A 49 years-old woman admitted to the hospital (Valiye Asr hospital, Iran, Fars, Fasa) at 11, March 2020 with a dry cough, fever, myalgia, respiratory distress, dizziness and nausea. Though O2 Saturation (SPO2%) was low (%) on the admission, O2 nebulizer administered (O2 5 lit/min), which resulted in the correction of O2 Saturation (87%) very soon (Table 1 and Supplementary Figure 1, A, B, and C and Supplementary table 1). Four days before admission, she had only dry cough without other symptoms. She declared no sign of reduced smell and taste senses. Before admission, she had a history of contact with her two daughters, her husband, and 1-year-old grandchildren, that all of them were positive for COVID-19 by real- time PCR test. She was the only member of her family with severe respiratory problems that needed to be hospitalized (and also the only person with RA in her family), whiles the rest of the family showed mild symptoms and quarantined at home. The Chest x-rays on the first day of hospitalization showed pneumonia signs alongside with bilateral ground-glass pattern, vascular dilation, and traction bronchiectasis in the middle and secondary lobes (Figure 1, A, B, and C). Positive Real-time PCR tests confirmed the SARS-CoV-2 infection. Laboratory findings on admission was a very low WBC count and reduced number of platelets, elevated ESR and PT (Table 1 and Supplementary table 2 and Supplementary Figures 4). The patient's first ECG revealed an ST-elevation (Supplementary Figure 2) that may be resulted in ST- Elevation Myocardial Infarction (STEMI). Because the cardiovascular events are among the most common cause of death in RA patients, the patient had a very sensitive condition to manage with intensive care strategy.
Therapy with Hydroxychloroquine was started on the 1st day and continued for 10 days. Oseltamivir was added on the 2nd day and continued for 6 days. The patient's nausea was controlled by Ranitidine, Ondansetron, and Pantoprazole. Kaletra (Lopinavir/Ritonavir 200-50 mg/day and night 2 tab each) was added to the antiviral regimen on the 4th day, continued as the main antiviral medication for 7 days until symptoms relieved. A cluster of Antibiotics was prescribed for the first week because of low WBC count and suppressed immunity to prevent secondary infection. In the following, she was treated with one period of Levofloxacin medication in the last week. Theophylline G and O2 Nebulizer treatment helped to support the airway and reduce the respiratory symptoms (Table 1 and Supplementary Figure 3). As laboratory findings and symptoms demonstrate, the patient’s condition was by the end of 1st week worsened. The WBC and RBC count were reduced (Supplementary Figures 4). Chest CT scans at the 2nd week revealed the destructive effects of inflammation of the infection (Figure 1, D, E, and F). Due to the laboratory findings and symptoms were more similar to the COVID- 19 cytopenia, we decided to redesign the treatment. So, the DMARDs and immunosuppressant treatment were omitted. We then discontinued the Ebtrex and Nisopred at the 2nd week by dose reduction, only Sulfasalazine was continued. This strategy led to increased WBC count and altered hematologic factors. By reducing the symptoms, the patient was discharged with a stable condition and quarantined for 14 days at home. Her real-time PCR was negative on day 21. The last CT scan showed a significant reduction in GGO on day 35 (Figure 1, G, H, and I).