Recent Advances in Giant Cell Arteritis

Tocilizumab in cranial and extracranial giant cell arteritis: a national multicentre study of 471 cases

OBJECTIVE

The spectrum of GCA includes various vascular phenotypes. Tocilizumab (TCZ) is the only biologic therapy currently approved, regardless of phenotype. We aimed to assess the effectiveness of TCZ in various phenotypes.

METHODS

This is a multicentre observational study of GCA patients treated with TCZ. They were divided into three phenotypes: (i) cranial (cGCA), (ii) extracranial GCA (ecGCA) and (iii) mixed GCA (mixGCA). Outcomes included clinical remission, EULAR complete remission, relapses, absence of inflammation as shown using imaging techniques, and safety.

RESULTS

We studied 471 patients (342 women; mean age 74.0 ± 9.0 years). The phenotypic distribution was: cGCA (n = 217; 46%), mixGCA (174; 37%) and ecGCA (80; 17%). Patients with ecGCA were younger (66.5 ± 10.1 years) than those with cGCA (74.8 ± 8.1) and those with mixGCA (71.4 ± 8.5), and had a longer delayed GCA diagnosis {median [interquartile range (IQR) [6 (1-14)] vs 1 (1-3) vs 2 (1-6) months, respectively}. Systemic manifestations were similar in the three groups, while ischaemic manifestations were more frequent in cGCA. Combined TCZ, in addition to glucocorticoids, was used more frequently in ecGCA (36%). Clinical remission was observed in 51%/43%/47% in cGCA/ecGCA/mixGCA, respectively, after the first month, and in 79%/81%/89% after 24 months. Complete EULAR remission in 35%/27%/28% (after 1 month) and 72%/73%/67% (after 24 months). Absence of inflammation being shown in the imaging techniques was 15%/26% after 12 months, and 22%/7% (ecGCA/mixGCA) (after 24 months). Relevant adverse events were observed in 109 (23.1%) patients.

CONCLUSION

TCZ shows rapid and maintained effectiveness in all GCA phenotypes in clinical remission and EULAR complete remission. By contrast, absence of inflammation as shown using imaging techniques was much lower in ecGCA and mixGCA.

The clinical significance of T-cell regulation in hypertension treatment

Hypertension, a globally prevalent condition, is closely associated with T cell-mediated inflammatory responses. Studies have shown that T cells, by secreting pro-inflammatory cytokines such as interferon-gamma (IFN-γ), Interleukin-17 (IL-17), and Tumor necrosis factor-alpha (TNF-α), directly lead to vascular dysfunction and elevated blood pressure. The activation of Th1 and Th17 cell subsets, along with the dysfunction of regulatory T cells (Tregs), is a critical mechanism in the onset and progression of hypertension. This review explores the role of T cells in the pathophysiology of hypertension and discusses potential therapeutic strategies targeting T cell regulation, such as immunotherapy and gene-editing technologies. These emerging treatments hold promise for providing personalized therapeutic options for hypertensive patients, reducing inflammatory complications, and improving treatment outcomes.

Giant cell arteritis and therapeutic response: a dual facet of immunotherapy in metastatic clear cell renal carcinoma

Immune checkpoint inhibitors have emerged as a promising cancer treatment, allowing significant and long-term therapeutic responses. Nivolumab, an anti-programmed cell death protein-1, is one of the molecules of this therapeutic class with known and manageable side effects. Giant cell arteritis is a rare immune-related adverse event most often manifested by headaches poorly released by common antalgics and can result in visual loss. We report its occurrence in an 80-year-old patient on maintenance nivolumab for metastatic clear cell renal carcinoma. Prompt diagnosis and initiation of glucocorticoid therapy led to symptom improvement and visual recovery.

