Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Allied Health Professionals’ Corner
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Commentary : Patient’s Voice
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guideline
Guidelines
Image in Nephrology
Images in Nephrology
In-depth Review
Letter to Editor
Letter to the Editor
Letter to the Editor – Authors’ reply
Letters to Editor
Literature Review
Nephrology in India
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Allied Health Professionals’ Corner
Author Reply
Book Review
Brief Communication
Case Report
Case Series
Clinical Case Report
Clinicopathological Conference
Commentary
Commentary : Patient’s Voice
Corrigendum
Editorial
Editorial – World Kidney Day 2016
Editorial Commentary
Erratum
Foreward
Guideline
Guidelines
Image in Nephrology
Images in Nephrology
In-depth Review
Letter to Editor
Letter to the Editor
Letter to the Editor – Authors’ reply
Letters to Editor
Literature Review
Nephrology in India
Notice of Retraction
Obituary
Original Article
Perspective
Research Letter
Retraction Notice
Review
Review Article
Short Review
Special Article
Special Feature
Special Feature - World Kidney Day
Systematic Review
Technical Note
Varia
View/Download PDF

Translate this page into:

Letter To Editor
32 (
4
); 396-397
doi:
10.4103/ijn.ijn_375_21

Onset of Remission Following COVID-19 Infection in a Patient with Refractory Lupus Nephritis

Department of Nephrology, Trichy SRM Medical college Hospital (formerly known as Chennai Medical College Hospital and Research Center), Irungalur, Chennai - Trichy Highway, Tamil Nadu, India
Department of Nephrology, Sundaram Hospital, 17, EVR Road, Puthur, Trichy, Tamil Nadu, India

Address for correspondence: Dr. Subrahmanian Sathiavageesan, Department of Nephrology, Sundaram Hospital, 17, EVR Road, Puthur, Trichy - 620 017, Tamil Nadu, India. E-mail: spssubrahmanian@yahoo.co.in

Licence

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.

Dear Sir,

The COVID-19 pandemic has raised several concerns for patients with systemic lupus erythematosus (SLE). Data from the COVID-19 Global Rheumatology Alliance registry indicate that intake of prednisolone ≥10 mg/day is associated with a higher odds of hospitalization for COVID-19 − affected rheumatic patients.[1] There are reports connecting SLE flare with COVID-19[2] and of de novo diagnosis of SLE following COVID-19.[3] Host's ability to mount antiviral response with attendant viral clearance, duration of viral shedding, and antibody response in the background of immunosuppression are other major concerns. While there are previous reports of SLE flare following COVID-19, we report quiescence of SLE activity in a patient with refractory lupus nephritis and central nervous system involvement following COVID-19.

A 21-year-old lady presented with Class IV lupus nephritis in May 2020. Mycofenolate was excluded due to severe gastrointestinal intolerance, and lupus nephritis was refractory to cyclophosphamide induction and culminated in crescentic glomerulonephritis in March 2021, necessitating temporary hemodialysis. She then manifested leukopenia and central nervous system symptoms like persistent headache and status epilepticus. Rituximab (2 g total) and four sessions of plasmapheresis were instituted. Her renal function improved and she became dialysis independent; her serum creatinine stabilized at 2.3 mg/dl. However, headache, leukopenia, and hypocomplementemia persisted even after rituximab and plasmapheresis. The SLE disease activity index year 2000 (SLEDAI 2K) score following plasmapheresis and rituximab remained high at 37, indicating active SLE. In April 2021, she developed fever and was diagnosed with COVID-19 based on reverse transcription-polymerase chain reaction (RT-PCR) testing. She was hospitalized and treated with remdesivir, thromboprophylaxis, and dexamethasone; she recovered well from COVID-19 after a mild illness that lasted for 2 weeks. While recovering from COVID-19, the patient had complete resolution of headache, normalization of serum complement level, resolution of leukopenia and erythrocyturia, and the SLEDAI 2K score declined to 4 [Table 1]. She continued to be in remission till the last follow-up in August 2021. She had residual subnephrotic proteinuria and low estimated glomerular filtration rate (eGFR) that could be ascribed to fibrous crescents in biopsy. On day 30 following COVID-19 onset, nasopharyngeal swab RT-PCR tested negative, while antibody to spike antigen remained undetectable.

