Patients With Systemic Lupus Erythematosus and COVID-19 Had Higher Risk of Death and Worse Outcomes


Results show a significantly higher risk of death and combined poor outcomes compared with patients without lupus and both with and without other comorbidities.

Patients with systemic lupus erythematosus (SLE) who developed COVID-19 were more likely to have worse outcomes and higher risks of death when compared with other patients, according to a study published in Rheumatology.1

“COVID-19 raised particular concern for people with autoimmune rheumatic diseases, particularly those with systemic lupus erythematosus (SLE), because of the known increased susceptibility to infections. Underlying this susceptibility is the chronic inflammatory autoimmune dysregulation of the disease and the use of immunosuppressive medications.”

Acute respiratory distress syndrome (ARDS) triggered by COVID-19 is especially concerning for patients with SLE. ARDS presents as flu-like symptoms in addition to respiratory discomfort, chest pressure, bluish color of the lips or face, and desaturation less than 95% room air.

This nationwide, cross-sectional study analyzed patients within the national Influenza Epidemiological Surveillance Information System and included 319 patients with SLE and 251,800 patients without an SLE diagnosis.

The primary aim was to determine the risk of death, intensive care unit (ICU) admission, mechanical ventilation (MV), and relative risks (RRs) in hospitalized patients with SLE and ARDS due to COVID-19. These results were then compared to patients without SLE and adjusted for factors such as age, sex, location, and comorbidities including diabetes mellitus, heart disease, lung disease, neurological disease, obesity, pregnancy, and oncological disease. The region of Brazil in which this study examined was also listed as a potential confounder. To control these variables, an adjustment instrument was utilized.

Logistic regression models were used for each comorbidity and demographic variable. A secondary analysis assessed exposure risk scores using the confounder summary score matching method.

A total of 607,326 cases of ARDS were reported in Brazil from January 1 to August 17, 2020, of which 51.4% (312,419) were directly related to COVID-19. Patients in the positive real-time reverse transcription-polymerase chain reaction (RR-PCR) cohort with SLE skewed younger (45.5 ± 16.5 years vs. 58.7 ± 18.9 years, P < 0.0001) when compared with patients without SLE. Additionally, ICU admission and MV use was more frequent in this patient population (132 [41.4%] vs. 77 572 [30.8%], P < 0.001, and 83 [26%] vs. 44 028 [17.5%], P < 0.001, respectively). After adjustment, the rate of death and poor outcomes was also significantly higher in patients with SLE when compared with patients without SLE (RR = 1.738 [95% CI: 1.557-1.914] and RR = 1.391 [95% CI: 1.282-1.492], respectively).

For all comorbidities examined, SLE was the highest contributing factor to poor outcomes and mortality, with SLE increasing the risk for mortality 2.21-fold (95% CI: 1.178-2.633).

Symptoms such as dyspnea (240 [75.2%] vs. 172 859 [68.6%], P = 0.013), oxygen desaturation (188 [58.9%] vs. 139 003 [55.2%], P = 0.016), and vomiting (39 [12.2%] vs. 19 653 [7.8%], P = 0.016) were more prevalent in the SLE patient population. Across all participants, cough, fever, and dyspnea were the most common symptoms.

The study design limits the analysis to predefined covariates that were available in the data set. Investigators included accuracy of information in the analysis as a confounding factor. RT-PCR sensitivity may have also played a role in decreasing the number of reported cases, therefore reducing the number of patients analyzed. Additionally, SLE classification, disease activity, and immunosuppressive treatments were not accounted for.

“This is the first study to evaluate the prognosis of COVID-19 due to ARDS in a large hospitalized SLE population and clearly show a significantly higher risk of death and combined poor outcomes compared with patients without lupus and without comorbidities and with other comorbidities,” investigators concluded. “This is an important alert to those caring for patients with SLE, and it is an additional reinforcement of the importance of preventive measures, such as vaccines, during a pandemic for this population.”


Bertoglio IM, Valim JML, Daffre D, et al. Poor Prognosis of COVID-19 Acute Respiratory Distress Syndrome in Lupus Erythematosus: Nationwide Cross-Sectional Population Study Of 252 119 Patients [published online ahead of print, 2021 Aug 23]. ACR Open Rheumatol. 2021;10.1002/acr2.11329. doi:10.1002/acr2.11329

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