Risk of Severe SARS-CoV-2 Infection in Patients with Autoimmune Rheumatic Diseases in Qatar: A Cohort Matched Study

Background: It remains unclear whether patients with autoimmune rheumatic diseases (ARDs) are at a higher risk of poor outcomes from a SARS-CoV-2 infection. We evaluated whether patients with an ARDs infected with SARS-CoV-2 were at a higher risk of a poorer outcome than those without an ARDs.

Methods: Patients with an ARDs infected with SARS-CoV-2 were matched to control patients without a known ARDs. Matching was performed according to age ( ± 6 years) and sex at a case-to-control ratio of 1:3. Demographic and clinical data were extracted from the databases and were compared between the two groups. Severe SARS-CoV-2 infection was the primary outcome and was defined as the requirement for oxygen therapy support, the need for invasive or noninvasive mechanical ventilation, or the use of glucocorticoids.

Results: A total of 141 patients with an ARDs were matched to 398 patients who formed the control group. The mean ages (SD) of the ARDs and non-ARDs groups were 44.4 years (11.4) and 43.4 years (12.2). Women accounted for 58.8% of the ARDs group and 56.3% of the control group (p = 0.59). Demographics and comorbidities were balanced between the groups. ARDs included connective tissue disease in 43 (30.3%) patients, inflammatory arthritis in 92 (65.2%), and other ARDs in 8 (5.7%). ARDs medications included biological/targeted synthetic disease-modifying antirheumatic drugs (b/ts-DMARDs) in 28 (15.6%) patients, conventional synthetic DMARDs in 95 (67.4%), and immunosuppressive antimetabolites in 13 (9.2%). The ARDs group had more respiratory and gastrointestinal symptoms related to SARS-CoV-2 infection than the control group (24.8% and 20.6% vs. 10% and 5.3%, respectively; p <  0.001 for both). Severe SARS-CoV-2 infection was more common in the ARDs group than in the control group (14.9% vs. 5.8%; p <  0.001).

Conclusions: In this single-center matched cohort study, patients with an ARDs experienced more respiratory and gastrointestinal symptoms related to SARS-CoV-2 infection and had more severe infection than those from the control group. Therefore, patients with an ARDs require close observation during the coronavirus disease 2019 pandemic.

AB1146 SARS-Cov-2 VIRAL LOAD IN PATIENTS WITH AUTOIMMUNE RHEUMATIC DISEASE, A RETROSPECTIVE COMPARATIVE STUDY

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load and its impact on disease outcome in patients with autoimmune rheumatic disease (ARD) are lacking. Also, whether patients with ARD receiving immunomodulators have different viral loads compared to the general population is unknown.

Objectives

To compare the viral load of SARS-CoV-2 and its trending between patients without and with ARD.

Methods

Retrospectively, patients with ARD infected with SARS-CoV-2 were matched by age and sex at a ratio of 1:2 to patients without ARD and not receiving immunosuppression or immunomodulator drugs. Viral load was determined by the cycle threshold (CT) value measured by a number of platforms: (a) Automated Platforms - the Roche Cobas 6800 system using the Cobas SARS-CoV-2 Test targeting the E and orf1a/b genes (Roche, Switzerland) and the Xpert Xpress SARS-CoV-2 targeting the E and N genes (Cepheid, USA); (b) Manual platforms - EZ1 (QIAGEN, USA), QIAsymphony (QIAGEN, USA), and Bioneer ExiPrepTM 96 Virus DNA/RNA kits Catalogue No K4614 (Bioneer, South Korea) extraction with thermal cycling using TaqPath™ PCR COVID-19 Combo Kit targeting the N, S and orf1a/b genes (Thermo Fisher Scientific, USA) on ABI 7500 thermal cyclers. Independent samples t-test was used to compare the mean CT values of the study groups at baseline and at 5 subsequent intervals (1 – 5.9, 6 – 11.9, 12 – 17.9, 18 – 23.9 and 24 – 30 days).

