COVID-19, Coronavirus and Rheumatic Disease 4.55/5 (128)

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


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 can be exposed to complications and 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).

People with Rheumatoid arthritis (arthritis) or Systemic lupus (SLE) who do not use prednisolone or similar corticosteroids do not appear to have a measurably higher risk of severe COVID-19 prognosis than others of similar age (reference: D'Silva KM, 2021; Fernandez-Ruiz R, 2021).

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 show that Plaquenil has no effect against coronary heart disease (Boulware DR, 2020).

Among children infected with Covid-19, MIS-C (multisystem inflammatory syndrome in children) is a rare complication. It is characterized by signs of serious illness with fever and signs of illness in many organs. Red, inflamed eyes, sore lips, swollen lymph nodes in the neck, rash and abdominal pain. One has previously thought that it was a part of Kawasaki syndrome, but is now perceived as a separate condition (reference: Diorio C, 2020).


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.

Course of disease

Most (approx. 80%) get a fairly mild course of the disease without the need for special treatment. The symptoms go away within 1-2 weeks.

Heavy breathing and / or chest pain is a sign of serious illness. Such symptoms usually begin 4-7 days after the first symptoms. A doctor should be contacted and hospitalization considered.

Among those who need to be hospitalized, 15-35% need intensive care, often with a respirator that requires breathing assistance. This is described as a critical disease phase with a risk of death.

Hospitalization and critical illness are most common among the elderly and in underlying diseases of the lungs and other important organs.

Late effects may include prolonged difficulty sleeping, fatigue and joint pain.


Coronavirus is transmitted mainly through 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. Thus, infected people can infect others before they even notice the disease.

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

Incubation time (the time between infection and symptoms) can be up to 14 days, but most often 4-5 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 usually proceeds in the same way as among non-pregnant women, but a slightly increased risk of hospitalization has been seen. 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

Vaccine against the COVID-19 virus and coronary heart disease are effective prevention against infection, usually with an effectiveness of 67-95%. It still carries a small risk of infection, even after full vaccination. The effect of the vaccines comes after 2-3 weeks. The vaccines are without adjuvant (a type of excipient), products from pigs or mercury. Not least for people with rheumatic disease, vaccination will prevent serious consequences of this viral disease. The vaccines that are first available 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 is strengthened so that it is prepared if it later encounters real COVID-19 viruses. 

Two vaccines BioNTech / Pfizer (Comirnaty) and Moderna's vaccine contain RNA (RNA vaccines) which are the recipe for part of the virus surface. The BioNTech / Pfizer vaccine is stored at -70 degrees, the Moderna vaccine in a standard freezer.

The AstraZeneca vaccine (Vaxzervia) and the Janssen / Johnson & Johnson vaccines have a different structure. They contain a harmless cold virus that transports the active part of the vaccine into our cells, so that the vaccine works in the body (vector vaccine). The transport virus does not multiply and dies quickly. Like the RNA vaccines, the AstraZeneca and Janssen / Johnson & Johnson vaccines are considered "dead vaccines" and can be given to people with weakened immune systems. Some deaths among healthy, younger people are nevertheless related to the AstraZeneca and Janssen / Johnson & Johnson vaccines. The causes appear to be an unusual reaction in the immune system that triggers a form of thrombotic thrombocytopenic purpura (vaccine-triggered immunological TTP). It is unknown why this occurs in some. The incidence after the AstraZeneca vaccine can be up to one case per 25.000 vaccinated and 6 cases (as of April 2021) have been detected in Norway. This side effect is seen up to 14 days after using the AstraZeneca vaccine. The AstraZeneca vaccine has therefore been taken out of use in Norway since March 2021.

Efficacy of the vaccines

The efficiency / effectiveness of the vaccines is measured by the proportion who are not infected among vaccinated people compared with the equivalent among non-vaccinated people. One can also measure antibodies in the blood to see if the immune system has responded as desired to the vaccine. BioNTech / Pfizer (Comirnaty) and the Moderna vaccine typically provide more than 90% protection against COVID-19 infection after full vaccination with two doses. The Janssen / Johnson & Johnson vaccine is given as a single dose and is reported to be effective in approx. 67%. Studies based on the measurement of antibodies suggest that people who use immunosuppressive drugs may have a reduced vaccine effect. This applies to many Systemic connective tissue diseases:, Vasculitis and severe joint disease. Drugs that may reduce the vaccine effect are Prednisone in high doses (over 10-30 mg daily over time), methotrexate and similar disease-suppressing drugs, as well Biological drugs. NSAIDs (Ibux, Voltaren and others), paracetamol and other painkillers do not affect the vaccine effect.

