Coronavirus disease 2019 (COVID-19) and immune-mediated inflammatory rheumatic diseases: at the crossroads of thromboinflammation and autoimmunity

Analysis of T-cell and Humoral Immune Response to SARS-CoV-2 Antigens in Rituximab-Treated Patients with Rheumatoid Arthritis Vaccinated with Combined Vector Vaccine Gam-COVID-Vac

The COVID-19 pandemic has brought significant changes in managing of patients with rheumatoid arthritis. Rituximab-treated patients were more susceptible to severe infection. This required a "switch" to another genetically engineered drug in the patients with high risk of adverse COVID-19. In this study, we assessed the severity of immune response to SARS-CoV-2 antigens in rituximab-treated patients with rheumatoid arthritis vaccinated with the combined vector vaccine Gam-COVID-Vac. Insufficient formation of the humoral response and a high level of T-cell response to SARS-CoV-2 antigens in this group of patients were revealed. An imbalance of cellular and humoral response may play a role in more severe COVID-19 in rituximab-treated patients with rheumatoid arthritis.

[Autoimmunity in rheumatology: A review]

Autoimmunity and autoinflammation, co-potentiating pathological processes, are considered within the "immune-inflammatory" continuum (continuity with a variety of elements), reflecting the close relationship between the innate and acquired immune responses. Autoimmunity is the leading pathogenetic mechanism for a specific type of human chronic inflammatory disorders - autoimmune diseases, affecting more than 10% of people in the general population. Advances in molecular biology, pharmacogenetics, and bioinformatics provided the background for individualizing therapy for systemic autoimmune rheumatic diseases within personalized medicine. Studying the immunopathogenesis mechanisms, improving diagnostics, interpreting the molecular taxonomy, and developing approaches to the prevention and personalized therapy of systemic autoimmune rheumatic diseases are the priority issues of modern medicine.

[Systemic lupus erythematosus and antiphospholipid syndrome: past, present, future]

Immune-inflammatory (autoimmune and autoinflammatory) rheumatic diseases are widespread severe chronic inflammatory diseases and also "models" for studying the fundamental mechanisms of pathogenesis and approach to pharmacotherapy of other diseases associated with autoimmunity and/or autoinflammation. Uncontrolled inflammation leading to hypercoagulation forms the basis of "thromboinflammation", which is considered a universal pathogenetic mechanism of organ involvement in immune-inflammatory rheumatic diseases, as well as in COVID-19 and atherosclerotic vascular lesions (atherothrombosis). Thrombo-inflammatory mechanisms play a crucial role in systemic lupus erythematosus and antiphospholipid syndrome. Russian rheumatology, under the leadership of academician Valentina Alexandrovna Nasonova, greatly contributed to the research of these disorders. This article addresses the current view about the overlapping pathogenetic mechanisms of thrombosis in systemic lupus erythematosus and antiphospholipid syndrome, the relevance of these studies during the COVID-19 pandemic, and the prospects for antithrombotic and anti-inflammatory therapy.

Coronavirus Infection 2019 (COVID-19) and Autoimmunity

The pandemic of coronavirus disease 2019, etiologically associated with the SARS-CoV-2 virus, has drawn the attention of the medical community to new clinical and fundamental problems in the immunopathology of human diseases. During a detailed analysis of the clinical manifestations and immunopathological disorders in COVID-19, it became apparent that SARS-CoV-2 infection is accompanied by the development of a wide range of extrapulmonary clinical and laboratory disorders, some of which are characteristic of immunoinflammatory rheumatic diseases and other human autoimmune and autoinflammatory diseases. All this taken together served as a theoretical justification for the repositioning of anti-inflammatory drugs in COVID-19, previously specifically designed for the treatment of immunoinflammatory rheumatic diseases. The prospects for studying the autoimmune mechanisms of COVID-19 and the possibility of anti-inflammatory therapy are discussed.

Peculiarities of blood coagulation disorders in patients with COVID-19

Aim. To study the relationship of hemostatic disorders with inflammation and estimate their role in the course and outcomes of COVID-19. Materials and methods. We examined 215 consecutive patients with moderate and severe forms of acute COVID-19. The patients were on anticoagulants and immunosuppressive drugs. Hemostasis was assessed using the thrombodynamics assay, thromboelastography, fibrinogen and D-dimer levels, prothrombin time, and soluble fibrin-monomer complexes (ethanol gelation test). The hemostatic parameters were correlated with hematological and biochemical tests, including markers of inflammation (C-reactive protein, interleukins 6 and 8), as well as with the disease severity and outcomes. Results. Laboratory signs of coagulopathy were revealed in the vast majority of the cases. Despite the use of low-molecular-weight heparins in the prophylactic and therapeutic doses, coagulopathy in COVID-19 manifested predominantly as hypercoagulability that correlated directly with the systemic inflammation and metabolic changes due to liver and kidney dysfunction. A direct relationship was found between the grade of coagulopathy and the severity of COVID-19, including comorbidities and the mortality. The chronometric hypocoagulability observed in about 1/4 cases was associated with a high level of C-reactive protein, which may decelerate coagulation in vitro and thereby mask the true inflammatory thrombophilia. Persistent hyperfibrinogenemia and high D-dimer in the absence of consumption coagulopathy suggest the predominance of local and/or regional microthrombosis over disseminated intravascular coagulation. Conclusion. The results obtained substantiate the need for laboratory monitoring of hemostasis and active prophylaxis and treatment of thrombotic complications in COVID-19.