Results

Mean age (SD) of 197 cases and 420 controls were 45.2 (11.8) and 44.1 (12.3) years, respectively. Females were predominant in both groups 60% vs. 52%, P=0.053. The most common ARD was rheumatoid arthritis in 82 cases (41.6%), followed by spondyloarthropathy in 33 (16.8%) and systemic lupus erythematosus in 31 (15.7%). Of the cases, 67% were on conventional synthetic disease modifying anti-rheumatic drugs (DMARDs), 15.2% on biological DMARDs and 4.6% patients were on rituximab. The mean CT values was significantly lower in the ARD group at baseline and persisted till day 24.

Table 1.

demographic characteristics and comparison of the mean CT values in the study groups at baseline and at different intervals with the corresponding OR (95% CI)

Case (N=197)Control (N=420)OR (95% CI)Mean (SD) age, years45.2 (11.8)44.1 (12.3)1.008 (0.994–1.022)Sex, female N (%)120 (60.9%)221 (52.6)0.713 (0.505–1.006)Mean (SD) CT values at Baseline22.9 (5.5)30 (5.2)0.799 (0.745–0.858)1 – 5.9 days22.1 (4.6)25.7 (6.3)0.901 (0.842–0.963)6 – 11.9 days26.9 (4.9)31.5 (3.9)0.802 (0.724–0.888)12 – 17.9 days29.6 (4.1)32.3 (3.2)0.827 (0.743–0.921)18 – 23.9 days32.1 (4)32.9 (2.5)0.903 (0.728–1.119)24 – 30 days31.2 (1.2)32.7 (2.6)0.824 (0.589–1.151)

Conclusion

Compared to patients without ARD, the viral load of SARS-CoV-2 in patients with ARD is significantly higher at baseline testing and persists till day 24. This finding may indicate that patients with ARD are at higher risk of severe SARS-CoV-2 infection and prolonged potential transmission. Clinical outcome correlation is needed.

References

None

Disclosure of Interests

None declared

POS1252 DURABILITY OF THE HUMORAL RESPONSE TO m-RNA BASED ANTI-SARS-CoV-2 VACCINES IN PATIENTS WITH AUTOIMMUNE RHEUMATIC DISEASE, A COMPARATIVE STUDY

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load and its impact on disease outcome in patients with autoimmune rheumatic disease (ARD) are lacking. Also, whether patients with ARD receiving immunomodulators have different viral loads compared to the general population is unknown.

Objectives

To compare the viral load of SARS-CoV-2 and its trending between patients without and with ARD.

Methods

Retrospectively, patients with ARD infected with SARS-CoV-2 were matched by age and sex at a ratio of 1:2 to patients without ARD and not receiving immunosuppression or immunomodulator drugs. Viral load was determined by the cycle threshold (CT) value measured by a number of platforms: (a) Automated Platforms - the Roche Cobas 6800 system using the Cobas SARS-CoV-2 Test targeting the E and orf1a/b genes (Roche, Switzerland) and the Xpert Xpress SARS-CoV-2 targeting the E and N genes (Cepheid, USA); (b) Manual platforms - EZ1 (QIAGEN, USA), QIAsymphony (QIAGEN, USA), and Bioneer ExiPrepTM 96 Virus DNA/RNA kits Catalogue No K4614 (Bioneer, South Korea) extraction with thermal cycling using TaqPath™ PCR COVID-19 Combo Kit targeting the N, S and orf1a/b genes (Thermo Fisher Scientific, USA) on ABI 7500 thermal cyclers. Independent samples t-test was used to compare the mean CT values of the study groups at baseline and at 5 subsequent intervals (1 – 5.9, 6 – 11.9, 12 – 17.9, 18 – 23.9 and 24 – 30 days).

