Early Italian experience of COVID-19 in patients with MDS

Infection is a common cause of death in patients with myelodysplastic syndromes (MDS), and during the early stages of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in Italy it was anticipated that large numbers of patients with MDS could experience severe symptomatic COVID-19 disease. A report of the early impact of the COVID-19 pandemic on patients with MDS in Italy has been published by Sandra Mossuto and colleagues in Hemasphere. Here we summarize this report.

Data collection

Data for patients with MDS and SARS-CoV-2 infection were collected from the national MDS registry and the regional registry for Rome and surrounding areas, which together provided data from 50 institutions across Italy.

• Data were collected between February 24, 2020 and April 28, 2020.
• The total number of patients with MDS followed up in that period was 5,326, with a median age of 73 years.

Key findings

• COVID-19 was confirmed in 63/5,326 patients with MDS (1.18%).
• The median age of patients with MDS and COVID-19 was 78 years.
• Most cases (70%) were in three regions of Northern Italy: Lombardy, Piedmont, and Emilia Romagna.
• This was consistent with a high cumulative incidence of SARS-CoV-2 infection (>500 cases/100,000 inhabitants) in these three areas, which comprised 62.4% of all Italian cases.
• Only 33/63 patients (52%) were alive at the time of analysis, indicating a higher death rate than that for a non-MDS population of an equivalent age range (70–79 years; 24% death rate).

Table 1 summarizes the characteristics and treatment administered to the 63 patients with MDS and COVID-19.

Table 1. Characteristics and treatment types for patients with MDS and COVID-19*

BSC, best supportive care; ESA, erythropoietin-stimulating agent; HMA, hypomethylating agent; ICU, intensive care unit; IPSS-R, Revised International Prognostic Scoring System; LMW, low molecular weight; MDS, myelodysplastic syndromes. *Adapted from Mossuto et al.1
Characteristic/treatment type	Patients with MDS, alive (n = 33)	Patients with MDS, deceased (n = 30)
Median age, years	78	78
Male, n (%)	20 (61)	22 (73)
IPSS-R, n               Very low               Low               Intermediate               High               Very high	0 19 8 2 2	2 4 7 11 6
MDS therapy, n               ESA               HMA               HMA + venetoclax               BSC               BSC + iron chelation               Lenalidomide               Danazol               Watchful waiting	16 4 1 8 1 — — 3	4 15 — 5 — 1 2 3
COVID-19 therapy, n               Antibiotics               Hydroxychloroquine               Steroids               LMW heparin               Lopinavir/ritonavir               Darunavir/cobicistat               Antivirals, not specified               Tocilizumab               Supportive therapy only               ICU	26 24 4 6 1 3 1 2 3 12	30 28 4 10 1 10 1 6 3 17

• COVID-19 was more frequent, and the number of COVID-19-related deaths was higher for male patients compared with female patients with MDS.
• The survival of patients with MDS did not appear to be influenced by age.
• The reported cause of death for all 30 patients was respiratory failure; COVID-19 was complicated by bacterial pneumonia in 82% of cases and by cardiac failure in 5% of cases.
• Most patients who recovered (62%) had a lower Revised International Prognostic Scoring System (IPSS-R) risk score, whereas most deceased patients (57%) had a high or very high risk score.
• An assessment of SARS-CoV-2 infection and survival by treatment type could not be made due to the small numbers of patients in each treatment group.

Summary

During this limited timeframe of analysis, the incidence of symptomatic SARS-CoV-2 infection was not as frequent as anticipated for patients with MDS, given their potential susceptibility. At the time of analysis, data were not available for asymptomatic patients with MDS infected with SARS-CoV-2, and routine testing for antibodies to SARS-CoV-2 is ongoing across Italian institutions for patients with MDS.