Health Outcomes of Multiple Sclerosis Patients with COVID-19

May 25, 2020 by Sam Bazzi

This week, I would like to focus on a topic that our lab has been interested in understanding for a long time, which is the health outcomes of multiple sclerosis (MS) patients with COVID-19. There have been primarily two published papers that discuss this topic and I will summarize the findings from one paper that came out earlier this week on MedRxive.

Parrotta and colleagues, from NYU Langone Multiple Sclerosis Comprehensive Care Centers (MSCCC), applied descriptive statistics to summarize demographic and clinical characteristics of MS patients or patients with similar autoimmune disorders that have been diagnosed with COVID-19 in order to better understand how COVID-19 affects health outcomes in patients with autoimmune disorders. Patients were recruited into this study after admission to the hospital with COVID-19 symptoms, or after describing symptoms of COVID-19 during teleneurology appointments.

76 total patients met the inclusion criteria, with 72 having MS and the other 4 having related disorders such as neuromyelitis optica spectrum disorder (NMOSD), chronic-relapsing-inflammatory-optic-neuropathy (CRION), neurosarcoidosis, and myelin-oligodendrocyte-glyocoprotein-IgG-associated disorder (MOGAD). The average age of enrolled patients was 44.9 years old, with 61.8% being female, which is typical for autoimmune disorders. 55 of the patients (76.4%) had relapsing-remitting MS (RRMS) while 17 (23.6%) had primary- or secondary-progressive MS (PPMS/SPMS). The most common symptoms seen in these patients were fever, cough, fatigue, shortness of breath, myalgia/arthralgia, anosmia, ageusia, and headache, which are all typical symptoms of COVID-19. More pertinent to autoimmune disorders, 21.1% reported neurologic symptom re-crudescence, which is suggestive of a pseudo-relapse. In some of these pseudo-relapses, the neurologic symptoms preceded the viral symptoms by a few days, which suggests that the virus may be mediating neurologic symptoms in patients with existing neurological autoimmune conditions during the incubation period ahead of actual viral syndrome.

84% of patients were on disease-modifying therapies (DMT). 44.7% of these patients were on anti-CD20 therapies such as rituximab and ocrelizumab, 13.5% were on sphingosine-1-phosphate modulations such fingolimod and siponimod, 7.9% were on glatiramer acetate (Copaxone), 5.3% were on natalizumab, 5.3% were on dimethyl fumarate, and 3.9% were on beta-interferons. The authors found that there were no significant differences between DMT use among patients who were either hospitalized or not hospitalized. Additionally, they did not find a statistical difference between hospitalization rates in patients taking or not taking anti-CD20 therapies, which is important because this has been a concern for some time since B-cell depletion may be a worrisome side effect of these drugs in patients who are battling an infectious respiratory virus.

18 of 76 patients were hospitalized (23.7%). Hospitalized patients were more likely to be older, have PPMS/SPMS, be less ambulatory, have comorbid obesity, have coronary artery disease, and have a history of venous thromboembolism. Eight patients had critical illness as defined by ICU admission or death. Like the hospitalized group, critically ill patients were more likely to be older, have PPMS/SPMS, be less ambulatory, have comorbid obesity, have coronary artery disease, and have a history of venous thromboembolism. There were also 9 patients with pediatric-onset MS, who were much younger and tended to fare better compared to older patients with COVID-19.

Overall, the rate of hospitalization (24%) and mortality (7.9%) in this subset of patients was similar to the data from another published MS patient database (Sormani, 2020). The  subset of patients in both studies also did not have significantly higher or lower hospitalization and mortality rates than the general population of patients with COVID-19. The MS-specific symptoms strongly associated with more severe COVID-19 outcomes included non-ambulatory status and a progressive disease course rather than relapsing-remitting disease. One limitation of this study is the small sample size, which makes it difficult to determine whether these patients with non-ambulatory status and progressive disease subtype fared worse because of their advanced age and other comorbidities or whether the MS-specific disability itself contributed to additional risk for COVID-19-related complications. Another limitation is that because of the way patients were recruited, the data set was skewed to represent patients with more severe outcomes, so asymptomatic cases were not adequately assessed. The authors recognize these limitations. Nonetheless, it is interesting to see in this early data that there has not been any additional risk attributed to taking B cell-depleting or other immunosuppressive/immunomodulatory therapies. It will be important to see if this conclusion still holds in future larger population studies.

Written by: Sam Bazzi
Edited by: Jina Zhou and Esther Melamed
5/25/2020