AB1160 IMPACT OF COVID-19 TREATMENTS ON PERIPHERAL CAPILLARY DENSITY EVALUATED BY NAILFOLD VIDEOCAPILLAROSCOPY

Background

Human SARS-CoV-2 infection can induce a wide spectrum of organ dysfunctions, including microvascular impairment [1]. S1 subunit of viral receptor-binding domain binds to the angiotensin-converting enzyme 2 receptor on endothelium and S2 subunit allows the virus to enter endothelial cells. The resulting breakdown of barrier integrity drives a cascade of inflammatory and thrombotic events, that aggravate the course of COVID-19 together with other risk factors [2-4]. Up to date, a lower capillary density has been reported in several distinct body districts, using sublingual video microscopy, ocular optical coherence tomography angiography, skin functional laser Doppler perfusion imaging and nailfold videocapillaroscopy (NVC) [5-8]. NVC examination has been performed in adult COVID-19 patients, however, without a control group [8].

Objectives

To confirm the statistical significance of the reduction in capillary density per linear millimeter evaluated by NVC in comparison with primary Raynaud’s phenomenon (PRP) patients and control subjects (CNT) and to evaluate the impact of an aggressive therapy against COVID-19 on the sparing in the number of capillaries.

Methods

Sixty-one COVID-19 survivors, thirty-one PRP patients and thirty CNT age and sex-matched underwent NVC analysis. Demographic and clinical data of COVID-19 survivors were collected with special regard to concomitant therapies, that included antivirals, antibiotics, anticoagulants and anti-inflammatory/immunomodulant drugs (glucocorticoids, hydroxychloroquine, IL-6 receptor antagonist). COVID-19 survivors were divided in two subgroups according to the severity of the active infection: thirty-four survivors with past mild-moderate disease (either unneedy for oxygen supplementation or need for Venturi mask) and twenty-seven survivors with past severe disease (need for Continuous Positive Airways Pressure and/or mechanical ventilation). The same Rheumatologist performed NVC evaluations in all patients and controls, using an optical probe, equipped with a 200x magnification lens and connected to a picture analysis software (Videocap, DS Medica, Milan, Italy). Absolute capillary number per linear millimeter was counted.

Results

COVID-19 survivors underwent NVC examination after a mean period of 126±53 days from the disease onset. Multivariate analysis showed differences in absolute capillary number per linear millimeter (p<0.001) after adjusting for age, sex, body mass index, comorbidities and concomitant drugs. The mean (± standard deviation) absolute nailfold capillary number per linear millimeter was significantly lower in severe (8.2±1.15) and mild-moderate (8.4±0.75) COVID-19 survivors than in both PRP (8.7±0.68) and CNT subjects (9.3±0.53) (p<0.001). The analysis of the impact of treatments on capillary density in the severe COVID-19 patients showed a positive trend (preservation of the capillary number) with antivirals (no: 7.8±1.53; yes: 8.5±0.64; p=0.35) and anti-IL-6 receptor antagonist administration (no: 7.8±1.36; yes: 8.6±0.74; p=0.16), while none of the other drugs was shown to be effective (glucocorticoids p = 0.46; antibiotics = 0.52; anticoagulants not evaluable as they were used in all COVID-19 patients).

Conclusion

SARS-CoV-2 infection seems associated to a significant capillary loss as distinctive NVC feature and data concerning the comparison of capillary density pre COVID-19 and post COVID-19 are desirable to reinforce this observation. The positive trend in saving the number of capillaries induced by aggressive anti-inflammatory therapies in COVID-19 survivors needs larger cohorts of patients.

References

[1]Rovas A et al. Angiogenesis. 2021;24:145-157.

[2]Raghavan S et al. Front Cardiovasc Med. 2021;8:687783.

[3]Cutolo M et al. RMD Open. 2020;6:e001454.

[4]Sulli A et al. Nutrients. 2021;13(3):717.

[5]Kanoore Edul VS et al. J Crit Care. 2021;61:73-75.

[6]Teo KY et al. Am J Ophtalmol. 2021;235:98-110.

[7]Sabioni L et al. Microvasc Res. 2021;134:104119.

[8]Natalello G et al. Microvasc Res. 2021;133:104071.

