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This has been reviewed and updated as of May 30, 2020.

Sick with the flu with RA

Fever. Cough. Shortness of breath or difficulty breathing. Chills. Muscle pain. Headache. Sore throat. New loss of taste and smell. As the list of potential COVID-19 symptoms continues to grow, so does our anxiety about whether we could have it. Some concerns are specific to people with certain chronic conditions.

Over the past few weeks, we at the Global Healthy Living Foundation have heard such concerns as:

  • I take methotrexate every day and tend not to get fevers — what if I can’t get tested?
  • I have chronic fatigue syndrome — how can I tell if my fatigue is from my condition, extra stress, or the actual coronavirus?
  • I have ankylosing spondylitis and shortness of breath and chest pain — is it from costochondritis, ramped-up anxiety, or could it be COVID-19?

Sound familiar? When you live with a rheumatic disease, you likely have some symptoms that can mimic those of COVID-19, including shortness of breath; chronic, dry cough; muscles aches; fatigue; gastrointestinal woes; and temperature spikes.

“The body has a limited number of ways to demonstrate illness, so many of the signs and symptoms are the same as those of rheumatic diseases,” says Susan M. Goodman, MD, a rheumatologist at Hospital for Special Surgery in New York City.

COVID-19 Symptoms in People with Autoimmune Conditions

So, what exactly should you be looking for?

“Unfortunately, I can’t say if you have symptoms one, two, and three you likely have COVID-19 and if you have four, five, and six, you have a bad cold,” says Uzma Haque, MD, assistant professor of medicine at the John Hopkins Arthritis Center. “We just don’t have enough data yet to say that our patients don’t present with fever, or our patients present with one core symptom, or our patients present with one symptom over another,” says Dr. Haque.

The Global Healthy Living Foundation spoke with multiple rheumatologists to help you better understand and navigate your symptoms. Here’s what we know now — and what you need to know about COVD-19 symptoms when you’re living with an autoimmune condition.

Defining the Symptoms of COVID-19

According to the latest information from the U.S. Centers for Disease Control and Prevention (CDC), the main symptoms of coronavirus are:

  • Fever (100.4 or higher)
  • Cough (dry)
  • Shortness of breath or difficulty breathing
  • Fatigue
  • Chills
  • Repeated shaking with chills
  • Muscle aches
  • Headache
  • Sore throat
  • New loss of taste or smell

These symptoms can appear two to 14 days after exposure, according the CDC.

Less common COVID-19 symptoms include:

  • Other cold and flu symptoms
  • Gastrointestinal symptoms (nausea, diarrhea, and loss of appetite)
  • Anecdotal reports of visual changes
  • Anecdotal reports of “COVID toes,” or pernio-like red bumps and lesions on toes and sometimes hands

What you need to know: “To the best of our knowledge, COVID-19 symptoms are the same in patients with autoimmune disease,” says Dr. Goodman. “Rheumatologists have started to report cases among their patients, so we will be learning more over time.”

In fact, a new study published in the Annals of the Rheumatic Diseases, which focused on people in the Boston area — with and without rheumatic diseases — who tested positive for COVID-19 in March and early April, found that those who contracted the virus generally experienced similar symptoms (such as cough and fever), regardless of whether they had a rheumatic disease such as rheumatoid arthritis, lupus, polymyalgia rheumatica, spondyloarthritis, myositis, or vasculitis. Read more about the study here.

While people with rheumatic conditions may be concerned that they are at higher risk for  COVID-19 complications, the data so far is reassuring.

“In these difficult times, I understand that everyone is anxious but there is some good news: We are not seeing clusters of patients with rheumatic disease [getting the coronavirus at increased rates compared to the general population] and those who are getting infections are recovering,” says Dr. Haque.

Read about preliminary research that found that autoimmune patients don’t have a higher risk of being hospitalized with COVID-19.

How to Make Sense of Coronavirus Symptoms That Can Overlap Those of Chronic Conditions

1. Fever

Fever — defined as 100.4 F (38 C) or higher —  is a key symptom of COVID-19. The virus typically causes your fever to rise in the late afternoon and evening, which is why experts recommend taking your temperature twice a day.

What you need to know: Again, since this is all new — to patients, medical professionals, and and researchers — we can’t know for sure how each medication and each rheumatic disease would impact fever if you were to get COVID-19. “There’s just not enough data, and we can’t hinge on one symptom,” say Dr. Haque.

In inflammatory arthritis and other conditions, fever can be a sign of a flare or even part of your normal disease activity.

Fever can also be blocked by or caused by certain medications.

Prednisone and non-steroidal anti-inflammatory drugs, or NSAIDs (aspirin, ibuprofen, diclofenac sodium, celecoxic, meloxicam) both block fever. Someone who is infected with COVID-19 may not have a fever if they are taking these drugs regularly, notes Dr. Goodman.

However, according to Brett Smith, DO, a rheumatologist with Blount Memorial Physicians Group in Alcoa, Tennessee, most patients on disease-modifying antirheumatic drugs, or DMARDs (such as methotrexate, sulfasalazine, leflunomide) and biologics and targeted therapies (such as TNF inhibitors, JAK inhibitors, abatacept) will mount fevers if they develop COVID-19.

“Rheumatoid arthritis can be treated by a drug that blocks IL-6 — a protein that acts as a messenger in the body and directs the body to develop fever as well as other signs of inflammation,” Dr. Goodman notes. “There are now trials to see if blocking IL-6 in severely ill patients with COVID 19 is beneficial,” she says, “[but] there is no evidence that people taking IL-6 blockers are protected from the virus.”

