Rheumatology Department, Complejo Asistencial Universitario de León, Leon, Spain.
Clin Rheumatol. 2020 Sep;39(9):2789-2796. doi: 10.1007/s10067-020-05301-2. Epub 2020 Jul 27.
Over the month of April, Spain has become the European country with more confirmed cases of COVID-19 infection, after surpassing Italy on April 2nd. The community of Castile and León in Spain is one of the most affected by COVID-19 infection and the province of León has a total of 3711 cases and 425 deaths so far. Rheumatic patients should be given special attention regarding COVID-19 infection due to their immunocompromised state resulting from their underlying immune conditions and use of targeted immune-modulating therapies. Studying epidemiological and clinical characteristics of patients with rheumatic diseases infected with SARS-CoV2 is pivotal to clarify determinants of COVID-19 disease severity in patients with underlying rheumatic disease.
To describe epidemiological characteristics of patients with rheumatic diseases hospitalized with COVID-19 and determine risk factors associated with mortality in a third level Hospital setting in León, Spain.
We performed a prospective observational study, from 1st March 2020 until the 1st of June including adults with rheumatic diseases hospitalized with COVID-19 and performed a univariate and multivariate logistic regression model to estimate ORs and 95% CIs of mortality. Age, sex, comorbidities, rheumatic disease diagnosis and treatment, disease activity prior to infection, radiographic and laboratorial results at arrival were analysed.
During the study period, 3711 patients with COVID-19 were admitted to our hospital, of whom 38 (10%) had a rheumatic or musculoskeletal disease. Fifty-three percent were women, with a mean age at hospital admission of 75.3 (IQR 68-83) years. The median length of stay was 11 days. A total of 10 patients died (26%) during their hospital admission. Patients who died from COVID-19 were older (median age 78.4 IQR 74.5-83.5) than those who survived COVID-19 (median age 75.1 IQR 69.3-75.8) and more likely to have arterial hypertension (9 [90%] vs 14 [50%] patients; OR 9 (95% CI 1.0-80.8), p 0.049), dyslipidaemia (9 (90%) vs 12 (43%); OR 12 (95% CI 1.33-108), p 0.03), diabetes ((9 (90%) vs 6 (28%) patients; OR 33, p 0.002), interstitial lung disease (6 (60%) vs 6 (21%); OR 5.5 (95% CI 1.16-26), p 0.03), cardiovascular disease (8 (80%) vs 11 (39%); OR 6.18 (95% IC 1.10-34.7, p 0.04) and a moderate/high index of rheumatic disease activity (7 (25%) vs 6(60%); OR 41.4 (4.23-405.23), p 0.04). In univariate analyses, we also found that patients who died from COVID-19 had higher hyperinflammation markers than patients who survived: C-reactive protein (181 (IQR 120-220) vs 107.4 (IQR 30-150; p 0.05); lactate dehydrogenase (641.8 (IQR 465.75-853.5) vs 361 (IQR 250-450), p 0.03); serum ferritin (1026 (IQR 228.3-1536.3) vs 861.3 (IQR 389-1490.5), p 0.04); D-dimer (12,019.8 (IQR 843.5-25,790.5) vs 1544.3 (IQR 619-1622), p 0.04). No differences in sex, radiological abnormalities, rheumatological disease, background therapy or symptoms before admission between deceased patients and survivors were found. In the multivariate analysis, the following risk factors were associated with mortality: rheumatic disease activity (p = 0.003), dyslipidaemia (p = 0.01), cardiovascular disease (p = 0.02) and interstitial lung disease (p = 0.02). Age, hypertension and diabetes were significant predictors in univariate but not in multivariate analysis. Rheumatic disease activity was significantly associated with fever (p = 0.05), interstitial lung disease (p = 0.03), cardiovascular disease (p = 0.03) and dyslipidaemia (p = 0.01).
Our results suggest that comorbidities, rheumatic disease activity and laboratorial abnormalities such as C-reactive protein (CRP), D-Dimer, lactate dehydrogenase (LDH), serum ferritin elevation significantly associated with mortality whereas previous use of rheumatic medication did not. Inflammation is closely related to severity of COVID-19. Key Points • Most patients recover from COVID-19. • The use of DMARDs, corticosteroids and biologic agents did not increase the odds of mortality in our study. • Rheumatic disease activity might be associated with mortality.
