• giant cell arteritis
• COVID-19
• ultrasonography

We read with great interest the paper published by Tomelleri et al 1 on ‘Impact of COVID-19 pandemic on patients with large-vessel vasculitis in Italy: a monocentric survey’. The authors aimed to evaluate the impact of COVID-19 and national lockdown among patients with large-vessel vasculitis (LVV) in a single centre by April 2020. First, we would like to congratulate them for the novelty of their work during the first wave of the pandemic in Italy. The implementation of ultrasound (US) fast-track pathways (FTPs) in rheumatology, aiming at an early diagnosis of giant cell arteritis (GCA), has led to a decrease in permanent vision loss.2 However, the COVID-19 pandemic lockdown has had a negative impact on patients with GCA, leading to difficulties in monitoring, reduced access to temporal artery biopsy3 and a decline in referral rates of patients accompanied by cases with delayed presentation and vision loss.4 Additionally, recent data suggest that COVID-19 seems to be more severe in patients with LVV with higher rates of hospitalisation and lethality,5 although these results should be further confirmed. The aim of our analysis was to assess the rate of US examinations included in our FTP and the rate of permanent visual loss due to GCA since the COVID-19 pandemic.

We conducted a retrospective observational study including patients referred to our US FTP for evaluation of possible GCA over a 16-month period. All patients underwent US examination within 24 hours per protocol. Visual loss due to anterior ischaemic optic neuropathy (AION) confirmed by ophthalmology evaluation was checked. The gold standard for GCA diagnosis was the clinical confirmation after 6 months of follow-up. We compared the 8-month pre-COVID and post-COVID-19 outbreak periods (July 2019–February 2020 and March 2020–October 2020). Since the beginning of the COVID-19 pandemic, 31 patients were referred to the FTP compared with 50 patients in the previous 8 months (38% reduction), although the service was regularly operating (figure 1). However, the number of newly GCA diagnosis during the COVID-19 pandemic remained similar, although the percentage over the total examinations was higher (45.2% vs 22%, p=0.028). Demographic, clinical and US variables of patients before and after the COVID-19 outbreak are shown in table 1. We found no notable differences in clinical referral patterns. However, it is noteworthy that two patients presented with AION during the COVID-19 pandemic, while no AION in the previous period occurred, although these differences were not statistically significant (p=0.14). During confinement, patients referred to the FTP presented higher markers of systemic inflammation as shown by higher C reactive protein (7.6 mg/dL vs 3.4 mg/dL, p=0.008), erythrocyte sedimentation rate (73.9 mm/hour vs 45.7 mm/hour, p=0.02), platelets (342.1 10⁹/L vs 254.1 10⁹/L, p=0.001) and lower haemoglobin levels (11.7 g/dL vs 12.8 g/dL, p=0.019). We found no differences in the proportion of patients with global positive US findings (38.7% vs 22%, p=0.115), although the halo and compression sign were more frequently found during the COVID-19 pandemic (38.7% vs 16%, p=0.021, and 25.8% vs 10%, p=0.06, respectively). It is also worth highlighting a higher proportion of positive temporal artery biopsy during the COVID-19 pandemic (50% vs 33%, p=0.049).

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Figure 1

Number of patients evaluated in the fast-track pathway and number of new GCA diagnosis over the study period. GCA, giant cell arteritis.

Our data show a reduction in use of GCA FTP since the COVID-19 outbreak and an increase of possibly preventable AION. The ischaemic complications of GCA include stroke, blindness or myocardial infarction, so an early and accurate diagnosis is needed. US FTP has been demonstrated to be useful in the reduction of permanent vision loss,2 6 so an impaired use of this tool may lead to worse outcomes. Our results go in line and confirm previous work that noticed a reduction in the requests for FTP assessments by May 2020.4 Although a higher proportion of patients referred to the FTP had GCA, the number of newly diagnosed GCA remained similar before and after the COVID-19 outbreak, in contrast with other studies that observed an increased number of GCA after the COVID-19 outbreak.7 8 In conclusion, our study highlights the potential risks of COVID-19 lockdown in the reduced referral of GCA with suspected GCA, the occurrence of permanent visual loss and the need for maintaining urgent access to FTP during the COVID-19 pandemic.