T-cell receptor signaling modulated by the co-receptors: Potential targets for stroke treatment

Stroke is a severe and life-threatening disease, necessitating more research on new treatment strategies. Infiltrated T lymphocytes, an essential adaptive immune cell with extensive effector function, are crucially involved in post-stroke inflammation. Immediately after the initiation of the innate immune response triggered by microglia/macrophages, the adaptive immune response associated with T lymphocytes also participates in the complex pathophysiology of stroke and partially informs the outcome of stroke. Preclinical and clinical studies have revealed the conflicting roles of T cells in post-stroke inflammation and as potential therapeutic targets. Therefore, exploring the mechanisms that underlie the adaptive immune response associated with T lymphocytes in stroke is essential. The T-cell receptor (TCR) and its downstream signaling regulate T lymphocyte differentiation and activation. This review comprehensively summarizes the various molecules that regulate TCR signaling and the T-cell response. It covers both the co-stimulatory and co-inhibitory molecules and their roles in stroke. Because immunoregulatory therapies targeting TCR and its mediators have achieved great success in some proliferative diseases, this article also summarizes the advances in therapeutic strategies related to TCR signaling in lymphocytes after stroke, which can facilitate translation. DATA AVAILABILITY: No data was used for the research described in the article.

Interleukin-6 cytokine: An overview of the immune regulation, immune dysregulation, and therapeutic approach

Several studies have shown that interleukin 6 (IL-6) is a multifunctional cytokine with both pro-inflammatory and anti-inflammatory activity, depending on the immune response context. Macrophages are among several cells that secrete IL-6, which they express upon activation by antigens, subsequently inducing fever and production of acute-phase proteins from the liver. Moreover, IL-6 induces the final maturation of B cells into memory B cells and plasma cells as well as an adaptive role for short-term energy allocation. Activation of IL-6 receptors results in the intracellular activation of the JAK/STAT pathway with resultant production of inflammatory cytokines. Several mechanisms-controlled IL-6 expression, but aberrant production was shown to be crucial in the pathogenesis of many diseases, which include autoimmune and chronic inflammatory diseases. IL-6 in combination with transforming growth factor β (TGF-β) induced differentiation of naïve T cells to Th17 cells, which is the cornerstone in autoimmune diseases. Recently, IL-6 secretion was shown to form the backbone of hypercytokinemia seen in the Coronavirus disease 2019 (COVID-19)-associated hyperinflammation and multiorgan failure. There are two classes of approved IL-6 inhibitors: anti-IL-6 receptor monoclonal antibodies (e.g., tocilizumab) and anti-IL-6 monoclonal antibodies (i.e., siltuximab). These drugs have been evaluated in patients with rheumatoid arthritis, juvenile idiopathic arthritis, cytokine release syndrome, and COVID-19 who have systemic inflammation. JAK/STAT pathway blockers were also successfully used in dampening IL-6 signal transduction. A better understanding of different mechanisms that modulate IL-6 expression will provide the much-needed solution with excellent safety and efficacy profiles for the treatment of autoimmune and inflammatory diseases in which IL-6 derives their pathogenesis.

Cellular signaling pathways of T cells in giant cell arteritis

Giant cell arteritis (GCA) is a commonly occurring large vacuities characterized by angiopathy of medium and large-sized vessels. GCA granulomatous formation plays an important role in the pathogenesis of GCA. Analysis of T cell lineages and signaling pathways in GCA have revealed the essential role of T cells in the pathology of GCA. T cells are the dominant population present in GCA lesions. CD4+ T cell subtypes that are present include Th1, Th2, Th9, Th17, follicular helper T (Tfh) cells, and regulatory T (Treg) cells. CD8 T cells can primarily differentiate into cytotoxic CD8+ T lymphocytes and Treg cells. The instrumental part of GCA is the interplay between dendritic cells, macrophages and endothelial cells, which can result in the vascular injury and the characteristics granulomatous infiltrates formation. During the inflammatory loop of GCA, several signaling pathways have been reported to play an essential role in recruiting, activating and differentiating T cells, including T-cell receptor (TCR) signaling, vascular endothelial growth factor (VEGF)-Jagged-Notch signaling and the Janus kinase and signal transducer and activator of transcription (STAT) pathway (JAK-STAT) pathway. In this review, we have focused on the role of T cells and their potential signaling mechanism (s) that are involved in the pathogenesis of GCA. A better understanding of the role of T cells mediated complicated orchestration during the homeostasis and the changes could possibly favor developments of novel treatment strategies against immunological disorders associated with GCA.