Disclosure of Interests

Emanuele Gotelli: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci S.p.a., Pietro Francesco Bica: None declared, Irene Schiavetti: None declared, Teresita Aloe’: None declared, Marco Grosso: None declared, Emanuela Barisione: None declared, Carmen Pizzorni: None declared, Sabrina Paolino: None declared, Vanessa Smith Grant/research support from: Boehringer Ingelheim, Janssen-Cilag, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Celgene, Pfizer, Boehringer Ingelheim

AB1370 MICROVASCULAR CAPILLAROSCOPIC ABNORMALITIES AND AUTOANTIBODY OCCURRENCE IN SARCOIDOSIS PATIENTS

Background

Sarcoidosis (S) is a granulomatous disease with multi-organ involvement displaying a mixed immune-mediated pathophysiology. Raynaud’s phenomenon (RP) has been occasionally reported in S patients [1] and serum positivity for autoantibodies has been detected in S patients but their significance is debated [2].

Objectives

We described nailfold videocapillaroscopy (NVC) findings and estimated the prevalence of serum anti-nuclear (ANA) and extractable nuclear antigen autoantibodies (ENA-Abs) in S patients, comparing them with age- and sex- matched healthy controls (HCs) and patients with primary Raynaud’s phenomenon (PRP). Secondarily, we analysed potential correlations between NVC findings with the occurrence of autoantibodies, immunomodulatory treatment, laboratory parameters, variables of pulmonary function and whole-body imaging.

Methods

Twenty-seven (27) S patients, classified according to WASOG criteria[3], were assessed through NVC examination, laboratory parameters (including serum concentrations of angiotensin-converting enzyme [ACE], C-reactive protein [CRP], calcium, phosphorus, albumin, 25-hydroxyvitamin D, parathormone, ANA and ENA), pulmonary function tests (PFTs), chest-X ray and positron emission tomography/computerized tomography (PET/CT).

Among NVC parameters, we analysed capillary dilations, giant capillaries, haemorrhages, nonspecific abnormalities, and capillary absolute number for mm [4].

Pulmonary involvement was classified by X-ray Scadding staging system (SSS) scoring S patients in 4 grades [5]. From PET data, the maximum standard uptake value (SUVmax) was quantified as a variable of tissue 18-fluorodeoxyglucose hyper-uptake: consequently, S patients were defined PET-positive when SUV value ≥ 2.5. NVC parameters and ANA/ENA dosage were recorded also in 30 PRPs and 30 HCs.

Results

We excluded, among the cohort of S patient, one participant having a systemic sclerosis in overlap with S. The remaining 26 S patients (mean age 56.5 ± 12.5 years, 53.8 % of females, disease duration 28.4 ± 55.1 months, 27% glucocorticoid-naïve) showed a significant higher rate of dilations and nonspecific abnormalities and a lower mean capillary absolute number than PRPs and HCs (p < 0.01 for all comparisons). (Figure 1)

The prevalence of ANA positivity was significantly higher in S patients compared with PRPs and HCs (p < 0.02 for both). Among the whole cohort of patients only one S patient displayed a positive ENA-Ab (Ro52).

In the analysis of S patients’ subgroup, a significant negative correlation was detected between serum ACE levels with the presence of capillary dilations (rho = -0.45, p = 0.04), between CRP and mean capillary absolute number (rho = -0.49, p = 0.02) and a positive correlation was also detected between the mean capillary absolute number and the forced vital capacity percentage (FVC%) (rho = 0.40, p = 0.04).

Conclusion

Our findings suggest a microvascular involvement in sarcoidosis whose investigation by NVC could be useful for the detection of an overlapping connective tissue disease and for the monitoring of the phenotypes of S patients displaying RP.

The positivity for autoantibodies in S patients is in line with literature data suggesting, at least partially, autoimmune features of the disease or the production of autoantibodies reactive to tissue damage.

The correlations between NVC findings with ACE levels and lung function variables generate hypotheses of a potential partial vascular impairment in sarcoidosis disease activity and lung involvement.

References

[1]Nigro A et al. Reumatismo 2004; 56: 278-81.

[2]Kobak S et al. Autoimmune Diseases 2014

[3]Judson M.A et al. Clin Rev Allergy Immunol 2015; 49: 63-78.

[4]Smith V et al. Autoimmun Rev 2020; 19: 102458.

[5]Scadding J.G. Br Med J 1961; 2: 1165-72.

Disclosure of Interests

None declared

AB0679 NAILFOLD VIDEOCAPILLAROSCOPY RESULTS IN COVID-19 PATIENTS RECOVERED FROM DIFFERENT DISEASE SEVERITY

Background:

COVID-19 is a multifaceted condition with a wide range of clinical manifestations, including microvascular/endothelial dysfunction, that starts in the early phase of the disease and may become dramatically harmful in the late stage, causing a massive pro-thrombotic state. Nailfold videocapillaroscopy (NVC) is the most used tool to identify microvascular status in a large spectrum of diseases [1]. Recently, non-specific NVC abnormalities have been described in a cohort of COVID-19 patients (no controls used) [2].

