[Scleritis and episcleritis]

Scleritis and episcleritis are rare ocular inflammatory diseases but deserve to be known by internists because of their frequent association with systemic autoimmune diseases. It is important to distinguish them between because their prognosis, therapeutic management and potential complications are very different. Episcleritis represents a superficial ocular inflammation with usually benign visual prognosis, no complication with local treatment, and is associated with a systemic autoimmune disease in rare cases. In contrast, scleritis is a potentially serious ophthalmological condition that can threaten the visual prognosis in the absence of appropriate systemic treatment. It is associated with an underlying disease in 40-50% of cases, in particular a systemic autoimmune disease (25-35% of cases) or an infectious cause (5-10% of cases). Rheumatoid arthritis and systemic vasculitides, particularly antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides, are the main autoimmune causes of scleritis and episcleritis. Scleritis can reveal the underlying autoimmune disease and requires systematic etiological investigations. Aggressive, complicated, refractory forms or those associated with a systemic autoimmune disease require glucocorticoids or even immunosuppressants, and close collaboration between ophthalmologists and internists is required. The development of biologic agents offers new effective therapeutic tools in the management of these difficult cases.

POS0825 CLINICAL CHARACTERISTICS AND TREATMENT MANAGEMENT OF NON-INFECTIOUS SCLERITIS WITH CORTICOSTEROID-SPARING THERAPY. A RETROSPECTIVE STUDY FROM A TERTIARY EYE CARE CENTER

Background

Non-infectious scleritis refers to a rare and sight-threatening scleral inflammation. An association with an underlying systemic disease is noted in 30% to 40% of cases. Their management may require the use of nonsteroidal anti-inflammatory drugs, oral corticosteroids, and sometimes steroid-sparing immunosuppressive agents. Because of the low incidence and prevalence of scleritis, treatment guidelines are currently not available.

Objectives

We analyzed in a retrospective observational study patients with scleritis referred to the Foundation Rothschild Hospital (Paris) from March 2011 to June 2021.

Methods

Characteristics, visual outcomes, ocular complications, associations with systemic diseases and efficacy of treatment were assessed in patients with non-infectious scleritis who needed steroid-sparing immunosuppressive agents.

Results

Among 731 patients diagnosed with scleritis, 54 patients (71 eyes, 7%) were treated by steroid-sparing immunosuppressive agents. Mean follow up was 111.9 ± 84.5 weeks. Mean age was 48.4 years ± 18.3, and 31 patients (57%) were female. Scleritis was anterior in 51 eyes (72 %), including 25 (35%) with diffuse scleritis, 24 (34%) with nodular scleritis and 2 (3%) with necrotizing scleritis. Scleritis was posterior in 20 eyes (28%). Bilateral involvement was noted in 17 patients (32 %). Ocular complications were observed in 52 eyes (73 %): scleral thinning in 25 eyes (35%), anterior uveitis in 24 eyes (34 %), loss of vision in 20 eyes (28%), posterior segment ocular complications in 18 eyes (25%), ocular hypertension in 17 eyes (24%) and corneal involvement in 16 eyes (23%). An underlying systemic disease was identified in 28 patients (52 %), and scleritis was the first manifestation of the systemic disease in 17 out of 28 patients. Rheumatoid arthritis was the most frequently identified disease (n=12), followed by granulomatosis with polyangiitis (n=8) and relapsing polychondritis (n=4). All patients received at least one immunosuppressive agent. Corticosteroid sparing with a daily dose ≤ 5 mg of prednisone was achieved in 85% of patients. Conventional immunosuppressive agents were used as the first steroid-sparing agent in 38 patients (70%) (methotrexate n=33, azathioprine n=4, mycofenolate mofetil (MMF) n=1) and as second steroid-sparing agent in 1 patient (MMF). This treatment led to control scleral inflammation in 23 (59%) patients after a mean delay of 10.0 ± 6.0 weeks. Biologic therapy was used in 33 (61%) patients (TNF alpha inhibitor n=17, IL6-R inhibitor n=7, anti-CD20 n=9), and as the first steroid-sparing agent in 16 (30%) (TNF alpha inhibitor n=4, IL6-R inhibitor n=4, anti-CD20 n=8). This treatment led to control scleral inflammation after a mean delay of 4,9 ± 3,7 weeks in 29 patients (87.9%).

