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Clinical characteristics and outcomes in patients with COVID‐19 and leprosy

2020; Wiley; Volume: 35; Issue: 1 Linguagem: Inglês

10.1111/jdv.16899

1468-3083

Victor Santana Santos, Lucindo José Quintans‐Júnior, W. S. Barboza, Adriano Antunes de Souza Araújo, Paulo Ricardo Martins‐Filho,

Dermatological and COVID-19 studies

The emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly infectious virus that causes coronavirus disease 2019 (COVID-19), has raised important questions about the target groups at risk of illness and/or death.1 COVID-19 mortality has been higher in men, older people, unassisted by health systems and those having non-communicable disease.1, 2 However, information is still lacking on how COVID-19 can affect people with infectious disease. Herein, we described the clinical features and outcomes in patients with COVID-19 and leprosy in an endemic area in Brazil. This was a surveillance study of all cases of COVID-19 in individuals with leprosy who were hospitalized in Aracaju, Sergipe state, from 17 March to 30 June 2020. Aracaju has a population of 571 149 people, is considered an endemic area for leprosy (~15.0 newly cases per 100 000 inhabitants annually),3 and as of 30 June 2020, 14 814 cases of COVID-19 and 286 deaths were registered.4 Data were obtained from two public domain information systems. Data on COVID-19 were obtained from the surveillance system of the Health Bureau of Aracaju, and information on leprosy cases was obtained from the National System of Notifiable Diseases. To identify which cases of COVID-19 could be co-infected with leprosy, we link the two databases using the RecLink III software. The information retrieved included age, sex, World Health Organization (WHO) leprosy classification, clinical presentation, presence of leprosy reactions and WHO grade disability. The findings were reported descriptively. A total of 378 leprosy cases were under treatment until June 2020. Of these, four (1%) were diagnosed with COVID-19 and hospitalized. Table 1 shows the individual characteristics of the patients. The age of the individuals varied from 39 to 87 years old. Two were men and two women. All individuals were multibacillary (MB) leprosy, with three presenting the lepromatous clinical form and one the borderline-lepromatous form. None of the individuals had a leprosy reaction, and one of them had grade 2 disability. Three of the four co-infected patients had some other co-morbidity, including hypertension, diabetes and smoking. Length of hospital stay ranged from 1 to 27 days. All co-infected patients died. This study describes the clinical characteristics and outcomes in patients with COVID-19 and leprosy. All co-infected patients died, and they had the lepromatous form. The dysregulated immune response in severe individuals with COVID-19 seems to be associated with a cytokine storm. Increased cytokine levels, especially IL-6, have been associated with lymphopenia and decreasing CD4+ and CD8+ cell counts, and severe lung injury.5 Leprosy represents a multifactorial complex disease model in which the bacillus also modulates the behaviour of the host immune response. There is a predominance of a T helper (Th) 2 response in the lepromatous form, which induces the production of IL-4, IL-10 and TGF-β that inactivate the microbicidal response of macrophages and a high production of TNF-α and IL-6 that contribute to worse disease progression.6 This study has limitations. Few COVID-19 and leprosy co-infected cases were identified, which has limited our ability to establish the causality between severity of SARS-CoV-2 infection, different forms of leprosy and mortality. However, the outcome of death in leprosy patients with lepromatous form poses a new challenge to dermatologists and leprologists who are dedicated to the care of these patients, as well as to physicians working in the emergency and intensive care services. With the sharp increase in the number of SARS-CoV-2 infections, the number of people affected by leprosy with COVID-19 is also likely to be high, especially in endemic areas. Further studies are needed to establish the real risk of severe illness and death due to COVID-19 in leprosy patients. We thank the Health Bureau of Aracaju, Sergipe, for making the databases available. None. None. Dr Santos and Dr Martins-Filho had full access to all of the data in the study, take responsibility for the integrity of the data and their accuracy, involved in concept and design, and contributed to drafting of the manuscript. Santos, Martins-Filho and Barboza contributed to acquisition, analysis or interpretation of data. Barboza, Quintans-Júnior and Araújo contributed to administrative, technical or material support. Quintans-Júnior, Araújo and Martins-Filho contributed to critical revision of the manuscript for important intellectual content. This study was approved by the Research Ethics Committee of the Federal University of Sergipe (CAAE No. 33095120.4.0000.5546) and following the Helsinki Declaration.