• giant cell arteritis
• ultrasonography
• COVID-19
• systemic vasculitis

We read with interest the correspondence by Montero et al 1 on our study about the impact of novel COVID-19 on Italian patients with large vessel vasculitis.2 First of all, we thank the authors for the positive appraisal of our study and for providing their original contribution, which certainly enhances our knowledge of the influence that the COVID-19 pandemic had, and is still having, on patients affected by giant cell arteritis (GCA).

The authors performed a comparative study evaluating the rate of referral to their ultrasound fast-track clinic (FTC) in Madrid before and during the first 8 months of the pandemic (July 2019–February 2020 and March 2020–October 2020). Interestingly, since the COVID-19 outbreak, they observed a 38% reduction in GCA FTC referrals, with no significant reduction in terms of new GCA diagnosis. In addition, they reported a slight increase of possibly preventable acute ischaemic optic neuropathies (AIONs). This topic is of fundamental importance for patients affected by GCA, as the possibility of reducing irreversible long-term complications has dramatically been enhanced by the increased introduction of GCA FTCs in many countries.3

In keeping with Montero et al’s observation, even in our centre (San Raffaele Hospital, Milan, Italy), we did not observe a significant reduction in the rate of newly diagnosed patients with GCA in the two reference periods, as the number varied from 26 (July 2019–February 2020) to 23 (March 2020–October 2020). However, we noticed a more remarkable drop in the 8-month period from November 2020 to June 2021, when a total of 19 patients were diagnosed with GCA, with a reduction of 27% compared with the pre-pandemic period. Notably, this variation was paralleled by an increase in the percentage of patients with GCA who developed arteritic ischaemic ocular complications, including AION and central retinal artery occlusion (CRAO). In the 8 months preceding the first-wave of the pandemic, the percentage of patients with ocular complications was 15% (n=4, all with AION). This fraction increased to 22% (AION, n=4; CRAO, n=1) in the following 8 months and peaked to 28% (AION, n=4; CRAO, n=1) in the last 8 months, although the difference was not statistically significant (p=0.46). It is though worth noticing that since November 2020, Italy and especially the Lombardy region started a second lockdown due to a dramatic increase in the number of new COVID-19 cases. Even if our FTC had been fully restored to function since May 2020, some patients refused to undergo hospital evaluations for suspected GCA due to concerns about the risk of SARS-CoV-2 infection.

The experience of our GCA FTC clinic and the experience of our Spanish colleagues further confirm the importance of a dedicated hospital referral pathway for patients with suspected GCA to avoid irreversible complications. GCA is a rheumatic emergency and any delay might have unbearable costs. Strategies aiming at increasing the referral of suspected patients with GCA should be even more implemented.