COVID-19, Coronavirus and Rheumatic Disease 4.56/5 (126)

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COVID-19 corona virus can cause complications in rheumatic disease. Photo Credit: US Army

Definition

Coronavirus / coronavirus is a group of different viruses that have a crown-like form (corona). Most types of coronavirus cause colds (another virus, rhinovirus, is the most common cause of colds). However, coronavirus has caused epidemics with more severe infections in the form of SARS (Severe Acute Respiratory Syndrome) 2002-2003, MERS (Middle East Respiratory Syndome) 2012. In December 2019, an epidemic started from the city Wuhan in China with the virus COVID-2 also called 2019-nCoV or the Wuhan virus. The virus causes the coronavirus disease that is called COVID-19 causing an epidemic in Norway and the rest of the world (pandemic).

Infection with the virus begins with its penetration into a cell, such as the lungs. The virus uses the cell to multiply, and it causes the cell to die. Cell door releases neurotransmitters that call for immune cells (monocytes, macrophages and T cells). Normally, the virus should then be neutralized and removed. In someone with Covid-19 disease, this immune response shoots sharply above the target so that this inflammatory process in itself becomes dangerous. Possibly genetic / hereditary mechanisms (the ACE2 gene and the TLR7 gene) are partly responsible for some becoming much sicker than others.

COVID-19 and Rheumatic Disease

Infection with the coronavirus COVID-19 can cause temporary muscle pain, but otherwise does not cause significant rheumatic symptoms, but people with a weakened immune system may be exposed to a serious course. This may apply to people over the age of 50 who use immunosuppressive therapy such as Biological drugs, Methotrexate, Imurel, CellCept and others and high doses Prednisone) against serious rheumatic diseases. A study of 600 patients with various rheumatic diseases from 40 countries showed that Prednisolone 10mg / day or more increased the risk of hospitalization in case of COVID-19 infection. Treatment with TNF inhibitors (a group of biological drugs) did not show an increased risk (reference: Gianfrancesco M, 2020). Norwegian data obtained between January and April 2020 among 4.1 million inhabitants over the age of 20 showed that 157 people with rheumatic disease had been infected. Of these, 35 (22%) were hospitalized, which was about twice as frequent as in the average population. When using biological drugs, 25% were admitted. In comparison, the need for hospitalization was greater in lung diseases such as COPD (42%) and asthma (25%), as well as in diabetes (34%) (reference: Nystad W, 2020). Later data indicate that the need for hospital admissions has decreased.

It has previously been shown that Rheumatoid arthritis (arthritis) debuts more frequently (9,2% increase) after epidemics with other coronaviruses (reference Joo YB, 2019), but data so far do not indicate this for COVID-19.

Some systemic connective tissue disorders, most often Systemic lupus (SLE) treated with hydroxychloroquine / hydroxychloroquine (Plaquenil). This medicine has been tested for prevention against coronavirus / RS-CoV-2 and Covid-19 disease. Results do not suggest that Plaquenil is effective against coronary heart disease (Boulware DR, 2020).

Symptoms

SARS, MERS and COVID-2 (covid-19 / Wuhan virus) causes the virus infection Covid-19 with symptoms such as sore throat, fever and dry cough and some notice decreased senses of smell and taste. Nasal congestion is not typical. People rarely sneeze, unlike the common cold. About 80% of those infected get a mild illness. However, has COVID-2 The virus has its own ability to attack the lungs and cause more severe symptoms such as difficulty breathing and pneumonia. If the lungs are attacked, stronger coughing and breathing complaints usually begin within a week of the first symptom.

Contamination

Coronavirus is transmitted by droplet transmission between humans. This can happen when you are in the same room with infected people or closer than 1-2 meters. The virus is contagious before the infected person notices symptoms.

The virus enters the body via mucous membranes of the mouth, nose and eyes. Contact infection by direct body contact, infected hands or via joint door handles and the like also occurs because the virus can survive for some days on such surfaces. Through the hands, the virus is transmitted to the mucous membranes.

Incubation time (the time between infection and symptoms) can be up to 14 days, but most often 4-6 days. If symptoms do not occur within 2 weeks of exposure, one has not been infected.

Detection of coronavirus

Assessment of symptoms that can be serious is usually done by a GP or emergency room. If you have been exposed to infection, you must call in advance to avoid the risk of infection spreading at attendance. Tests for corona virus are performed at separate centers in each municipality. Information can be found on the internet, for example at website for testing in Oslo,

Pregnant women with COVID-19 infection

The infection proceeds in the same way as among non-pregnant women. The risk of pneumonia is not increased, and infection between mother and fetus / child is not expected. Nevertheless, COVID-19 disease in the pregnant woman may cause unfavorable stress to the fetus and premature birth in some cases (Mascio DD, 2020).

