COVID risks and risks of COVID might sum up today’s post, highlighting the possible two-way street between this coronavirus pandemic and autoimmunity diseases. Two questions have arisen from the COVID 19 pandemic. First, who is at risk? Second, after the infection is over what problems are left behind? Autoimmunity, or the condition where our bodies attack themselves finds itself in the hot seat for both of these critical questions.
We have an epidemic of autoimmunity in our nation as more and more patients develop various autoimmune conditions where their immune systems turn on some tissue and start causing destruction. Lupus, type 1 diabetes, rheumatoid arthritis, and Hashimoto’s thyroid disease top the lists, but dozens exist affecting millions. We know that genetic and environmental factors play a role, but our understanding is far from complete in what causes each patient’s disease nor in treating the sufferers. Most of our conventional therapies address either symptoms or damage control. Only functional medicine really strives to find and treat root causes. We do have significant success for many when we uncover toxins, infections, or food triggers as a root cause.
With COVID19’s rapid pace and clear preference for harming some and not others, the question of who is at higher risk for the infection and the complications quickly arose. The elderly and the chronically ill were obvious targets from early in the pandemic. Then medicine began asking which chronic conditions were the biggest targets. The CDC keeps an up to date list of high-risk conditions as noted as the end. This includes those with a suppressed immune system which may or may not apply to those with autoimmunity. If the autoimmune patient is taking an immune suppressing medication, they may fall into that category. However, if they are not, their immune system may handle the virus quite well unless another chronic illness hinders the immune defense work. Despite the increased risk of COVID, one should not stop their immune modulating medications without a risk-benefit discussion with their prescribing doctor.
There do appear a few specific autoimmune conditions which confer a higher rate of COVID 19 morbidity and mortality as noted here:
Lupus
Autoimmune hepatitis
Multiple Sclerosis
Myasthenia Gravis
Guillain-Barre syndrome
Rheumatoid Arthritis
Scleroderma
Sjogren’s
Idiopathic pulmonary fibrosis
Dressler’s syndrome
Autoimmune Myocarditis
As the pandemic continues, the second question arises regarding whether or not this virus will contribute to the rising incidence of autoimmune disease. The spectre of COVID “long-haulers” haunts us as we hear of more and more COVID patients having long term symptoms of their disease. We also know that other viruses are known to trigger autoimmune conditions. A list of citations for those viruses is at the end. They include: Epstein-Barr-virus, Parvovirus B19, Human Herpes Virus 6, Hepatitis A, Hepatitis C, Cytomegalovirus (CMV), and HTLV-1. As noted in Ehrenfeld et al they have been implicated in a number of autoimmune conditions: “rheumatoid arthritis, systemic lupus erythematosus, Sjogren’s syndrome, primary biliary cholangitis, multiple sclerosis, polymoysitis, uveitis, Henoch Schonlein Purpura, Systemic Juvenile Idiopathic arthritis, systemic sclerosis, Hashimoto thyroiditis and autoimmune hepatitis”
For COVID itself we have a number of reports hinting at a possible connection between COVID and autoimmune disease development. A case series by Silber et al in July reviewed neurological complications of 43 COVID patients. They found 12 cases of brain inflammation including 9 cases of acute disseminated encephalomyelitis (ADEM). They also had 8 cases of Guillain-Barre syndrome, a paralytic condition known to occur after other infections. For the ADEM patients, the virus was not found in the cerebrospinal fluid and is presumed to be an aberrant immune response causing the disease.
Gao et al looks at the possibility that COVID 19 could trigger autoimmune conditions like the other viruses. The virus does raise levels of multiple cytokines which are pro-inflammatory. The study by Zhou Y and colleagues demonstrated that the rates of some autoantibodies where higher in some COVID 19 patients. Case et al described the similarities between radiologic lung finding in COVID 19 patients and autoimmune diseases.