A tearfully painful darkness

A 70-year-old woman presented with new onset of left eye and facial pain. Ophthalmic and neurological examinations, magnetic resonance imaging brain, erythrocyte sedimentation rate, and C-reactive protein were unrevealing. A few days later, she developed vision loss in her left eye. Examination revealed decreased visual acuity with a relative afferent pupillary defect in the left eye and a diffuse mild swelling of the left optic nerve head. Repeat magnetic resonance imaging showed T2 hyperintensity and enhancement of the intraorbital optic nerve and surrounding tissues with no other intracranial abnormalities. Serum studies showed elevated myelin oligodendrocyte glycoprotein IgG titer. She was treated with IV methylprednisolone 1000 mg daily for 3 days and was discharged on prolonged prednisone taper with return of vision to baseline.

A case of giant cell arteritis presenting with nodular posterior scleritis mimicking a choroidal mass

Purpose

Herein we present a case of giant cell arteritis presenting with nodular posterior scleritis and exudative retinal detachment mimicking a choroidal mass.

Observations

A 67-year-old man presented with sudden onset left-sided periorbital pain, blurry vision, and a choroidal lesion in the posterior pole. Despite treatment with high-dose oral prednisone for suspected nodular posterior scleritis mimicking a choroidal mass, the vision in his left eye did not recover, and he developed optic nerve pallor on exam. Further evaluation revealed an ESR of >140 mm/hr (Upper limit of normal = 20 mm/hr), a CRP of 113 mg/L (Upper limit of normal = 9 mg/L), and a temporal artery biopsy consistent with GCA. The patient was started on methotrexate and the oral steroids were slowly tapered.

Conclusions

Given the potential for GCA to present with scleritis and the potential for nodular posterior scleritis to mimic a choroidal mass, presence of a painful choroidal lesion with optic nerve swelling should prompt an evaluation for GCA to prevent permanent and bilateral vision loss.

Gene and miRNA expression in giant cell arteritis-a concise systematic review of significantly modified studies

Giant cell arteritis (GCA) is a systemic vasculitis in individuals older than 50 years, characterized by headaches, visual disturbances, painful scalp, jaw claudication, impairment of limb arteries, and systemic inflammation, among other symptoms. GCA diagnosis is confirmed by a positive temporal artery biopsy (TAB) or by imaging modalities. A prominent acute phase response with inflammation is the hallmark of the disease, predominantly targeting large- and medium-sized arteries leading to stenosis or occlusion of arterial lumen. To date, there are no reliable tissue markers specific for GCA. Scarce reports have indicated the importance of epigenetics in GCA. The current systematic review reports significantly changed candidate biomarkers in TABs of GCA patients compared to non-GCA patients using qPCR.

Use of Noninvasive Imaging in Giant Cell Arteritis

Giant cell arteritis (GCA) requires a prompt diagnosis to avoid significant morbidity among the elderly. An accurate diagnosis is also paramount given the side effect profile of long-term corticosteroid treatment. Temporal artery biopsy (TAB) has long remained the gold standard for the diagnosis of GCA but requires an invasive procedure that is not without risk. This article discusses the argument for and against the use of noninvasive imaging including ultrasound, magnetic resonance imaging, and positron emission tomography scanning for the diagnosis of GCA. It also provides a suggested diagnostic algorithm for when to consider noninvasive imaging versus TAB.