COVID-19 vaccine

  • The vaccines that first come on the market consist of a small part of the COVID-19 virus. These fragments are not viable and can not cause viral disease. Nevertheless, our immune system strengthens so that it is prepared if it later encounters real COVID-19 viruses. 
  • Please read in general about vaccines for rheumatic disease in a separate chapter

Treatment

Avoid getting infected by not traveling to areas where infection is to be expected or large crowds. Distance between people is important. Frequent and thorough hand washing with soap and good general hygiene is recommended. Antibac and other disinfectant spirits for hands, joint door handles and the like can also be used. Infected people should use mouthwash to avoid spreading the infection. Mouth dressing can also protect against infection.

Preventive measures are especially important for people with a weakened immune system. However, people who use immunosuppressive drugs and do not have symptoms of infection should continue with their regular treatment during an epidemic to prevent the aggravation of severe rheumatic disease. If signs of infection with fever and other flu symptoms should occur, at least 1-2 weeks of treatment break with the immunosuppressive therapy may be appropriate. However, it assumes that one is not completely dependent on the treatment. Each person should seek advice from their physician for current symptoms of the viral disease. Prednisolone and other cortisone preparations should not be terminated abruptly.

Vaccines against COVID-19 are unlikely to become widely available until spring 2021 at the earliest. Antibiotics (against bacteria) do not work against viruses. Anti-viral drugs specifically for coronavirus are not available (as of March 2020).

Hydroxychloroquine (Plaquenil) and braces have not shown a safe effect.

Dexamethasoma is a type of cortisone used among hospitalized, seriously ill people with oxygen needs

Monoclonal antibodies are being tested. RAIN-cov2 is one such antibody combination

Prognosis

Usually (in about 80%) flu symptoms (sore throat, lethargy, fever and dry cough without much mucus) develop with a good prognosis. Some cases cause serious organ damage and death. With COVID-19 infection, a small proportion of those infected get severe pneumonia and pneumonia, which can be fatal in a total of 0,12% percent (one in a thousand) of those infected in Norway. Most vulnerable are people with pre-existing lung disease, diabetes, heart disease, significant obesity, high blood pressure or a weakened immune system (for example due to immunosuppressive drugs for rheumatic disease, others Autoimmune diseases or cancer). Age over 65 is also a risk factor. Mortality among infected people over the age of 80 is 4% in Norway.

The National Institute of Public Health's division into risk groups (as of August 2020)

Groups with slightly increased risk

  • Age 66–80 years (and especially from 70 years) OR
  • Age 50–65 years and one of the following chronic diseases:
    • cardiovascular disease (other than well-regulated high blood pressure)
    • obesity (body mass index (BMI) ≥ 30 in combination with weight-related diseases or BMI≥40)
    • diabetes
    • chronic kidney disease and kidney failure
    • chronic lung disease (other than well-regulated asthma)
    • chronic liver disease
    • immunosuppressive therapy such as cytotoxic drugs, radiation therapy and immunosuppressive therapy for autoimmune diseases

People under the age of 50 have a low risk of a serious course of covid-19, but some people with poorly regulated or combinations of several underlying diseases may have a higher risk.

Groups with moderate or high risk

  • Age over 80 years, OR
  • Resident in nursing home OR
  • Age 66–80 years and one of the following chronic diseases, OR age 50–65 years and two or more of the following chronic diseases:
    • cardiovascular disease (other than well-regulated high blood pressure)
    • obesity (body mass index (BMI) ≥ 30 in combination with weight-related diseases or BMI≥40)
    • diabetes
    • chronic kidney disease and kidney failure
    • chronic lung disease (other than well-regulated asthma)
    • chronic liver disease
    • immunosuppressive therapy such as chemotherapy, radiation therapy and immunosuppressive therapy for autoimmune diseases OR
  • Serious health, regardless of age *: 
    • People with active cancer, ongoing or recently discontinued treatment for cancer (especially immunosuppressive therapy, radiation therapy for the lungs or chemotherapy). Blood cancer has a higher risk than other cancers. neurological diseases or muscle diseases that cause reduced coughing force or lung function (eg ALS)
    • congenital immunodeficiency in the unstable phase that carries the risk of serious respiratory infections
    • blood diseases that include cells or organs that are important for the immune system
    • bone marrow transplant or organ transplant
    • HIV infection with low CD4 count
    • significantly impaired renal function or liver function
    • other, assessed by a physician

* The National Institute of Public Health has chosen to include some serious health conditions in the list of diseases that give a higher risk of a precautionary principle, although at present there are no studies that indicate a risk of a serious course of all diseases.

Literature: helsenorge.no pr 13.08 2020

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