Increased number of cases of giant cell arteritis and higher rates of ophthalmic involvement during the era of COVID-19

Jaw-related complications in COVID-19 patients; a systematic review

OBJECTIVE

The aim of this review was to highlight jaw-related complications in COVID-19 manifestations, their etiology, and prevention methods.

METHODS

A systematic review of literature was conducted. MEDLINE/PubMed, and Google Scholar were searched for the following keywords: "COVID-19" "Oral manifestations", "Musculoskeletal patients", "Mandible", "Jaw", "Osteonecrosis", "MRONJ", and "dry socket".

RESULTS

Only nine articles were included in this review. Jaw-related disorders associated with COVID-19 were dry socket, osteonecrosis, and orofacial pain related to temporomandibular joint disorders (TMD) and giant cell arteritis (GCA).

CONCLUSION

COVID-19 potentially predisposes to osteonecrosis due to thrombotic inflammatory phenomena caused by the disease itself or its therapeutic modalities. All jaw osteonecrosis cases reported so far in relation to COVID-19 affected the upper jaw. Orofacial pain in COVID-19 patients was related to TMD and GCA. Clinical evidence-based studies are required to investigate the actual prevalence and possible correlation between COVID-19 and jaw-related disorders.

Secondary Vasculitis Attributable to Post-COVID Syndrome

While the acute phase of the COVID-19 pandemic has largely come to pass, the chronic physiologic effects of the coronavirus continue to unfold. Specifically, the number of COVID-19-associated vasculitis cases has steadily increased since the onset of the pandemic. Data have shown that vasculitis may develop less than two weeks after COVID-19 or during a later onset of the disease. At this time, research has demonstrated that the novel coronavirus invades more than just the lungs; it can also attack the nervous system, cardiovascular system, and kidneys. In addition, there is a greater understanding of the pathogenesis regarding COVID-19-induced vasculitis via humoral immunity and immune complex disease. Recent case reports have shown an association between COVID-19 and secondary vasculitis. This review paper discusses case reports and data that suggest that COVID-19 may lead to specific vasculitis diseases such as giant cell arteritis, ophthalmic arteritis, aortitis, and Kawasaki-like disease. More research needs to be performed on this association to aid in diagnosis and treatment.

Arteritic Anterior Ischemic Optic Neuropathy (AAION) Associated with COVID-19 Infection: A Case Report and Review of the Literature

Anterior ischemic optic neuropathy (AION) is the most frequent cause of acute optic nerve damage in the elderly, usually causing acute, unilateral, and painless permanent visual loss. Arteritic anterior ischemic optic neuropathy (AAION) is a result of endothelial cell inflammation and the subsequent thrombosis and occlusion in the blood-supplying arteries of the optic nerve head. AAION accounts only for 5-10% of all AION cases that are associated with vasculitis which usually takes place in the course of a giant cell arteritis (GCA). In this paper, we report a case of AAION following a COVID-19 respiratory infection. Although it is uncertain whether SARS-CoV-2 infection triggered the AAION or was coincidental, the possible association of the events is concerning.

Incidence of giant cell arteritis is associated with COVID-19 prevalence: A population-level retrospective study

Background

Following the first wave of the COVID-19 pandemic, it was observed that giant cell arteritis (GCA) diagnoses increased at the Royal National Hospital for Rheumatic Diseases (RNHRD) in Bath, UK. This finding may support the viral aetiology hypothesis of GCA. Better understanding of the causes of GCA may help improve diagnostic and treatment strategies leading to better outcomes for patients.

Objectives

The study aims to estimate the local incidence of GCA during the early COVID-19 pandemic (2020-2021) and compare it to pre-pandemic (2015-2019) data. This study will also evaluate the temporal relationship between COVID-19 infections and GCA diagnoses.

Methods

Annual incidence rates of GCA were calculated between 2015 and 2021. Local COVID-19 prevalence was estimated by measuring the number of hospital beds taken up by COVID-19 positive patients. Poisson statistics were used to compare the annual mean incidence of GCA between 2019 and 2020, and Granger causality tested the temporal relationship between COVID-19 prevalence and GCA incidence.

Results

There were 60 (95% confidence interval [CI] 46-77) GCA diagnoses made in 2020 compared to 28 (CI 19-41) in 2019 (P = 0.016). Peaks in the number of COVID-19 inpatients correlated with peaks in GCA diagnoses. Granger causality testing found a statistically significant association between these peaks with a lag period of 40-45 days.

Conclusion

The incidence of GCA in Bath was significantly increased in 2020 and 2021 compared to 2015-2019. The lag period between peaks was 40-45 days, suggesting that the COVID-19 virus may be a precipitating factor for GCA. More work is currently underway to interrogate the causal relationship between these two diseases.

