SKIN November 2022 Volume 6 Issue 6 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 497 RESEARCH LETTER Severity of COVID-19 in Patients with Dermatomyositis: A Single Center, Retrospective Observational Cohort Study Jessica Johnson, BS1, Amy S. Nowacki, PhD2, Jatin Narang, MD1, Sarah Young, MD3, Anthony P. Fernandez, MD3,4 1 Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, OH 2 Quantitative Health Science, Cleveland Clinic, Cleveland, OH 3 Department of Dermatology, Cleveland Clinic, Cleveland, OH 4 Department of Pathology, Cleveland Clinic, Cleveland, OH Patients with chronic immune-mediated diseases (IMIDs), especially when taking certain immunomodulatory medications, have been shown to have an increased risk of developing severe COVID-19.1-3 Although dermatomyositis (DM) patients have been included in large cohorts of patients with IMIDs evaluating for COVID-19 risk and severity, there is little literature specifically evaluating DM patient cohorts. We performed a single-center, retrospective cohort study to evaluate the severity of COVID-19 in DM patients and to assess for risk factors related to severe COVID-19 disease course. Only patients >18 years-old with confirmed, positive COVID-19 polymerase-chain reaction (PCR) tests between March 2020 – July 2021 were included. All patients met European League Against Rheumatism (EULAR) criteria for DM diagnosis. 4 Patients must have been seen by a Cleveland Clinic provider for their DM within the last 10 years (January 2011 – July 2021). Hospitalization was defined as >1 night in the hospital for COVID-19. Depending on the sample size, the Wilcoxon rank sum test or Fisher’s exact test was used to compare the characteristics of the hospitalized versus not hospitalized patients in the DM cohort. Our cohort included 27 patients with confirmed DM. Detailed characteristics of our DM cohort are included in Table 1. Within our cohort, 74.1% were on systemic therapy for their DM at the time of their COVID-19 diagnosis (Table 2). Within the DM cohort, 6 (22.2%) were hospitalized for their COVID-19 disease. One individual required ICU care (3.7%), and another died as a result of COVID-19 (3.7%). Despite an underlying increased risk for thromboembolic events, none of the patients in our DM cohort had a thrombotic event during their COVID-19 infection 5. Additionally, only one of the patients in our cohort had a worsening of their DM symptoms after their COVID-19 infection. The hospitalized DM patients had a median age of 66 years, compared to 52 years in the non-hospitalized group (Table 2). No clinical features significantly differed between the hospitalized and non-hospitalized DM INTRODUCTION OTHER RESULTS SKIN November 2022 Volume 6 Issue 6 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 498 Table 1. Dermatomyositis cohort demographic factors Count 27 Female 24 (88%) Age* 54 (26, 67) BMI* 27.2 (22.7, 32.1) DM Subtypes Classic 20 (74%) Amyopathic 1 (4%) Juvenile 3 (11%) Malignancy Associated 3 (11%) Medications at time of COVID-19 Diagnosis Corticosteroids 6 (22%) DMARDS 18 (67%) Combined Systemic Therapy (Corticosteroids + DMARD or >1 DMARD) 10 (37%) Any Systemic Therapy 20 (74%) DM Autoantibody Status Positive Myositis Antibodies 12 (44%) Negative Myositis Antibodies 9 (33%) N/A 6 (22%) *Median (Q1 – Q3) SKIN November 2022 Volume 6 Issue 6 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 499 Table 2. Hospitalized versus non-hospitalized dermatomyositis patients Hospitalized (n = 6) Not Hospitalized (n = 21) p-value Female 6 (100%) 18 (86%) .99 Age* 56 (40 – 69) 54 (25 – 67) .58 BMI* 31.9 (27.9, 36.4) 26.5 (22.5, 30.9) .10 DM Subtypes Classic 5 (83%) 15 (71%) Amyopathic 0 1 (5%) Juvenile 0 3 (14%) Malignancy Associated 1 (17%) 2 (10%) Medications at time of COVID- 19 Diagnosis Corticosteroids 3 (50%) 3 (14%) .10 DMARDS 5 (83%) 13 (62%) .63 Combined Systemic Therapy (Corticosteroids + DMARD or >1 DMARD) 3 (50%) 7 (33%) .56 Any Systemic Therapy 6 (100%) 14 (67%) .15 DM Autoantibody Status Positive Myositis Antibodies 3 (50%) 9 (43%) Negative Myositis