Results

Mean age (SD) of 197 cases and 420 controls were 45.2 (11.8) and 44.1 (12.3) years, respectively. Females were predominant in both groups 60% vs. 52%, P=0.053. The most common ARD was rheumatoid arthritis in 82 cases (41.6%), followed by spondyloarthropathy in 33 (16.8%) and systemic lupus erythematosus in 31 (15.7%). Of the cases, 67% were on conventional synthetic disease modifying anti-rheumatic drugs (DMARDs), 15.2% on biological DMARDs and 4.6% patients were on rituximab. The mean CT values was significantly lower in the ARD group at baseline and persisted till day 24.

Table 1.

Demographic characteristics and comparison of the mean CT values in the study groups at baseline and at different intervals with the corresponding OR (95% CI)

Case (N=197)Control (N=420)OR (95% CI)Mean (SD) age, years45.2 (11.8)44.1 (12.3)1.008 (0.994–1.022)Sex, female N (%)120 (60.9%)221 (52.6)0.713 (0.505–1.006)Mean (SD) CT values at Baseline22.9 (5.5)30 (5.2)0.799 (0.745–0.858) 1 – 5.9 days22.1 (4.6)25.7 (6.3)0.901 (0.842–0.963) 6 – 11.9 days26.9 (4.9)31.5 (3.9)0.802 (0.724–0.888) 12 – 17.9 days29.6 (4.1)32.3 (3.2)0.827 (0.743–0.921) 18 – 23.9 days32.1 (4)32.9 (2.5)0.903 (0.728–1.119) 24 – 30 days31.2 (1.2)32.7 (2.6)0.824 (0.589–1.151)

Conclusion

Compared to patients without ARD, the viral load of SARS-CoV-2 in patients with ARD is significantly higher at baseline testing and persists till day 24. This finding may indicate that patients with ARD are at higher risk of severe SARS-CoV-2 infection and prolonged potential transmission. Clinical outcome correlation is needed.

References

None

Disclosure of Interests

None declared

Post COVID 19 acute acalculous cholecystitis raising the possibility of underlying dysregulated immune response, a case report

Introduction

Novel Coronavirus disease 2019 or COVID-19 has rapidly spread throughout the world and has become an unprecedented pandemic. It has a vast spectrum of clinical presentations and can affect various organs. Rarely, it has been reported to cause acalculous cholecystitis in a non ICU setting patient.

Case presentation

Here we report a rare association of COVID 19 with acalculous cholecystitis in a 40 years old healthy woman. She developed fever, malaise, generalized body weakness, and right hypochondrial pain after fourteen days of COVID 19 infection, raising the possibility of Post COVID dysregulated immune response resulting in acalculous cholecystitis. She was managed conservatively with broad spectrum antibiotics.

Discussion

Acalculous cholecystitis primarily occurs due to the gall bladder's hypomotility and most commonly seen in critically ill patients such as severe burns, mechanically ventilated patients, and prolonged parenteral nutrition. The management depends upon treating the underlying pathology and, in some severe cases, may need surgical intervention as well. Up to our knowledge, COVID 19, causing acalculous cholecystitis, is a rare association described only in a few critically ill patients but not in young, healthy patients. It can be attributed to the body's dysregulated immunological response against the virus resulting in systemic inflammation.

Conclusion

Currently, there is are no clear guidelines for managing acute cholecystitis in COVID-19 patients. It depends on the patient's clinical state and disease severity. We aim to highlight the importance of early diagnosis and management in such clinical scenarios to avoid fatal complications.

Managing potential drug-drug interactions between gastric acid-reducing agents and antiretroviral therapy: experience from a large HIV-positive cohort