Angiotensin receptor blockade is associated with increased risk of giant cell arteritis

OBJECTIVES

Angiotensin II is implicated in GCA pathology. We examined whether the use of angiotensin receptor blockers (ARBs) is associated with GCA risk compared with angiotensin-converting enzyme inhibitors (ACEis) or other antihypertensives.

METHODS

We performed a matched cohort study including adults who were initiators of antihypertensives in UK primary care data between 1995 and 2019. Treatment-naïve individuals without prior GCA or PMR were categorized into three groups-ARB initiators, ACEi initiators, or other antihypertensive initiators (beta-blockers, calcium channel blockers, diuretics or alpha-adrenoceptor blockers)-and followed for up to 5 years. Incident GCA was defined using validated Read codes, with age of onset ≥50 years and two or more glucocorticoid prescriptions. Inverse probability-weighted Cox models were used to model outcome risk, adjusting for lifestyle parameters, comorbidities and comedications.

RESULTS

Among >1 million new starters of antihypertensives (81 780 ARBs, 422 940 ACEis and 873 066 other antihypertensives), the incidence rate of GCA per 10 000 patient-years was 2.73 (95% CI 2.12, 3.50) in the ARB group, 1.76 (95% CI 1.25, 2.39) in the ACEi group and 1.90 (95% CI 1.37, 2.56) in the other antihypertensives group. The hazard of GCA was higher in ARB initiators [hazard ratio (HR) 1.55; 95% CI 1.16, 2.06] than initiators of ACEis, but similar between initiators of other antihypertensives and ACEis (HR 1.08; 95% CI 0.87, 1.35).

CONCLUSIONS

Initiation of ARBs is associated with a higher risk of GCA compared with ACEis or other antihypertensives. Mechanistic studies of angiotensin receptor biology will provide further clarity for our findings.

Clinical characteristics of COVID-19 associated vasculopathic diseases

Coronavirus disease 19 (COVID-19) has shown to be an infectious disease affecting not only of the respiratory system, but also cardiovascular system leading to different COVID-19-associated vasculopathies. Venous and arterial thromboembolic events have been frequently described among hospitalized patients with COVID-19 and inflammatory vasculopathic changes have also been observed. Several of the reported COVID-19 associated vasculopathies exhibit differences on epidemiology, clinical characteristics and outcome compared to non-COVID-19 types. This review focuses on the epidemiology, clinical, diagnostic and therapeutic characteristics as well as outcome data of COVID-19 associated thromboembolic events and inflammatory vasculopathies, elaborating similarities and differences with non-COVID-19 cohorts.

Genetic predisposition between coronavirus disease 2019 and rheumatic diseases: A 2-sample Mendelian randomization study

OBJECTIVE

The causalities between the coronavirus disease 2019 (COVID-19) and the risk of rheumatic diseases remain unclear. The purpose of this study was to investigate the causal effect of COVID-19 on rheumatic disease occurrence.

METHODS

Single nucleotide polymorphisms (SNPs), acquired from published genome-wide association studies, were used to perform 2-sample Mendelian randomization (MR) on cases diagnosed with COVID-19 (n = 13 464), rheumatic diseases (n = 444 199), juvenile idiopathic arthritis (JIA, n = 15 872), gout (n = 69  374), systemic lupus erythematosus (SLE, n = 3094), ankylosing spondylitis (n = 75 130), primary biliary cholangitis (PBC, n = 11 375) and primary Sjögren's syndrome (n = 95 046). Three MR methods were used in the analysis based on different heterogeneity and pleiotropy using the Bonferroni correction.

RESULTS

The results revealed a causality between COVID-19 and rheumatic diseases with an odds ratio (OR) of 1.010 (95% confidence interval [CI], 1.006-1.013; P = .014). In addition, we observed that COVID-19 was causally associated with an increased risk of JIA (OR 1.517; 95%CI, 1.144-2.011; P = .004), PBC (OR 1.370; 95%CI, 1.149-1.635; P = .005), but a decreased risk of SLE (OR 0.732; 95%CI, 0.590-0.908; P = .004). Using MR, 8 SNPs were identified to associate with COVID-19 and recognized as significant variables. None of them were previously reported in any other diseases.

CONCLUSIONS

This is the first study to use MR to explore the impact of COVID-19 on rheumatic diseases. From a genetic perspective, we found that COVID-19 could increase the risk of rheumatic diseases, such as PBC and JIA, but decrease that of SLE, thereby suggesting a potential surge in the disease burden of PBC and JIA following the COVID-19 pandemic.

Incidence of biopsy-proven giant cell arteritis (GCA) in South Australia 2014-2020

Objective

To determine the incidence of biopsy proven giant cell arteritis (GCA) in South Australia.

