‘Very little evidence’ that COVID-19 alters course of rheumatic, autoimmune diseases
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SAN DIEGO — Although a flood of COVID-19 and long COVID research continues to emerge, concerns may be limited for rheumatologists, according to a speaker at the 2024 Congress of Clinical Rheumatology West.
“There is very little evidence that COVID-19 alters the natural history of our rheumatic diseases,” Leonard Calabrese, DO, RJ Fasenmyer chair of clinical immunology at the Cleveland Clinic, and chief medical editor of Healio Rheumatology, told attendees.
Although patients on B-cell depleting therapies may be at risk for complications associated with acute COVID-19, antivirals are available to manage this issue, he said.
However, preexposure prophylaxis of COVID-19 is a different story.
“The FDA needs to get some sanity and approve these agents in rapid fire,” Calabrese said.
Meanwhile, although experts, including Calabrese, have invested significant time in attempting to define the associations between long COVID and rheumatic and autoimmune diseases, they have been unable to draw conclusions.
“Whether incident inflammatory diseases occur as a sequelae of long COVID is far from clear,” Calabrese said. “There is no compelling evidence that they are palpably increased in incidence because of this.”
According to Calabrese, the relationship between autoimmunity and viral infections is complicated and often “far from clear.”
Regarding self-limiting viruses and their associations with viral arthritis, Calabrese noted that the aches and pains from influenza go away when the virus is cleared.
“They are non-erosive and non-destructive,” he said.
However, parvovirus B19 has recently begun to proliferate, according to Calabrese.
“We are in a major wave of B19 infection in the United States,” he said. “It occurs in two flavors — one in children and one in adults.”
Although musculoskeletal complaints are rare in children, adults experience these complications in as many as half of cases.
“It is non-erosive but quite painful,” Calabrese said, noting that the condition is marked by “early morning stiffness.”
Rheumatologists may also have to manage patients with musculoskeletal signs and symptoms of chikungunya virus, particularly in those who have traveled to places where that pathogen is endemic.
“Some of these patients can be quite debilitated,” Calabrese said. “A subgroup has something that looks like rheumatoid arthritis, but we do not understand the precise relationship.”
Although “supportive care” and “non-steroidals” should be used to treat this condition, low-dose prednisone may also be effective, according to Calabrese.
Turning to chronic persistent viral infections, Calabrese noted that HIV, hepatitis B virus and hepatitis C virus are all “de-accelerating” for the first time in decades.
“We can now send HCV patients to a hepatologist, get them on direct-acting antivirals and in 6 weeks they are cured,” he said. “That is quite a thing to be able to say.”
Although joint manifestations in HBV are rare, reactivation of HBV during immunosuppressive therapy to treat a rheumatic or autoimmune disease may occur.
“If you are going to immunosuppress a patient, screen them for hepatitis B,” Calabrese said. “Have a good relationship with a hepatologist or gastroenterologist who is facile with using these drugs and you will stay out of trouble.”
Meanwhile, reactive arthritis or a papulosquamous rash may occur in individuals with HIV, according to Calabrese.
“Treat with DMARDs and they do well,” he said.
Regarding latent viral infections, age is the major risk factor for zoster, according to Calabrese. He stressed that immunocompromised patients should be vaccinated for this infection.
“We have a vaccine that is highly effective,” he said. “How you define immunocompromised is up to you but we strongly recommend this.”
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Calabrese L. Viral Infections in Rheumatic Disease 2024: Etiology, Management and Prevention. Presented at The Congress of Clinical Rheumatology West; Sept. 26-29, 2024. (hybrid meeting).
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