Table 1 Clinical course of SLE and COVID-19 on a timescale
Month 1 2 3 4 5 6 7 8 9 10 11 12 13-16
Ailment SLE, class IV LN, active lupus with worsening proteinuria, lupus headache, skin rash, MMF-induced hemorrhagic gastritis, steroid-induced diabetes mellitus, diabetic ketoacidosis, hypertension Renal flare, leukopenia Status epilepticus, lupus head ache COVID-19 (Mild), AKI SLE remission
Urine PCR g/g 1.3 1.2 2.0 2.7 3.6 4.5 4.8 5.2 3.7 0.5
Urine erythrocytes 3+ 3+ 2+ 3+ 3+ 2+ 3+ 3+ 1+ Nil
Creatinine mg/dl 1.0 0.8 0.7 0.6 0.8 0.8 0.8 0.7 1.0 1.8 6.7 2.3-3.7 1.8
eGFR ml/min/1.73 m2 80.5 105 124 130 105 105 105 124 80.5 39.5 8.1 28.4-16.5 39.5
Kidney biopsy Class IV LN TMA crescent-fibrous & cellular
WBC count Cells/mm3 14,000 12,100 15,000 13,300 7800 10,600 5780 6500 4800 2500 2100 13,700 11,600
C3 mg/dl 56 64 48 100
C4 mg/dl 5 8 2 28
SLEDAI 2K 30 37 4
Treatment MMF
PDN
Monthly Intravenous cyclophosphamide – 750 mg×7 doses
PDN 30 mg/day to 15 mg/day
Hydroxychloroquine
Hemodialysis
Rituximab 2 g total
Apheresis four sessions
Dexamethasone Remdesivir, anticoagulant PDN 10 mg/day

AKI = acute kidney injury, C3 and C4 = complement components, eGFR = estimated glomerular filtration rate expressed as ml/min/1.73 m2, LN = lupus nephritis, MMF = mycofenolate mofetil, PCR = protein creatinine ratio, PDN = prednisolone, SLE = systemic lupus erythematosus, SLEDAI 2K = SLE disease activity index year 2000, TMA = thrombotic microangiopathy, WBC = white blood cells

This patient had active lupus with renal, hematologic and central nervous system involvement that defied intense immunosuppression including rituximab and plasmapheresis. She entered into remission following COVID-19 illness. Since this patient had received intense immunosuppressant therapy including rituximab and plasmapheresis just preceding COVID-19, it cannot be argued that COVID-19 and the onset of SLE remission are connected. However, it is evident that SLE did not flare after COVID-19 and that there is scope for remission of SLE following COVID-19.

Comorbidities like diabetes, hypertension, and obesity are determinants of adverse outcomes with COVID-19 in rheumatic patients, similar to those in the general population.[4] Patients with rheumatic disease and COVID-19 could be at a higher risk of requiring mechanical ventilation and admission to intensive care unit compared to patients not having rheumatic disease.[5] Glucocorticoid use for rheumatic disease has been found to be associated with hospitalization for COVID-19.[6] This patient had several risk factors for adverse outcome, including diabetes mellitus, hypertension, and prednisolone intake >10 mg/day. However, she had a mild COVID-19 without any hypoxia or necessity for admission to intensive care unit. The United States Food and Drug Administration has approved remdesivir for all hospitalized patients irrespective of the severity of COVID-19 illness, and this patient received a 5-day course of remdesivir since she had several risk factors for adverse outcome. She made a good recovery from COVID-19. Heightened interferon activity in the context of active lupus is postulated to exert a protective antiviral effect.[7] The patient had prolonged viral shedding and blunted antibody response to COVID-19, which could be explained by the background immunosuppression.

While there is a concern that SLE could flare following COVID-19, this case highlights that there could be remission of disease activity following COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , , , , , . Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: Data from the COVID-19 global rheumatology alliance physician-reported registry. Ann Rheum Dis. 2020;79:859-66.
    [Google Scholar]
  2. , , , , . A case of systemic lupus erythematosus flare triggered by severe coronavirus disease 2019. J Clin Rheumatol. 2020;26:234-5.
    [Google Scholar]
  3. , , , , . Concomitant new diagnosis of systemic lupus erythematosus and COVID-19 with possible antiphospholipid syndrome. Just a coincidence? A case report and review of intertwining pathophysiology. Clin Rheumatol. 2020;39:2811-5.
    [Google Scholar]
  4. , , , . COVID-19 in patients with systemic lupus erythematosus: Lessons learned from the inflammatory disease. Transl Res. 2021;232:13-36.
    [Google Scholar]
  5. , , , , , , . Clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and rheumatic disease: A comparative cohort study from a US 'hot spot' Ann Rheum Dis. 2020;79:1156-62.
    [Google Scholar]
  6. , , , , , , . Coronavirus disease 2019 (COVID-19) in autoimmune and inflammatory conditions: Clinical characteristics of poor outcomes. Rheumatol Int. 2020;40:1593-8.
    [Google Scholar]
  7. , . Interferon alpha as a primary pathogenic factor in human lupus. J Interferon Cytokine Res. 2011;31:887-92.
    [Google Scholar]
Show Sections