We obviously need further research to confirm the answers to both of these questions so that we can know how to respond to both of these patient’s needs. For those already suffering from autoimmune conditions, do they need changes to their care in order to prevent COVID 19 infection? For those who get COVID 19, can we prevent or treat a resulting autoimmune condition? One final question arises from the combination of the first two: Do those with autoimmune conditions have a higher risk for developing another autoimmune disease? We don’t yet know. In the meantime, functional MD’s like myself will continue to work at root causes and integrative therapies to help our patients live healthier more abundant lives by overcoming COVID and its complications using the same successful tools we do for other infectious and autoimmune conditions.
Studies on the risks of COVID 19 in Autoimmune Conditions:
Emmi, Giacomo et al. “SARS-CoV-2 infection among patients with systemic autoimmune diseases.” Autoimmunity reviews vol. 19,7 (2020): 102575. doi:10.1016/j.autrev.2020.102575
Zingone, Fabiana et al. “Risk of COVID-19 in celiac disease patients.” Autoimmunity reviews vol. 19,10 (2020): 102639. doi:10.1016/j.autrev.2020.102639
Onder, Graziano et al. “Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy.” JAMA vol. 323,18 (2020): 1775-1776. doi:10.1001/jama.2020.4683
Figueroa-Parra, Gabriel et al. “Are my patients with rheumatic diseases at higher risk of COVID-19?.” Annals of the rheumatic diseases vol. 79,6 (2020): 839-840. doi:10.1136/annrheumdis-2020-217322
Sarzi-Puttini, Piercarlo et al. “How to handle patients with autoimmune rheumatic and inflammatory bowel diseases in the COVID-19 era: An expert opinion.” Autoimmunity reviews vol. 19,7 (2020): 102574. doi:10.1016/j.autrev.2020.102574
Pablos, Jose L et al. “Prevalence of hospital PCR-confirmed COVID-19 cases in patients with chronic inflammatory and autoimmune rheumatic diseases.” Annals of the rheumatic diseases vol. 79,9 (2020): 1170-1173. doi:10.1136/annrheumdis-2020-217763
Montero, Fernando et al. “Coronavirus disease 2019 (COVID-19) in autoimmune and inflammatory conditions: clinical characteristics of poor outcomes.” Rheumatology international vol. 40,10 (2020): 1593-1598. doi:10.1007/s00296-020-04676-4
Liu, Ming et al. “The association between severe or dead COVID-19 and autoimmune diseases: A systematic review and meta-analysis.” The Journal of infection vol. 81,3 (2020): e93-e95. doi:10.1016/j.jinf.2020.05.065
Grange, Lucile et al. “Challenges of autoimmune rheumatic disease treatment during the COVID-19 pandemic: A review.” Therapie vol. 75,4 (2020): 335-342. doi:10.1016/j.therap.2020.06.013
Post COVID disease:
Galeotti, Caroline, and Jagadeesh Bayry. “Autoimmune and inflammatory diseases following COVID-19.” Nature reviews. Rheumatology vol. 16,8 (2020): 413-414. doi:10.1038/s41584-020-0448-7
Cañas, Carlos A. “The triggering of post-COVID-19 autoimmunity phenomena could be associated with both transient immunosuppression and an inappropriate form of immune reconstitution in susceptible individuals.” Medical hypotheses, vol. 145 110345. 14 Oct. 2020,
Talotta, Rossella, and Erle Robertson. “Autoimmunity as the comet tail of COVID-19 pandemic.” World journal of clinical cases vol. 8,17 (2020): 3621-3644. doi:10.12998/wjcc.v8.i17.3621
Shah, Sanket et al. “Autoimmune and rheumatic musculoskeletal diseases as a consequence of SARS-CoV-2 infection and its treatment.” Rheumatology international vol. 40,10 (2020): 1539-1554. doi:10.1007/s00296-020-04639-9