Methods

Patients with biopsy-proven GCA were identified from pathology reports of temporal artery biopsies at state-based pathology laboratories, from 1 January 2014 to 31 December 2020. Incidence rates for biopsy-proven GCA were calculated using Australian Bureau of Statistics data for South Australian population sizes by age, sex, and calendar year. Seasonality was analyzed by cosinor analysis.

Results

There were 181 cases of biopsy-proven GCA. The median age at diagnosis of GCA was 76 years (IQR 70, 81), 64% were female. The estimated population incidence for people over 50 was 5.4 (95% CI 4.7, 6.1) per 100,000-person years. The female: male incidence ratio was 1.6 (95% CI 1.2, 2.2). There was no ordinal trend in GCA incidence rates by calendar year (p = 0.29). The incidence was, on average, highest in winter, but not significantly (p = 0.35). A cosinor analysis indicated no seasonal effect (p = 0.52).

Conclusion

The incidence of biopsy-proven GCA remains low in Australia. A higher incidence was noted compared to an earlier study. However, differences in ascertainment and methods of GCA diagnosis may have accounted for the change.

COVID-19 among patients with giant cell arteritis: a single-centre observational study from Slovenia

OBJECTIVES

Patients with giant cell arteritis (GCA) represent a fragile population with an increased infection risk. In a recent study, older age, a higher number of comorbidities, higher disease activity and prednisolone ≥ 10 mg/day were associated with worse COVID-19 outcome. We aimed to evaluate the frequency and severity of COVID-19 in a well-defined GCA cohort.

METHODS

We reviewed medical records of histologically and/or by imaging-proven GCA patients diagnosed between September 2011 and February 2020 at our secondary/tertiary centre and followed during the COVID-19 pandemic between March 2020 and February 2022 (24 months). Descriptive statistics were used to explore the studied population.

RESULTS

Of 314 patients with GCA diagnosed for the first time during a 102-month period, 49 patients died before March 2020. Of the remaining 265 patients, 55 (20.8%) patients suffered from a total of 57 SARS-CoV-2 infections. We observed 44 (77.2%) mild and 13 (22.8%) severe COVID-19 episodes (the latter defined as needing hospitalization, death or thrombotic complication). Patients with severe COVID-19 were more likely to have arterial hypertension (12 [92.3%] vs. 25 [56.8%]; p = 0.022), cardiovascular disease (7 [53.8%] vs. 10 [22.7%]; p = 0.043) or obesity (5 [38.5%] vs. 5 [11.4%]; p = 0.038). Neither prednisolone dose 1-5 mg/day (p = 0.483) nor leflunomide use (p = 1.000) was associated with COVID-19 course. There were no significant differences in sex, age, GCA type, GCA disease duration and other comorbidities in patients with mild and severe COVID-19 in our cohort.

CONCLUSION

More than a fifth of our GCA patients had severe COVID-19. Treatment with leflunomide or low doses of glucocorticoids were not associated with severe course in our cohort. Key Points • Treatment with leflunomide or low doses of glucocorticoids were not associated with worse COVID-19 outcome. • Outcomes of COVID-19 improved as the COVID-19 pandemic, prevention and treatment options evolved. • Arterial hypertension, cardiovascular disease or obesity were associated with severe COVID-19.

Arteritic Anterior Ischemic Optic Neuropathy in the Course of Giant Cell Arteritis After COVID-19

BACKGROUND Giant cell arteritis (GCA) is an inflammation of large vessels that affects the lining of the arteries and leads to vessel swelling and the eventual reduction of blood flow. This can result in ischemia of the optic nerve, which is known as arteritic anterior ischemic optic neuropathy (AAION). The present case seems noteworthy because the patient developed GCA with the ocular manifestation of AAION shortly after having COVID-19. CASE REPORT A 69-year-old woman was admitted to the Clinic of Ophthalmology after having COVID-19. She reported vision loss in the left eye, which appeared 2.5 weeks after a positive SARS-CoV-2 test. While in the hospital, she was diagnosed with AAION and GCA. The patient was treated with enoxaparin sodium, prednisone, and methotrexate. Three months after the hospitalization, the visual acuity of the left eye was limited to light perception, and optic nerve atrophy was reported. CONCLUSIONS We would like to emphasize the role of SARS-CoV-2 infection as a possible risk factor for the onset of GCA and its ocular manifestations, such as AAION. However, further research is needed to determine the relationship between SARS-CoV-2 infection and GCA. Because some symptoms of the 2 diseases are similar, the diagnosing process might be long and challenging. The diagnosis of GCA should be made as soon as possible to avoid serious complications, such as bilateral vision loss.