Screening neuromyelitis optica patients for COVID-19 infection.

Dear editor,

Nowadays, SARS CoV 2 a new coronavirus with high infect ability, is in pandemic stage and most countries all over the world are involved [1].

Neuromyelitis optica (NMO) is an inflammatory disease of the central nervous system (CNS) affecting women more than men [2]. Treatment options include immuno-suppressive agents which may predispose patients to the wide range of infections such as COVID-19. So, careful monitoring of NMO patients is essential and neurologists have to pay attention to these cases such as other patients with autoimmune diseases like Multiple sclerosis (MS) [3].We designed this study to screen NMO patients for COVID-19 infection during the pandemic stage.

The study was performed in accordance with good clinical practice and the Declaration of Helsinki.

From April 1th to April 4th 2020 a link to Google Form survey including a translated (and modified) version of the digital triage proposed by Bonavita et al. [3] was sent through Whatsapp. The inclusion criteria were: NMO diagnosis based on the international 2015 consensus criteria [4], age > 18 years and ability to use internet.

The link was sent to 200 NMO patients and finally 157 filled forms were gathered. Mean age and mean disease duration were 38 ± 10.8 and 6 ± 4 years, respectively. One hundred and twenty-five were female (79.8%) and 50.3% were treated with Rituximab and 49.7% with Azathioprine. The most common symptoms were myalgia, and headache/vertigo (Table 1).

Table 1

Symptoms during pandemic stage.

Symptoms	n (%)
Fever	6 (3.8%)
Cough	12 (7.6%)
Shortness of the breath	9 (5.7%)
Myalgia	27 (17.2%)
Diarrhea	4 (2.5%)
Nausea/vomiting	4 (2.5%)
Headache/vertigo	20 (12.7%)
Imbalance	13 (8.3%)
Anosmia	1 (0.6%)
Ageusia	5 (3.2%)

Except two patients, all others followed quarantine rules and 145 family members helped the patients to follow the rules. Five had contacted with confirmed COVID-19 cases. Six had COVID-19 diagnosis (based on nose or throat samples or CT scan) and two were hospitalized.

Two cases with COVID-19 diagnosis were admitted. Both were male (one 41 years old with disease duration of 6 years and the other 34 with the disease duration of 13 years), both under treatment with Rituximab, and had no contact with confirmed cases. The first one had ICU admission.

As in NMO pathogenesis AQP4-IgG plays an important role, rituximab therapy, causing B cell depletion in the peripheral blood [5] is effective [6] in reducing disease activity; however, one of the concern about rituximab treatment is the increased infection risk mainly linked to the following decreased level of immunoglobulins [7].

We also found that most NMO patients are aware of preventive strategies of COVID-19 infection and they try to follow the rules. As these patients are taking immunosuppressive agents, they have to follow the rules seriously and careful surveillance by their health care providers is recommended. Online screening and monitoring as well as preventing unnecessary face to face visits during this pandemic will help patients to stay safe and will reduce their risk of contact with healthy carrier of SARS-CoV 2. Patients with NMO disease should be screened for COVID-19 infection.