Background/Purpose: To study the effect of SARS-CoV2 infection on disease flares in patients with systemic lupus erythematosus (SLE).

Methods: Patients who fulfilled the ACR or SLICC criteria for SLE and were followed in our rheumatology clinics were retrospectively studied. We identified patients who had documented COVID-19 (Omicron and its variants) between February and November 2022 and a group of SLE controls who did not have COVID-19 randomly matched for age, sex, and the time period of COVID-19 in a 1:2 ratio. The primary outcomes of interest were SLE flares (clinical or serological) within 90 days of SARS-CoV2 infection.SLE flares were assessed by the SELENA flare instruments, with modifications (mild/moderate or severe). The rates of SLE flares were compared between SARS-CoV2-infected SLE patients and controls.

Results: 91 SLE patients with COVID-19 (age 48.6±14.0 years; 95.6% women; SLE duration 14.2±8.3 years; 53% history of lupus nephritis) and 182 SLE controls not infected by COVID-19 (age 48.7±13.8 years; 95.6% women; SLE duration 15.2±9.0 years) were studied. Eleven of 90 (12.2%) SARS-CoV2-infected patients had serious manifestations (oxygen requirement, use of mechanical ventilator, lung infiltrates on imaging studies or admission to the intensive care unit). Patients with mild COVID-19 were treated symptomatically or oral anti-viral agents whereas those with serious COVID-19 was treated with intravenous remdesivir, dexamethasone, and/or biologic/targeted agents. One (1.1%) of our patients died and 7(7.7%) patients developed severe complications. Within 90 days of SARS-CoV2 infection, 14 (15.4%) patients developed mild/moderate SLE flares, and 2 (2.2%) patients had severe SLE flares. The incidence of SLE flares in SARS-CoV2-infected patients was significantly higher than those without (17.6% vs. 5.5%; p=0.001). The changes in anti-dsDNA and complement C3 levels, however, were not significantly different between the two groups. Among SARS-CoV2-infected SLE patients, those with clinical SLE flares had significantly lower C3 values (p=0.004) but non-significantly higher anti-dsDNA titer (p=0.32) before SARS-CoV2 infection than those without SLE flares. Herpes zoster (HZ) reactivation occurred in 2 patients (2.2%) with COVID-19, which was numerically higher than those not infected by COVID-19 (2 patients, 1.1%; p=0.48). No particular risk factors were identified for HZ reactivation after COVID-19 infection.

Conclusion: In this retrospective case-control study, clinical flares within 90 days were significantly more common in patients infected with SARS-CoV2 than age and gender-matched non-infected SLE controls.SLE patients with lower C3 levels were more likely to flare after COVID-19. The results from our study support the hypothesis for a viral trigger for disease exacerbation in SLE.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/effect-of-sars-cov2-infection-on-disease-flares-in-patients-with-systemic-lupus-erythematosus-a-case-control-study/