Gao, Zhao-Wei et al. “The correlation between SARS-CoV-2 infection and rheumatic disease.” Autoimmunity reviews vol. 19,7 (2020): 102557. doi:10.1016/j.autrev.2020.102557
Ross W Paterson, Rachel L Brown, Laura Benjamin, Ross Nortley, Sarah Wiethoff, Tehmina Bharucha, Dipa L Jayaseelan, Guru Kumar, Rhian E Raftopoulos, Laura Zambreanu, Vinojini Vivekanandam, Anthony Khoo, Ruth Geraldes, Krishna Chinthapalli, Elena Boyd, Hatice Tuzlali, Gary Price, Gerry Christofi, Jasper Morrow, Patricia McNamara, Benjamin McLoughlin, Soon Tjin Lim, Puja R Mehta, Viva Levee, Stephen Keddie, Wisdom Yong, S Anand Trip, Alexander J M Foulkes, Gary Hotton, Thomas D Miller, Alex D Everitt, Christopher Carswell, Nicholas W S Davies, Michael Yoong, David Attwell, Jemeen Sreedharan, Eli Silber, Jonathan M Schott, Arvind Chandratheva, Richard J Perry, Robert Simister, Anna Checkley, Nicky Longley, Simon F Farmer, Francesco Carletti, Catherine Houlihan, Maria Thom, Michael P Lunn, Jennifer Spillane, Robin Howard, Angela Vincent, David J Werring, Chandrashekar Hoskote, Hans Rolf Jäger, Hadi Manji, Michael S Zandi, for the UCL Queen Square National Hospital for Neurology and Neurosurgery COVID-19 Study Group, The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings, Brain, Volume 143, Issue 10, October 2020, Pages 3104–3120, https://doi.org/10.1093/brain/awaa240
Ehrenfeld, Michael et al. “Covid-19 and autoimmunity.” Autoimmunity reviews vol. 19,8 (2020): 102597. doi:10.1016/j.autrev.2020.102597
Zhou, Yaqing et al. “Clinical and Autoimmune Characteristics of Severe and Critical Cases of COVID-19.” Clinical and translational science, 10.1111/cts.12805. 21 Apr. 2020, doi:10.1111/cts.12805
Caso F., Costa L., Ruscitti P., Navarini L., Del Puente A., Giacomelli R. Could Sars-coronavirus-2 trigger autoimmune and/or autoinflammatory mechanisms in genetically predisposed subjects? Autoimmun. Rev. 2020;19(5):102524. doi: 10.1016/j.autrev.2020.102524.
CDC list of high risk conditions
Other Virus’s Associated with Autoimmune Disease:
Barzilai O., Ram M., Shoenfeld Y. Viral infection can induce the production of autoantibodies. Curr Opin Rheumatol. 2007;19:636–643.
Watad A., Amital H., Shoenfeld Y. The environment in autoimmune diseases. Harefuah. 2015;154:308–311
Barzilai O., Sherer Y., Ram M. Epstein–Barr virus and cytomegalovirus in autoimmune diseases are they truly notorious? A preliminary report. Ann N Y Acad Sci. 2007;1108:567–577.
Ram M., Gershwin M.E., Shoenfeld Y. Hepatitis B virus (HBV) and autoimmune disease. Clin Rev Allergy Immunol. 2008;34:85–102.
Pablobic M., Kats A., Carvall M., Shoenfeld Y. Clinical and molecular evidence for association of SLE with parvovirus B19. Lupus. 2010;19:783–792.
Li Sakkas, Bogdanos D.P. Infections as a cause of autoimmune rheumatic diseases. Auto Immun Highlights. 2016;7:13.
Shoenfeld Y., Selmi C., Zimlichman E., Gershwin M.E. The autoimmunologist: geoepidemiology, a new center of gravity, and prime time for autoimmunity. J Autoimmun. 2008;31:425–430.
Sanctuary Functional Medicine, under the direction of Dr Eric Potter, IFMCP MD, provides functional medicine services to Nashville, Middle Tennessee and beyond. We frequently treat patients from Kentucky, Alabama, Mississippi, Georgia, Ohio, Indiana, and more... offering the hope of healthier more abundant lives to those with chronic illness.