Conclusion

Scleritis is a severe ocular inflammatory disease that requires repeated and thorough ophthalmologic and general examinations given the high frequency of complications and the possibility of an underlying systemic disease. This study reports real-life experience in management of non-infectious scleritis. Biological therapies seemed to be associated with a better outcome and a quicker reponse than conventional immunosuppressive agents. Further studies are warranted to develop specific guidelines

Disclosure of Interests

None declared

POS0808 CHARACTERISTICS AND PROGNOSIS OF BINOCULAR DIPLOPIA IN PATIENTS WITH GIANT CELL ARTERITIS

Background

Giant cell arteritis (GCA) is a large vessel vasculitis associated with a risk of permanent ophthalmologic complications. Diplopia is an uncommon feature at GCA diagnosis and data about diplopia in GCA are scarce, especially regarding its prognosis.

Objectives

This study was designed to better characterize diplopia in newly diagnosed GCA patients.

Methods

All consecutive patients diagnosed with GCA between January 2015 and April 2021 in a French tertiary ophthalmologic center were retrospectively reviewed. GCA diagnosis relied on 1990 ACR criteria and either a positive temporal artery biopsy or high-definition MRI.

Results

Among 111 patients diagnosed with GCA in our tertiary eye-care center, 80 patients (72%) had visual signs, including 30 patients (27%) with binocular diplopia. Characteristics of patients with diplopia were similar to other GCA patients. Twenty-eight patients (93%) had cephalic symptoms (Headaches n = 25, scalp tenderness n = 14, jaw claudication n = 17) and 7 patients (23%) had associated polymyalgia rheumatica. All patients with diplopia had an elevated C-reactive protein compared with 91% of patients without diplopia (p = 0.06). Large vessel involvement was found in 4 patients (16%) with diplopia. Diplopia was attributed to cranial nerve palsy in 21/24 (88%) patients, especially third (50%) and sixth cranial nerve (48%) palsies. Median duration of diplopia before GCA diagnosis was 10 days (Inter-quartile range [IQR]: 4-19). Eleven patients (37%) were diagnosed with ocular ischemic lesions, including 5 patients (17%) with bilateral visual impairment, resulting in a severe loss of vision in 9 patients and a resolution of binocular diplopia in all these patients due to unilateral or bilateral vision loss. Acute ischemic optic neuropathy (AION) was diagnosed in 11 eyes, central retinal artery occlusion (CRAO) in 4 eyes and paracentral acute middle maculopathy in 2 eyes. Diplopia resolved spontaneously in 6 patients (20%). In the remaining 13 patients, diplopia resolved after the initiation of corticosteroids in 12 patients (92%) with a median delay of 10 days (IQR: 5-24). IV corticosteroids seemed to be associated with a quicker improvement than oral corticosteroids (6 days [IQR 4-28] vs 11 days [IQR 6-13], p = 0.81) but with a similar resolution rate of diplopia at one month (66% vs 78 %, p = 1). Two patients had visual impairment after the initiation of corticosteroids and two patients had diplopia relapse during the course of GCA.

Conclusion

Diplopia is a rare but not exceptional feature at GCA diagnosis and should raise clinician suspicion for GCA when associated with cephalic symptoms and elevated inflammatory biomarkers. We confirmed in this study that patients with diplopia were also at risk of ischemic ocular lesions, particularly AION and CRAO, with a subsequent risk of severe loss of vision. In patients without visual impairment, the prognosis of diplopia is good after initiation of treatment with a complete resolution in most patients at one month but with a potential risk of diplopia recurrence in case of GCA relapse.