2019 Coronavirus disease (COVID-19): contribution of rheumatology

The 2019 coronavirus disease (COVID-19) pandemic become a major challenge for humanity and a unique opportunity to get an idea of the real achievements of modern biology and medicine. In the course of the pandemic, a large number of new fundamental and medical issues have been revealed regarding the relationship between viral infection and many common chronic non-infectious diseases, among which immune-mediated rheumatic diseases (IMRD) occupy an important position. It is now well known that SARS-CoV-2 infection is accompanied by a wide range of extrapulmonary clinical and laboratory disorders, some of which are characteristic of IMRD and other autoimmune and autoinflammatory diseases in humans. The most severe consequence of alterations in regulation of the immunity in COVID-19 and IMRD is the so-called cytokine storm syndrome, which is defined as COVID-19-associated hyperinflammatory syndrome in COVID-19, and as macrophage activation syndrome in IMRD. The COVID-19-associated hyperinflammatory syndrome was used as a reason for drug repurposing and off-label use of a wide range of anti-inflammatory drugs, which have been specially developed for the treatment of IMRD over the past 20 years. Common immunopathological mechanisms and approaches to pharmacotherapy in COVID-19 and IMRD determined the unique place of rheumatology among medical specialties contributing to combat the COVID-19 pandemic. The article provides the basic provisions of the International and National Association of Rheumatologists and the Association of Rheumatologists of Russia (ARR) recommendations for management of patients with IMRD during the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) and autoimmunity

The coronavirus 2019 pandemic (coronavirus disease, COVID-19), etiologically related to the SARS-CoV-2 virus (severe acute respiratory syndrome coronavirus-2), has once again reawakened healthcare professionals’ interest towards new clinical and conceptual issues of human immunology and immunopathology. An unprecedented number of clinical trials and fundamental studies of epidemiology, virology, immunology and molecular biology, of the COVID-19 clinical course polymorphism and pharmacotherapy have been conducted within one year since the outbreak of 2019 pandemic, bringing together scientists of almost all biological and physicians of almost all medical specialties. Their joint efforts have resulted in elaboration of several types of vaccines against SARS-CoV-2 infection and, in general, fashioning of more rational approaches to patient management. Also important for COVID-19 management were all clinical trials of biologics and “targeted” anti-inflammatory drugs modulating intracellular cytokine signaling, which have been specifically developed for treatment immune-mediated inflammatory rheumatic disease (IMIRDs) over the past 20 years. It became obvious after a comprehensive analysis of the entire spectrum of clinical manifestations and immunopathological disorders in COVID-19 is accompanied by a wide range of extrapulmonary clinical and laboratory disorders, some of which are characteristic of IMIRDs and other autoimmune and auto-in-flammatory human diseases. All these phenomena substantiated the practice of anti-inflammatory drugs repurposing with off-label use of specific antirheumatic agents for treatment of COVID-19. This paper discusses potential use of glucocorticoids, biologics, JAK inhibitors, etc., blocking the effects of pro-inflammatory cytokines for treatment of COVID-19.

Coronavirus Desease 2019 (COVID-19) in Children: Lessons from Pediatric Rheumatology

The clinical presentation and outcomes of infection with the novel coronavirus (COVID-19) are characterized by exceptional variability in manifestations, which depend on many factors, one of which is the patient’s age. One of the severe life-threatening manifestations in adults is severe acute respiratory syndrome (SARS-CoV-2), in some cases accompanied by the development of multiple organ failure. During the first two to three months of the COVID-19 pandemic, the global medical community was of the opinion that this disease in children is usually mild and not fatal. However, with the accumulation of new information, it became clear that there is a growing recognition of the existence of multisystem inflammatory syndrome in children, chronologically associated with SARS-CoV-2, which can lead to serious consequences. The article presents the main epidemiological, clinical and laboratory characteristics of the syndrome, as well as discusses the issues of its pathogenesis, differential diagnosis with a number of other acute conditions associated with an dysbalance of cytokines.