It is relevant for vaccinated people with suspected impaired vaccine effect to test the vaccine effect in a blood sample. SARS-CoV-2 spike antibody indicates whether the vaccine has been effective. SARS-CoV-2 nukeoprotein antibody does not knock out in vaccinated people, but detects previous infection. These antibody tests knock out weeks after vaccination or infection and are distinguished from SARS-CoV-2 RNA (PCR) test which detects current infection.

It is likely that many people with immunosuppressive therapy will need a third dose of vaccine to achieve the vaccine effect / immunity. The National Institute of Public Health has drawn up guidelines (14.09.21) for which drugs indicate that a third vaccine dose is appropriate. These include most disease-suppressing drugs used to treat inflammatory rheumatic diseases. For users of Prednisone applies to doses of more than 20mg / day over more than one month which are relatively high doses. Plaquenil (hydroxychlorokine) most commonly used in systemic lupus (SLE) reduces the immune system relatively little and is not on the list. It is each municipality that facilitates the vaccination.

The National Institute of Public Health recommends that pregnant women in the 2nd and 3rd trimesters be vaccinated. Breastfeeding can also be vaccinated. There is still a lack of experience with COVID vaccine in pregnant women in the first trimester (first 12 weeks of pregnancy). Vaccination of pregnant women with special needs may therefore be relevant (when the need exceeds the disadvantages) (National Institute of Public Health 09.09.21).

Common vaccine side effects

Common vaccine side effects include pain at the injection site and in the arm for a few days. Headaches, fatigue, nausea, chills, night sweats, fever and body aches are also not uncommon. The symptoms usually last a couple of days. If signs of side effects increase after 3-4 days from vaccination, a medical examination may be appropriate.

If you have had a COVID-19 infection, you should wait approx. 3 months of vaccination.

  • All COVID-19 vaccines (as of April 2021) are "dead vaccines" and are safe for rheumatic disease and anti-rheumatic treatment
  • The risk of recurrence of rheumatic disease or worsening after vaccination is low
  • Disease-suppressing treatment for rheumatic disease is continued during vaccination. To ensure the best vaccine effect, methotrexate and JAK inhibitors delayed 1-2 weeks and rituximab 2-4 weeks after vaccination. Also high doses of prednisolone (above 15mg / day) can also reduce the vaccine effect. Nevertheless, in some cases it may be appropriate to carry out vaccination, because some protection is likely and treatment of a serious rheumatic disease can not always be postponed.

Literature: Park KJ, March 25, 2021; ACR Recommendations March 4, 2021

Please read in general about vaccines for rheumatic disease in a separate chapter

Please read more about COVID-19 vaccines on the National Institute of Public Health's information pages


Avoid becoming infected by not traveling to areas where infection must be expected or large crowds gather. Distance between people is important. Frequent and thorough hand washing with soap and good general hygiene is recommended. Antibac and other hand sanitizer, common door handles and the like can also be used. Infected people should wear face masks so as not to spread the infection. Mouthpieces 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.

  • Antibiotics (against bacteria) do not work against viruses.
  • Hydroxychloroquine (Plaquenil) and stradesvir (a virus agent) have not shown a safe effect.
  • Dexamethasone is a type of cortisone that is used among hospitalized, seriously ill people with oxygen needs
  • Monoclonal antibodies are being tested. RAIN-cov2 is one such antibody combination
  • If the lungs are attacked, oxygen and respiratory assistance (including a respirator) in a hospital can be life-saving until the body has fought the infection.


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 develop severe pneumonia and pneumonia, which can be fatal in a total of 0,15% (1-2 per thousand) of those infected in Norway. Most vulnerable are people with known 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 has been approx. 4% in Norway before vaccination, but has since fallen significantly.

Literature: pr 05.05 2021

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