Drug-drug interactions between antiretroviral therapy and other drugs are well described. Gastric acid-reducing agents are one such class. However, few data exist regarding the frequency of and indications for prescription, nor risk assessment in the setting of an HIV cohort receiving antiretroviral therapy. To assess prevalence of prescription of gastric acid-reducing agents and drug-drug interaction within a UK HIV cohort, we reviewed patient records for the whole cohort, assessing demographic data, frequency and reason for prescription of gastric acid-reducing therapy. Furthermore, we noted potential drug-drug interaction and whether risk had been documented and mitigated. Of 701 patients on antiretroviral therapy, 67 (9.6%) were prescribed gastric acid-reducing therapy. Of these, the majority (59/67 [88.1%]) were prescribed proton pump inhibitors. We identified four potential drug-drug interactions, which were appropriately managed by temporally separating the administration of gastric acid-reducing agent and antiretroviral therapy, and all four of these patients remained virally suppressed. Gastric acid-reducing therapy, in particular proton pump inhibitor therapy, appears common in patients prescribed antiretroviral therapy. Whilst there remains a paucity of published data, our findings are comparable to those in other European cohorts. Pharmacovigilance of drug-drug interactions in HIV-positive patients is vital. Education of patients and staff, and accurate data-gathering tools, will enhance patient safety.

Utility of therapeutic drug monitoring in the management of HIV-infected pregnant women in receipt of lopinavir

The pharmacokinetics of antiretroviral drugs in pregnancy is poorly understood. We reviewed the use of therapeutic drug monitoring (TDM) in clinical settings to document plasma concentrations of lopinavir during pregnancy and investigated how clinicians acted upon TDM results. A retrospective review was carried out of all HIV-infected pregnant women taking boosted lopinavir-based highly active antiretroviral therapy (HAART) at five National Health Service (NHS) centres in the UK between May 2004 and March 2007. Seventy-three women in receipt of lopinavir were identified, of whom 89% had plasma lopinavir concentrations above the suggested minimum recommended for wild-type HIV. Initial TDM results prompted dosage change in 10% and assessment of adherence and/or pharmacist review in 11%. TDM was repeated in 29%. TDM can play an important role in the clinical management of HIV-positive pregnant women, allowing informed dose modification and an alternative measure of adherence.

Reliability of rapid testing for hepatitis B in a region of high HIV endemicity

Hepatitis B (HBV) and HIV co-infection is common in resource-poor settings. A recent study from Malawi revealed poor correlation between hepatitis B surface antigen (HBsAg) point-of-care tests and reference tests in patients co-infected with HIV. We studied a cohort of 300 Malawian adults entering a treatment programme for HIV. Sera were tested for HBsAg first using the Determine rapid test and re-tested using a commercial enzyme immunoassay (EIA). All tests were done under optimal conditions in Liverpool, UK. Sera from all 25 patients positive for HBsAg using the rapid test and from 50 who were negative, were re-tested using the EIA, with complete concordance of results. The kappa correlation was 1, specificity 100% (93-100%) and sensitivity 100% (86-100%) compared to the reference test. Patients had advanced immune suppression (mean CD4=175 cells x 10(6)/l). In a non-field setting, the results of point-of-care Determine rapid hepatitis B tests appear reliable in patients with HIV-1 co-infection.

Quantifying the metabolic activation of nevirapine in patients by integrated applications of NMR and mass spectrometries

Nevirapine (NVP), an antiretroviral drug, is associated with idiosyncratic hepatotoxicity and skin reactions. Metabolic pathways of haptenation and immunotoxicity mechanisms have been proposed. NVP is metabolized by liver microsomes to a reactive intermediate that binds irreversibly to protein and forms a GSH adduct. However, no reactive metabolite of NVP, trapped as stable thioether conjugates, has hitherto been identified in vivo. This study has defined the metabolism of NVP with respect to reactive intermediate formation in patients and a rat model of NVP-induced skin reactions. An integrated NMR and mass spectrometry approach has been developed to discover and quantify stable urinary metabolite biomarkers indicative of NVP bioactivation in patients. Two isomeric NVP mercapturates were identified in the urine of HIV-positive patients undergoing standard antiretroviral chemotherapy. The same conjugates were found in rat bile and urine. The mercapturates were isolated from rat bile and characterized definitively by NMR as thioethers substituted at the C-3 and exocyclic C-12 positions of the methylpyrido ring of NVP. It is proposed that NVP undergoes bioactivation to arene oxide and quinone methide intermediates. The purified major mercapturate was quantified by NMR and used to calibrate a mass spectrometric assay of the corresponding metabolite in patient urine. This is the first evidence for metabolic activation of NVP in humans, and only the second minimum estimate in patients of bioactivation of a widely prescribed drug associated with idiosyncratic toxicities. The method can be used as a template for comparative estimations of bioactivation of any drug in patients.

