Case series/case reports (Indigo)
Teriflunomide is an immunomodulatory drug approved for multiple sclerosis (MS) treatment that inhibits dihydroorotate dehydrogenase, a mitochondrial enzyme involved in the de novo pyrimidine synthesis pathway. This mechanism can produce antiviral effects, thus teriflunomide has gained attention during COVID-19 pandemic. Moreover, in recent months, some case reports have been published describing MS patients treated with teriflunomide who developed mild and self-limiting forms of COVID-19. In this article, the authors describe the case of a 57-year-old man affected by MS, and treated with teriflunomide, who developed a mild form of SARS-CoV-2 infection. Moreover, they provide a detailed literature review on cases of COVID-19 in MS patients treated with teriflunomide reporting clinical features, disease course and outcome. Apart from the present report, five papers have been published describing 14 MS patients who developed SARS-CoV-2 infection during teriflunomide treatment. Patients were mostly female (53%), with an average age of 50.5 (±11.3) years. Median EDSS was 2.25 (range 0-6). The average time on treatment with teriflunomide was 3.7 (± 1.6) years. Relevant comorbidities were present in 4 patients (27%). Regarding SARS-CoV-2 infection, the most common symptom was fever (100%) followed by gastrointestinal disturbances (67%), fatigue (55%) and cough (55%). 5 patients were hospitalised and 2 required oxygen support. In patients hospitalised (n=5) compared to the others (n=10), age was significantly higher (59.6 vs 45.9 years, p=0.025) while gender, EDSS, duration of teriflunomide therapy and comorbidities were not significantly different. Outcome was good for all patients with a variable recovery time, ranging from few days to weeks. Teriflunomide was continued during the entire course of SARS-CoV-2 infection in all patients except for two. The authors concluded that available data suggest that teriflunomide therapy should not be discontinued in MS patients who develop SARS-CoV-2 infection.