COVID‐19 in dimethyl fumarate‐treated patients with multiple sclerosis

Despite a few initial reports [1,2,3,4,5], the risk and course of COVID-19 in patients with multiple sclerosis (MS) is still unclear. Although neurological disability and comorbid conditions may be important factors, the role played by immune-based disease-modifying therapies (DMTs) in patients with MS has attracted the most attention in this regard [6]. Patients with MS have a generally increased risk of infections [7], particularly those with more severe disability or significant co-morbidities, with evidence for a role for infections in triggering MS relapses or worsening pre-existing MS symptoms [8]. MS patients are generally twice as likely to be hospitalized for infections than the general population [9].

Recently, Maghzi et al. [10] reported in this journal a case series of five teriflunomide-treated MS patients who developed COVID-19 infection and continued their therapy with a self-limiting infection and without any relapse. The authors hypothesized that the immune-biologic mechanisms pertaining to teriflunomide have a potential role in favoring a COVID-19-positive outcome.

Here, we would like to draw attention to another oral DMT. We report a case series of seven patients treated with dimethyl fumarate (DMF) that developed a self-limiting COVID-19 infection, during the peak of COVID cases in Lecco’s province between March and May 2020. The diagnosis was based on the typical symptoms of COVID-19 infection (dry cough, anosmia, ageusia, fever, asthenia, and shortness of breath, see Table 1), associated with contacts with COVID-19-confirmed or suspected (respectively in 5 and 1 cases) subjects. Nasal swab and chest X-ray/CT were not performed due to the local guidelines at the time. All patients continued their therapy with DMF, and none of them experienced an MS relapse. Clinical characteristics and hematological values are reported in Table 1. Patients were mostly female (71%), with an average age of 35.9 (± 11.4) years and a disease duration of 6.71 (± 5.6) years. Median EDSS was 1.5 (range 1.5–2), and the average time on treatment with DMF was 2.4 (± 1.9) years. None had severe lymphopenia, and only one patient had grade two lymphopenia (0.67 ×103/μL). No patient required hospitalization, ICU care, or intubation. They all improved without receiving any specific treatment. One of the patients reported left hand paresthesia during the respiratory symptoms, interpreted as a pseudo-relapse by the treating neurologist.

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