While there’s no simple way to determine what is causing a fever, you can take comfort in the fact that if it is caused by a disease flare there is also a pattern of symptoms — not just fever alone — that you’ll be able to recognize, says Dr. Goodman.

For now, your rheumatologist or other health care provider wants to know if you’re feeling feverish, especially if you feel different than how you normally feel. If you have a fever of 100.4 F or greater, presume it is infectious and call your rheumatologist or physician, says Dr. Smith.

“Do not go straight to an emergency room,” adds Dr. Goodman. “If you have a mild case [of coronavirus], there is no treatment except fluids, rest, and acetaminophen. And if you’re not infected, you’ll risk being exposed to the virus when you go in.”

2. Cough and Shortness of Breath

A dry cough — one that you feel in your chest — is another key COVID-19 symptom. You’ll feel like your bronchial tubes are inflamed and you won’t cough anything up, William Schaffner, MD, a professor of medicine in the division of infectious diseases at the Vanderbilt University School of Medicine in Nashville, Tennessee, told CNN.

In coronavirus, shortness of breath can occur with or without a cough and your symptoms won’t improve (and may worsen) after a week or so. If shortness of breath is severe and you experience any of the following signs, call 911:

  • Trouble breathing
  • Persistent pain or pressure in the chest
  • Sudden mental confusion or inability to arouse
  • Bluish lips or face (from a lack of oxygen)

What you need to know: Chest pain, shortness of breath, and even a dry cough can also be part of your chronic condition. Many people living with rheumatic diseases are also living with asthma or COPD. The same chronic, systemic inflammation that targets your joints can also affect your lungs and chest wall.

“Any systemic inflammatory disease can inflame the structures that comprise the chest wall, as muscles connect to tendons and bones to expand the chest wall in normal respiration, and all of those structures can become inflamed,” says Dr. Goodman. “For some systemic inflammatory diseases like lupus, the inflammation may be in the lining of the lungs, which is called pleurisy.”

Costochondritis, an inflammation in the costosternal joints — the segments of cartilage that connect the ribs to the breastbone — is common in inflammatory arthritis like rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis. However, a patient with a flare or costochondritis will typically not report cough or shortness of breath, says Dr. Goodman.

“Patients should be alert to progressive shortness of breath, as this appears to be the harbinger of the moderate to severe COVID-19 cases,” says Dr. Smith. “The shortness of breath is very rapid in individuals with coronavirus, with progression over one to two days typically, which is highly atypical for [inflammatory arthritis].”

Any time you experience chest pain, especially if it is accompanied by a dry cough and shortness of breath, you should call your rheumatologist or primary care physician.

Do not try to assess for yourself whether this symptom is from asthma, anxiety, a heart attack, costochondritis, COVID-19, or something else.

3. Fatigue and Body Aches

While cold- and flu-like symptoms don’t top the list of common COVID-19 symptoms, there have been reports of body aches and fatigue as well as headaches, digestive issues (nausea and diarrhea), runny nose, sore throat, and sneezing.

Most likely, however, experts say these symptoms alone — without fever and cough or shortness of breath — indicate cold, flu, seasonal allergies, or something else, not COVID-19.

What you need to know: “When you’re living with a chronic illness, there are innumerable reasons for chronic fatigue, so no one should assume they have COVID-19 due to only fatigue or body aches,” says Dr. Smith.

Instead, it is best to just listen to your body. “Our patients are very savvy in recognizing their symptoms and being able to tease apart an arthritis flare or fibromyalgia flare [from other body aches],” says Dr. Haque. “I tell my patients if you have fatigue in a way that’s not common for you, or body aches that you’re not used to, or a little bit of a cough and feel down and awful, then reach out to your rheumatologist or primary care physician.”

There is no such thing as being too vigilant about your health right now. “If you feel that anything is unusual — or different than your typical underlying chronic disease — bring it up to your doctor,” says Dr. Haque.

Monitoring Your Symptoms

If you feel anxious about your symptoms, consider tracking and monitoring them in a journal. Dr. Smith recommends documenting the following:

  • Temperature check (oral, axillary, or forehead)
  • Time taken
  • Symptoms
  • Progressive symptoms (cough or shortness breath)

“If your symptoms haven’t budged in a few days, you may be reassured,” says Dr. Haque. Still, this approach isn’t for everyone and may make you feel more stressed out.  “I have patients who keep diaries and journals and others who don’t because it makes them more anxious,” she says. “Do what will make you feel comfortable and in control of your body and your disease.”

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D’Silva KM, et al. Clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) and rheumatic disease: a comparative cohort study from a US ‘hot spot.’ Annals of the Rheumatic Diseases. May 26, 2020. doi: https://doi.org/10.1136/annrheumdis-2020-217888.

Haberman R, et al. Covid-19 in Immune-Mediated Inflammatory Diseases — Case Series from New York. New England Journal of Medicine. April 29, 2020. doi: https://doi.org/10.1056/NEJMc2009567.

Interview with Brett Smith, DO, a rheumatologist with Blount Memorial Physicians Group in Alcoa, Tennessee

Interview with Susan M. Goodman, MD, rheumatologist at Hospital for Special Surgery in New York City

Interview with Uzma Haque, MD, assistant professor of medicine at the John Hopkins Arthritis Center

Symptoms of Coronavirus. U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.

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