articles published as of August 30, 2021, using combinations of the following keywords: post-COVID-19 syndrome, post-SARS-CoV-2, long COVID-19, long COVID-19 syndrome, and pathophysiology of post-COVID-19. Data were analyzed using the constant comparison method.

RESULTS

The search generated 27,929 articles. After removing duplicates and screening abstracts and full-text reviews, we retained 68 articles and examined 54 specific articles related to the pathophysiology of post-COVID-19 syndrome. The findings from our review indicated that there were four pathophysiologic categories involved: virus-specific pathophysiologic variations, oxidative stress, immunologic abnormalities, and inflammatory damage.

DISCUSSION

Although studies examining the pathophysiology of post-COVID-19 syndrome are still relatively few, there is growing evidence that this is a complex and multifactorial syndrome involving virus-specific pathophysiologic variations that affect many mechanisms but specifically oxidative stress, immune function, and inflammation. Further research is needed to elucidate the pathophysiology, pathogenesis, and longer-term consequences involved in post-COVID-19 syndrome.

Reactive arthritis after COVID-19: a case-based review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of the coronavirus disease 19 (COVID-19) pandemic, which is deeply affecting the whole world. In this new case for the scientific world, scientists are investigating the etiopathogenesis of viral infection-induced damage and have started to focus on the short and long-term immune system effects and alterations after SARS-CoV-2 infection. The case is here reported of a 53-year-old female patient with acute monoarthritis after SARS-CoV-2 infection, who responded adequately to 150 mg/day diclofenac treatment, and the available case reports are comprehensively reviewed. With the focus on arthritis after SARS-CoV2 infection, which emerges as a new pathological condition associated with COVID-19, it was aimed to examine the possible immunological mechanisms of post-COVID-19 arthritis based on the current data on SARS-CoV-2 and the known pathogenetic background of viral arthritis.

COVID-19 and features of cardiovascular involvement

The article provides an overview of current information on the pathogenesis of COVID-19 and organ-specific lesions developing in this disease. The data on inflammation and its biochemical markers, on the features of coagulopathy, endothelial damage and microthrombosis are presented in detail. Particular attention is paid to the role of receptors for angiotensin converting enzyme type 2 and transmembrane serine protease type 2 in the development of organ-specific lesions in COVID-19. The pathogenesis of damage to the cardiovascular system is considered in detail with the presentation of data from foreign literature on changes in the myocardium and the author's results of transthoracic echocardiographic examination in patients who have undergone COVID-19.

Overview of the pathogenesis of COVID-19 (Review)

At present, the pathogenesis of the novel coronavirus disease 2019 (COVID-19) has not been fully elucidated. Clinical and experimental findings from studies investigating COVID-19 have suggested that the immune-inflammatory response has a crucial role in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The present article aimed to systematically review the available literature on the pathogenesis of COVID-19. Severe COVID-19 is characterized by organ dysfunction, hypercytokinemia and lymphopenia. It is assumed that the direct cytopathological damage of host cells and the dysregulated immune response caused by SARS-CoV-2 may be the primary underlying mechanisms of COVID-19. Based on the published literature, this review attempts to provide an integrated view of the immunological mechanisms and the potential pathogenesis of COVID-19, providing an in-depth summary of the host-pathogen interaction and host immune responses. It is of great importance to elucidate the possible pathogenesis of COVID-19 to determine the direction of future research.

Rheumatology university faculty opinion on coronavirus disease-19 (COVID-19) vaccines: the vaXurvey study from Egypt

OBJECTIVES

The aim of the present work was to explore the perspectives of Egyptian Rheumatology staff members as regards the coronavirus disease-19 (COVID-19) vaccine.

METHODS

The survey is composed of 25 questions. Some questions were adapted from the global rheumatology alliance COVID-19 survey for patients.

RESULTS

187 rheumatology staff members across Egypt from 18 universities and authorizations actively participated with a valid response. The mean time needed to complete the survey was 17.7 ± 13 min. Participants were 159 (85%) females (F:M 5.7:1). One-third agreed that they will be vaccinated once available, 24.6% have already received at least one dose, 29.4% are unsure while 16% will not take it. Furthermore, 70.1% agreed that they will recommend it to the rheumatic diseases (RD) patients once available, 24.1% are not sure while 5.9% will not recommend it. RD priority to be vaccinated against COVID-19 in descending order include SLE (82.9%), RA (55.1%), vasculitis (51.3%), systemic sclerosis (39.6%), MCTD (31.6%), Behcet's disease (28.3%). The most common drugs to be avoided before vaccination included biologics (71.7%), DMARDs (44.4%), biosimilars (26.7%), IVIg (17.1%) and NSAIDs (9.1%).

CONCLUSIONS

The results of the study and specifically the low rate of acceptability are alarming to Egyptian health authorities and should stir further interventions to reduce the levels of vaccine hesitancy. As rheumatic disease patients in Egypt were not systematically provided with the vaccine till present, making the vaccine available could as well enhance vaccine acceptance. Further studies to investigate any possible side effects, on a large scale of RD patients are warranted.