Objectives:

To assess microvascular damage in recovered COVID-19 patients (range of 40-270 days from recovery) by considering the previous severity of the disease, and, as mandatory, the comparison with matched individuals suffering from primary Raynaud’s phenomenon (PRP) and healthy volunteers (HV).

Methods:

NVC investigations were performed during standard clinical assessments in forty-four recovered COVID-19 patients (mean age 58±14 years, mean days from disease onset 129±54, mean days from disease recovery 106±52), twenty-two patients with PRP (mean age 60±15 years, mean years from disease onset 11±10) and twenty-two HV (mean age 60±14 years). COVID-19 patients were divided into two subgroups, according to the need of oxygen supplementation: twenty-two patients with severe lung involvement (need of Continuous Positive Airways Pressure and/or mechanical ventilation, mean age 57±12 years) vs twenty-two patients with mild-moderate lung involvement (need of Venturi mask or no need of oxygen supplementation, mean age 59±15 years). Clinical and demographic data of all the enrolled subjects were collected, during NVC examination. The following capillaroscopic parameters were evaluated: capillary number, dilated capillaries, giant capillaries, microhemorrhages, angiogenesis, disorganization of the microvascular array. A validated semiquantitative scoring (0-3) was adopted for NVC abnormalities [3-5]. Statistical analysis was carried out by non-parametric tests.

Results:

After COVID-19 recovery, no statistically significant difference was observed between COVID-19 patients and control groups of subjects concerning the score for the following NVC parameters: dilated capillaries, giant capillaries, disorganization of the microvascular array, angiogenesis. However, the capillary number per linear millimeter was significantly lower in COVID-19 patients (8.3±0.9) than in PRP (8.8±0.7, p=0.05) and HV (9.3±0.6, p<0.0001). Surprisingly, recovered COVID-19 patients showed significantly less microhemorrhages (score 0.4±0.3) than subjects of the other groups (PRP 0.6±0.5, p=0.01; HV 0.6±0.6, p=0.05). In particular, recovered patients who had more severe COVID-19 showed less microhemorrhages than patients with mild/moderate disease (score 0.18±0.4 vs 0.36±0.5), but this didn’t reach the statistical significance (p=0.18). On the other hand, patients recovered from severe SARS-CoV-2 infection also showed higher rate of angiogenesis (0.18±0.4) than patients with mild/moderate disease (no case, p=0.04).

Conclusion:

COVID-19 doesn’t seem to significantly induce, in short-term, specific alterations in peripheral microvascular array as evaluated by NVC, despite the severity of the disease, except for a significant reduction of the absolute number of nailfold capillaries. The topic needs longer time of evaluation and larger number of COVID-19 recovered cases to also assess the role of concomitant therapies.

References:

[1]Ingegnoli F et al. Curr Rheumatol Rev. 2018;14:5-11.

[2]Natalello G et al. Microvasc Res. 2021;133:104071.

[3]Smith V et al. Autoimmun Rev 2020;19:102458.

[4]Cutolo M et al. Clin Rheumatol. 2019;38:2293-2297.

[5]Sulli A et al. Ann Rheum Dis. 2008;67:885-7.

Disclosure of Interests:

None declared

Balancing evidence and frontline experience in the early phases of the COVID-19 pandemic: current position of the Italian Society of Anti-infective Therapy (SITA) and the Italian Society of Pulmonology (SIP)

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease 2019 (COVID-19), which has rapidly become epidemic in Italy and other European countries. The disease spectrum ranges from asymptomatic/mildly symptomatic presentations to acute respiratory failure. At the present time the absolute number of severe cases requiring ventilator support is reaching or even surpassing the intensive care unit bed capacity in the most affected regions and countries.

OBJECTIVES

To narratively summarize the available literature on the management of COVID-19 in order to combine current evidence and frontline opinions and to provide balanced answers to pressing clinical questions.

SOURCES

Inductive PubMed search for publications relevant to the topic.

CONTENT

The available literature and the authors' frontline-based opinion are summarized in brief narrative answers to selected clinical questions, with a conclusive statement provided for each answer.

IMPLICATIONS

Many off-label antiviral and anti-inflammatory drugs are currently being administered to patients with COVID-19. Physicians must be aware that, as they are not supported by high-level evidence, these treatments may often be ethically justifiable only in those worsening patients unlikely to improve only with supportive care, and who cannot be enrolled onto randomized clinical trials. Access to well-designed randomized controlled trials should be expanded as much as possible because it is the most secure way to change for the better our approach to COVID-19 patients.