CHEARS

At the end of 2019, a novel corona virus that was named severe acute respiratory syndrome corona virus 2(SARS –Cov-2) was identified in Wuhan, by 2020 infection with this virus lead to pandemic that has spread throughout all most all the countries of the world. The illness mainly affects lung with symptoms ranging from mild upper respiratory tract infection to severe pneumonia ,acute respiratory distress syndrome and death. Severe illness can occur in  healthy individuals, but also in patients with medical conditions including systemic rheumatic diseases. The presence of a rheumatic disease alone is not known to associated with an increased risk for developing Covid -19. Patients presented with rheumatic diseases, have a higher prevalence of several comorbid conditions advanced age, chronic pulmonary, kidney disease ,heart disease, hypertension ,diabetes are the major risk factors .

The clinical features of Covid -19 among patients with systemic rheumatic diseases are variable. Although some clinical features that can mimic Covid -19 includes malaise, myalgia, fatigue etc. Patients who are with an existing case of rheumatic disease the clinician may need to distinguish disease flare from possible Covid-19 infection, and high level of suspicion should be maintained.

Adjustment to medication regimens in patients with stable rheumatic disease who are asymptomatic but thought to be recently exposed to covid -19 should be individualized.

· Hydroxychloroquine(HCQ)/chloroquine(CQ) ,sulfasalazine(SSZ) and NSAIDs may be continued.

· Methotrexate (MTX) or leflunomide (LEF) discontinuation is determined on case by case basis.

· Cyclophosphamide (CYC), mycophenolate mofetil (MMF),azathioprine (AZA),tacrolimus, anti-tumor necrosis factor (TNF) agents, abatacept, and janus kinase inhibitors should be stopped temporarily ,pending a negative test result for covid -19 or after two weeks of symptoms free observation.

· Interleukin 6(IL-6) receptor inhibitors may be continued in selected patients, particularly those at high risk for developing a cytokine release like syndrome.

Modifications to routine rheumatologic care that associated with minimizing risk of exposure to Covid-19 when possible includes optimal use of tele-health visits, decreased frequency of routine laboratory surveillance when associated risk is deemed to be low. Decisions regarding the safest intervals for testing need to be individualized, for example based on patient overall clinical status, comorbidities , prior stability of testing and the usage of medication.