The value of the post-take ward round: are new working patterns compromising junior doctor education?

This prospective observational study assessed the impact of the changes in junior doctors' working hours and waiting-time initiatives on teaching and learning opportunities for junior doctors in acute medicine. An audit cycle of post-take ward rounds including all medical admissions to an urban teaching hospital was conducted. During two seven-day periods in July 2006 and 2008, 317 and 354 patients were admitted respectively. In the two-year interval a number of changes were implemented resulting in a significant increase in patients reviewed by a consultant within 24 hours of admission. Target waiting times were being met but there were many missed learning opportunities for junior staff. Senior doctors continue to perform the majority of post-take reviews in the absence of the doctors who had admitted the patient. Similar patterns are likely to be found in other hospitals attempting to balance training with government targets for waiting times and junior doctors' working hours.

A rapid and sensitive HPLC–MS method for the detection of plasma and cellular rifampicin

Rifampicin is active against both intracellular and extracellular Mycobacterium tuberculosis. The ability to measure rifampicin drug concentrations in both plasma and in cells may be useful in evaluating the suitability of dosage regimens for populations and individuals. Here a novel simple, precise and accurate method for the quantification of rifampicin in both cells and plasma is reported. Sample proteins were precipitated with acetonitrile containing the internal standard and then diluted with water. Aliquots of supernatant were then injected into the HPLC-MS system for chromatographic separation and detection. Rifampicin calibration curves encompassed concentrations from 100 to 12,800 ng/mL. Intra- and inter-assay precision and accuracy were determined using low, medium and high concentration quality control samples and was found to be within 10% in all cases. Rifampicin concentrations were found to be unaffected by freeze-thaw cycles, but were significantly affected by heat-inactivation (58 degrees C, 40 min). This assay was successfully utilised to determine the pharmacokinetic profile of rifampicin in plasma and peripheral blood mononuclear cells (PBMC) in 8 tuberculosis patients receiving rifampicin over an 8h period.

Are intestinal helminths a risk factor for non-typhoidal Salmonella bacteraemia in adults in Africa who are seropositive for HIV? A case-control study

In Africa, invasive, non-typhoidal Salmonella (NTS) infections are a common but life-threatening complication in adults who are seropositive for HIV. The high prevalence of human infection with intestinal helminths which penetrate the gut could explain the greater importance of NTS bacteraemia in Africa compared with that in industrialized countries. If helminth infection is a major risk factor for NTS it would provide a locally relevant, public-health target. Intestinal helminth carriage in 57 HIV-positive patients with NTS bacteraemia (the cases) was compared with that in 162 HIV-positive controls who were similar to the cases in terms of age, sex, urban dwelling and socio-economic factors. The prevalence of helminth infection, 29% overall, was lower among the cases (18%) than among the controls (33%), giving a crude odds ratio of 0.40 [with a 95% confidence interval (CI) of 0.21-0.9] and an adjusted odds ratio (aOR) of 0.79 (CI = 0.4-1.8). Five (9%) of the cases and 12 (7%) of the controls were infected with nematodes which penetrate the gut (Ascaris lumbricoides and/or Strongyloides stercoralis). The aOR for infection with these penetrating worms, corrected for age, sex, urban dwelling and phase of study, was 1.40 (CI = 0.4-4.5). The present results do not exclude the possibility that helminths play a role in invasive NTS infections, but are not consistent with helminths being a sufficient risk factor in this population to be a public-health target. Anthelmintics are unlikely to have a major impact on preventing NTS bacteraemia in patients diagnosed HIV-positive in Africa.