在 4 月期间，西班牙已经成为欧洲 COVID-19 感染确诊病例最多的国家，超过了 4 月 2 日的意大利。西班牙卡斯蒂利亚-莱昂自治区是受 COVID-19 感染影响最严重的地区之一，莱昂省共有 3711 例确诊病例和 425 例死亡病例。由于潜在免疫状况和使用靶向免疫调节疗法，风湿患者应特别注意 COVID-19 感染。研究感染 SARS-CoV2 的风湿性疾病患者的流行病学和临床特征对于阐明潜在风湿性疾病患者 COVID-19 疾病严重程度的决定因素至关重要。
描述在西班牙莱昂三级医院住院的风湿性疾病患者的流行病学特征，并确定与死亡率相关的危险因素。
我们进行了一项前瞻性观察性研究，从 2020 年 3 月 1 日至 6 月 1 日，包括患有 COVID-19 的风湿性疾病成年患者，并进行了单变量和多变量逻辑回归模型，以估计死亡率的比值比（OR）和 95%置信区间（CI）。分析了年龄、性别、合并症、风湿性疾病诊断和治疗、感染前疾病活动度、入院时的影像学和实验室结果。
在研究期间，共有 3711 例 COVID-19 患者入住我院，其中 38 例（10%）患有风湿或肌肉骨骼疾病。53%为女性，入院时的平均年龄为 75.3（IQR 68-83）岁。中位住院时间为 11 天。共有 10 例患者（26%）在住院期间死亡。死于 COVID-19 的患者年龄较大（中位数年龄 78.4 IQR 74.5-83.5），与存活的 COVID-19 患者相比（中位数年龄 75.1 IQR 69.3-75.8），更有可能患有动脉高血压（9 [90%] 例 vs 14 [50%] 例；OR 9[95%CI1.0-80.8]，p0.049）、血脂异常（9 [90%] 例 vs 12 [43%] 例；OR 12[95%CI1.33-108]，p0.03）、糖尿病（9 [90%] 例 vs 6 [28%] 例；OR 33，p0.002）、间质性肺病（6 [60%] 例 vs 6 [21%] 例；OR 5.5[95%CI1.16-26]，p0.03）、心血管疾病（8 [80%] 例 vs 11 [39%] 例；OR 6.18[95%CI1.10-34.7]，p0.04）和中度/高度风湿疾病活动度指数（7 [25%] 例 vs 6[60%] 例；OR 41.4[4.23-405.23]，p0.04）。在单变量分析中，我们还发现死于 COVID-19 的患者的高炎症标志物水平高于存活的患者：C 反应蛋白（181[IQR120-220] vs 107.4[IQR30-150]；p0.05）；乳酸脱氢酶（641.8[IQR465.75-853.5] vs 361[IQR250-450]；p0.03）；血清铁蛋白（1026[IQR228.3-1536.3] vs 861.3[IQR389-1490.5]；p0.04）；D-二聚体（12019.8[IQR843.5-25790.5] vs 1544.3[IQR619-1622]；p0.04）。死亡患者和幸存者之间在性别、影像学异常、风湿性疾病、背景治疗或入院前症状方面没有差异。在多变量分析中，以下危险因素与死亡率相关：风湿疾病活动度（p0.003）、血脂异常（p0.01）、心血管疾病（p0.02）和间质性肺病（p0.02）。年龄、高血压和糖尿病在单变量分析中是显著预测因素，但在多变量分析中不是。风湿疾病活动度与发热（p0.05）、间质性肺病（p0.03）、心血管疾病（p0.03）和血脂异常（p0.01）显著相关。
我们的结果表明，合并症、风湿疾病活动度和 C 反应蛋白（CRP）、D-二聚体、乳酸脱氢酶（LDH）、血清铁蛋白升高等实验室异常与死亡率显著相关，而风湿性药物的既往使用与死亡率无关。炎症与 COVID-19 的严重程度密切相关。
• 大多数患者从 COVID-19 中康复。
• 在我们的研究中，使用 DMARDs、皮质类固醇和生物制剂并没有增加死亡率的几率。
• 风湿疾病活动度可能与死亡率相关。