Disclosure of Interests

None declared

Pre-COVID-19 Immunity to Common Cold Human Coronaviruses Induces a Recall-Type IgG Response to SARS-CoV-2 Antigens Without Cross-Neutralisation

The capacity of pre-existing immunity to human common coronaviruses (HCoV) to cross-protect against de novo COVID-19is yet unknown. In this work, we studied the sera of 175 COVID-19 patients, 76 healthy donors and 3 intravenous immunoglobulins (IVIG) batches. We found that most COVID-19 patients developed anti-SARS-CoV-2 IgG antibodies before IgM. Moreover, the capacity of their IgGs to react to beta-HCoV, was present in the early sera of most patients before the appearance of anti-SARS-CoV-2 IgG. This implied that a recall-type antibody response was generated. In comparison, the patients that mounted an anti-SARS-COV2 IgM response, prior to IgG responses had lower titres of anti-beta-HCoV IgG antibodies. This indicated that pre-existing immunity to beta-HCoV was conducive to the generation of memory type responses to SARS-COV-2. Finally, we also found that pre-COVID-19-era sera and IVIG cross-reacted with SARS-CoV-2 antigens without neutralising SARS-CoV-2 infectivity in vitro. Put together, these results indicate that whilst pre-existing immunity to HCoV is responsible for recall-type IgG responses to SARS-CoV-2, it does not lead to cross-protection against COVID-19.

Évolution clinique et facteurs de risque de développer une forme grave de la maladie à coronavirus 2019 (COVID-19) chez les patients atteints de lupus systémique

Introduction

Matériels et méthodes

Résultats

Conclusion

The cerebrospinal fluid CD4/CD8 ratio and interleukin-6 and -10 levels in neurosarcoidosis: a multicenter, pragmatic, comparative study

BACKGROUND AND PURPOSE

Neurosarcoidosis is a rare inflammatory disorder of unknown cause. The aim of this study was to evaluate the value of T/B lymphocyte population counts and the concentrations of the cytokines interleukin (IL) 6 and IL-10 in the cerebrospinal fluid (CSF) of neurosarcoidosis patients.

METHODS

A retrospective study CSF biomarkers was conducted in patients with neurosarcoidosis who underwent CSF analysis between 2012 and 2017 as well as various control populations.

RESULTS

Forty-three patients with neurosarcoidosis, 14 with multiple sclerosis (MS) and 48 with other inflammatory disorders were analyzed. The CSF IL-6 levels were higher in sarcoidosis patients than in MS patients (median 8 vs. 3 pg/ml, P = 0.006). The CSF CD4/CD8 ratio was higher in sarcoidosis patients than in MS patients and in patients with other inflammatory disorders (median 3.18 vs. 2.36 and 2.10, respectively, P = 0.008). The CSF IL-6 level was higher in patients with active neurosarcoidosis than in non-active neurosarcoidosis patients (median 13 vs. 3 pg/ml, P = 0.0005). In patients with neurosarcoidosis, a CSF IL-6 concentration >50 pg/ml was associated with a higher risk of relapse or progression-free survival (hazard ratio 3.60; 95% confidence interval 1.78-23.14). A refractory neurosarcoidosis patient was treated with an anti-IL-6 monoclonal antibody that produced a complete neurological response.

CONCLUSIONS

The CSF CD4/CD8 ratio and IL-6 concentration are increased in neurosarcoidosis compared to MS and other inflammatory disorders. A CSF IL-6 concentration >50 pg/ml is associated with relapse or progression of neurosarcoidosis. IL-10 levels may be elevated in neurosarcoidosis.

[Mediastinitis following endobronchial ultrasound-guided transbronchial needle aspiration]

INTRODUCTION

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure designed to explore mediastinal lymphadenopathy. Its use and indications have increased recently and severe, though rare, complications have been reported.

CASE REPORT

EBUS-TBNA was performed in a 64-year-old patient presenting with mediastinal lymphadenopathy, probably due to sarcoidosis, but without histological proof. Within hours of the aspiration of subcarinal lymph nodes (station 7), the patient developed fever and dry cough associated with progressive dysphagia and dysphonia that persisted for four weeks. Mediastinitis was diagnosed after a CT-scan revealed a collection in the subcarinal space previously tapped using CT guidance. Intravenous antibiotics were started and both symptoms and the mediastinal collection resolved without need of a surgical procedure. The patient recovered fully.

CONCLUSION

EBUS-TBNA is associated with a risk of mediastinitis that may manifest as an isolated fever arising within hours of the procedure. The pathogens responsible are usually contaminants from the oropharynx such as Streptococcus sp, probably inoculated directly into the mediastinum during transbronchial needle aspiration. Rapid diagnosis and treatment are necessary in order to reduce morbidity and mortality associated with mediastinitis.