The important role of Internist in the recognition of ANCA-associated vasculitis in an ordinary Internal Medicine ward

Introduction: Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) are a group of systemic vasculitides that predominantly affect small vessels. Clinical phenotype is heterogeneous: kidney and/or pulmonary involvement is described in up to 75-90% of cases. Among these, rapidly progressive glomerulonephritis and diffuse alveolar haemorrhage are the most serious manifestations. Description of the case: A 73-year-old man presented with 15 days history of fever, productive cough and fatigue (SARS-CoV- 2 nasopharyngeal swab negative);antibiotic therapy prescribed was ineffective. Afterwards he developed necrosis of right hand distal phalanx, oedema of lower extremities, dyspnoea for mild exertion and acute renal failure, that needed dialysis. A lung HRCT showed ground glass opacities, blood tests underlined high inflammatory indices and high title PR3-ANCA positivity. Diagnosis of PR3-ANCA associated vasculitis was made and glucocorticoid therapy with methylprednisolone (1mg/Kg/day) was started. For the occurrence of emoptysis, respiratory failure and anemization, suspecting diffuse alveolar haemorrhage, methylprednisolone pulse therapy (500 mg/day for 5 days), plasmapheresis and rituximab (375 mg/m2/week for 4 infusions) were administered. There was a progressive clinical-laboratory improvement. However the patient developed intestinal perforation and died. Conclusions: AAV represent rare diseases, burdened by a poor prognosis. They need a careful internist and a multidisciplinary approach to ensure an early therapeutic intervention.

Monoclonal antibody therapy for high-risk Coronavirus (CoViD-19) patients with mild to moderate disease presentation: An encouraging experience in Frosinone Hospital

Background and Aim: The coronavirus disease 2019 (CoViD-19) pandemic has caused a worldwide crisis and encouraged an urgent search for prevention and treatment of infection. SARS-CoV- 2 neutralizing monoclonal antibodies (NMA), that bind the viral spike glycoprotein, are a new treatment able to attenuate disease progression. In this observational study we reported our experience in the NMA treatment of early CoViD-19. Materials and Methods: From March to May 2021 we enrolled patients affected by CoViD-19 with risk factors to develop severe disease and early onset of symptoms (preferably within 72 hours, not more than 10 days). All patients were subjected to phone monitoring up to 30 days after drug administration. Results:We evaluated 40 patients (M/F 24/16;median age 58.5 years, IQR 12.25;median symptoms duration before treatment 5 days, IQR 2), of which 36 were treated with bamlanivimab/etesevimab association, 3 with casirivimab/imdevimab, 1 with bamlanivimab. Sixteen patients (40%) were affected by obesity, 21 (52.5%) by hypertension, 9 (22.5%) by diabetes, 8 (20%) by chronic lung disease, 7 (17.5%) by secondary immunodeficiency. Serious adverse events did not occur during infusion and follow up. Five patients (12.5%) developed severe CoViD-19 with lung failure and needed hospitalization. Of these, one patient died. Conclusions: SARS-CoV-2 NMA could be a valid therapeutic option to decrease hospitalization and mortality rate. However we need to select eligible patient, evaluating risk factors and early timing of intervention.