Antibodies 2 (33%) 7 (33%) N/A 1 (17%) 5 (24%) *Median (Q1 – Q3) SKIN November 2022 Volume 6 Issue 6 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 500 patients in our cohort. However, corticosteroid usage was higher in the hospitalized group, with 50% on corticosteroids when infected with COVID-19 compared to 14.3% in the non-hospitalized group. Additionally, body mass index (BMI) was higher in hospitalized patients compared to non-hospitalized patients (31.9 kg/m2 vs 26.5 kg/m2). Of those on corticosteroids when hospitalized, 2 were on dosages > 10 mg. DMARD use and combined corticosteroid and DMARD use were both slightly higher in the hospitalized group (83.3% vs. 62%, 50% vs. 33%, respectively). Similarly, 100% of DM patients who were hospitalized were on some form of systemic therapy, compared to 67% in the non- hospitalized group. In summary, our results suggest risk factors for severe COVID-19 in DM patients include those previously identified in other cohorts of autoimmune disease patients; namely, advanced age, higher body mass index (BMI) and active treatment with immunosuppressive agents.1,4 The main limitation of our study is its small sample size, which limited our ability to potentially detect significant differences between clinical characteristics of hospitalized vs. non- hospitalized DM patients. Therefore, we focused on descriptive measures and the clinical importance of observed differences to generate hypotheses in the DM cohort. Alternatively, strengths of our study include an ability to review detailed information about our cohort patients, thus being confident about their DM diagnosis, medication regiment at time of COVID-19 diagnosis, and their COVID-19 disease course. Further characterization in larger cohorts should be conducted to explore these possible associations. Until then, awareness of these potential risks is important for clinicians caring for DM patients in order to optimize their care and protection from a severe COVID-19 disease course. Conflict of Interest Disclosures: JJ, AN, JC, SY and have no conflicts of interest or financial disclosures. APF is an investigator for Pfizer, Corbus, Mallinckrodt, and Novartis and receives personal research support from Mallinckrodt and Novartis; honorarium from AbbVie, Alexion, BMS, UCB, Novartis, and Mallinckrodt for consulting and advisory board participation, and honorarium from AbbVie, Novartis, Kyowa Kirin and Mallinckrodt for teaching and speaking (non-promotional). Funding: None Corresponding Author: Anthony P. Fernandez, MD, PhD Departments of Dermatology and Pathology Cleveland Clinic; 9500 Euclid Avenue, A61 Cleveland, OH 44195 Telephone: (216) 445-8776 Fax: (216) 636-0711 Email address: fernana6@ccf.org References: 1. Gianfrancesco M, Hyrich KL, Hyrich KL, et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician- reported registry. Ann Rheum Dis. 2020;79(7):859-866. doi:10.1136/ANNRHEUMDIS-2020-217871 2. Strangfeld A, Schäfer M, Gianfrancesco MA, et al. Factors associated with COVID-19- related death in people with rheumatic diseases: results from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis. 2021;80(7):930. doi:10.1136/ANNRHEUMDIS-2020-219498 3. Severity of COVID-19 and survival in patients with rheumatic and inflammatory diseases: data from the French RMD COVID-19 cohort of 694 patients. Ann Rheum Dis. 2020;80(4):527-538. doi:10.1136/ANNRHEUMDIS-2020-218310 4. Lundberg IE, Tjärnlund A, Bottai M, et al. 2017 European League Against Rheumatism/American College of Rheumatology classification criteria for adult and juvenile idiopathic inflammatory CONCLUSION mailto:fernana6@ccf.org SKIN November 2022 Volume 6 Issue 6 (c) 2022 THE AUTHORS. Published by the National Society for Cutaneous Medicine. 501 myopathies and their major subgroups. Ann Rheum Dis. 2017;76(12):1955-1964. doi:10.1136/ANNRHEUMDIS-2017-211468 5. Li Y, Wang P, Li L, Wang F, Liu Y. Increased risk of venous thromboembolism associated with polymyositis and dermatomyositis: a meta-analysis. Ther Clin Risk Manag. 2018;14:157. doi:10.2147/TCRM.S157085