Opsonic phagocytosis of Streptococcus pneumoniae by alveolar macrophages is not impaired in human immunodeficiency virus-infected Malawian adults

Streptococcus pneumoniae is a major cause of pneumonia, bacteremia, and meningitis, especially among adults infected with the human immunodeficiency virus (HIV). Alveolar macrophages (AMs) are critical components of cellular defense against bacterial infection and are both infected and affected by HIV. In this study, AMs obtained at bronchoscopy from 44 Malawian adults (24 HIV positive and 20 HIV negative) were exposed in vitro to opsonized S. pneumoniae and coagulase-negative staphylococci. AMs from HIV-positive and -negative volunteers showed no significant difference in binding to or internalization of either S. pneumoniae or coagulase-negative staphylococci. In HIV-positive subjects, the presence of detectable HIV in lung fluid was not associated with AM impairment. AMs from HIV-infected adults did not exhibit impaired pneumococcal phagocytosis in the assay used. This suggests that an alternative mechanism of susceptibility is operating in these individuals.

Bacteraemia and mortality among adult medical admissions in Malawi--predominance of non-typhi salmonellae and Streptococcus pneumoniae

OBJECTIVES

The high seroprevalence of HIV in Malawi might be expected to alter the pattern of pathogens isolated from bacteraemic patients. We aimed to describe the frequency and seasonal pattern of bacterial isolates from blood, their antibiotic susceptibility, and patient outcome, in order to provide data on which to base empirical antibiotic therapy and further studies of pathogenesis.

METHODS

Over a 12-month period, blood cultures were taken from all febrile adult medical admissions to Queen Elizabeth Central Hospital, Blantyre.

RESULTS

A total of 2789 out of 9298 adult general medical admissions had blood culture performed, of whom 449 (16.1%) grew significant pathogens. Non-typhi salmonellae (NTS) (37%) and Streptococcus pneumoniae (30%) were the two commonest isolates. Mortality was 18% among general medical admissions and 38% among bacteraemic patients. Mortality for individual pathogens was: NTS 33%; S. pneumoniae 36%; Escherichia coli 54%; Klebsiella spp. 58%; Neisseria meningitidis 44%; Salmonella typhi 17%. Despite an overwhelming association between the major pathogens and HIV infection (95% of S. pneumoniae cases and 92% of NTS cases were seropositive for HIV), a seasonal pattern was preserved. Streptococcus pneumoniae was more frequently isolated in the cold dry months, while STM isolates increased following a rise in temperature. A case of bacteraemia with Vibrio cholerae (serotype 01) was detected during a cholera outbreak in the rainy season. Although S. pneumoniae isolates were relatively susceptible to penicillin (88%) and chloramphenicol (74%), S. typhimurium isolates were fully susceptible only to chloramphenicol.

CONCLUSIONS

This large study confirms the dominance of NTS and S. pneumoniae in bacteraemia in an area affected by HIV-1 and allows comparison of mortality by individual pathogens. It demonstrates a preserved seasonal pattern of bacteraemia for these major pathogens, despite an overwhelming association with HIV infection.

Bacterial meningitis in Malawian adults: pneumococcal disease is common, severe, and seasonal

We prospectively collected laboratory details and outcome data on all patients with laboratory-confirmed cases of meningitis that presented to our unit in Blantyre, Malawi, from 1 April 1998 through 31 March 1999. There were 502 patients with cases of meningitis; the most common causative organisms were Cryptococcus neoformans and Streptococcus pneumoniae. This pattern probably reflects the local human immunodeficiency virus (HIV) seroprevalence (31%) and is different from the pattern in 1974, when Neisseria meningitidis was the most common isolate. There has been an 8-fold increase in the number of meningitis cases per year since 1974, and a doubling of the percentage of medical admissions due to meningitis. The inpatient mortality rate among patients with cases of pneumococcal meningitis was 61%, and in the group as a whole was 41%. Despite the HIV-related pattern of infecting pathogens among these cases of meningitis and the increased incidence of the condition, there was evidence that the typical seasonal pattern of pneumococcal meningitis, which peaks in the cold, dry season, was preserved.