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Moleiro AF, Vilares-Morgado R, Falcão-Reis F, Torres-Costa S. WHEN THE PICTURE MASKS THE DIAGNOSIS - AN ATYPICAL AND SEVERE GIANT CELL ARTERITIS CASE REPORT. Retin Cases Brief Rep 2024; 18:446-450. [PMID: 36989505 PMCID: PMC11302579 DOI: 10.1097/icb.0000000000001409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
PURPOSE The purpose of this study was to describe an atypical and severe case of giant cell arteritis (GCA). METHODS This was a case report description. RESULTS The authors report the case of a 76-year-old man who presented with severe and progressive bilateral visual loss. On presentation at the ophthalmology emergency room, the patient's right eye (OD) displayed aqueous flare, hyphema, rubeosis iridis , and dense posterior capsular opacification. After YAG laser capsulotomy, vitreous densifications, intraretinal hemorrhages, cotton wool spots, retinal ischemia, and vasculitis were observed in the fundoscopy. The patient's left eye (OS) also presented intraretinal hemorrhages and cotton wool spots around the temporal arcades. The diagnostic workup excluded infectious diseases, demyelinating diseases, and ocular ischemic syndrome due to carotid obstruction. Proteinogram revealed a monoclonal gammopathy, suggesting a possible hematologic condition. High-dose corticotherapy was initiated, which improved the vitreous densifications and enabled the visualization of the pale optic disk. The remaining study did not confirm the diagnosis of hematologic disease. During follow-up, bilateral VA deteriorated, with the development of progressive pallor in the OS optic disk. Follow-up fluorescein angiography demonstrated progressive retinal and choroidal ischemia. Finally, owing to high clinical suspicion, temporal artery Doppler ultrasound was performed, confirming the diagnosis of GCA. CONCLUSION GCA may present multiple ocular features. The knowledge of these different presentations, including retinal and choroidal ischemia or uveitis, is critical for timely diagnosis and treatment initiation. Since patients with GCA often present with vision loss, ophthalmologists may be the first medical doctors who contact with these patients, being on the frontline of GCA diagnosis.
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Affiliation(s)
- Ana Filipa Moleiro
- Department of Ophthalmology, Centro Hospitalar e Universitário São João, Porto, Portugal; and
- Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Rodrigo Vilares-Morgado
- Department of Ophthalmology, Centro Hospitalar e Universitário São João, Porto, Portugal; and
- Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Fernando Falcão-Reis
- Department of Ophthalmology, Centro Hospitalar e Universitário São João, Porto, Portugal; and
- Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Sónia Torres-Costa
- Department of Ophthalmology, Centro Hospitalar e Universitário São João, Porto, Portugal; and
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Kang MK, Hong Y, Kim YH, Park HK, Kim SK, Sohn JH, Kim J, Kwon KH, Cho SJ. Diagnosis, Treatment, and Follow-Up of Giant-Cell Arteritis: A Retrospective Multicenter Study. J Clin Neurol 2024; 20:306-314. [PMID: 38627226 PMCID: PMC11076186 DOI: 10.3988/jcn.2023.0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/29/2023] [Accepted: 11/22/2023] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND AND PURPOSE Giant-cell arteritis (GCA) is the most common type of vasculitis in the elderly and is associated with high risks of visual loss and recurrence. Owing to its rarity in Asian populations, the current clinical interventions for these patients are not well known. Here we aimed to characterize the current management status of patients with GCA using Korean multicenter data. METHODS This retrospective study analyzed medical records of patients with GCA at six Korean university hospitals from February 2009 to November 2022. GCA had originally been diagnosed based on the 1990 American College of Rheumatology (ACR) criteria, and cases were selected for inclusion in this study based on the 2022 ACR/European Alliance of Associations for Rheumatology criteria. We evaluated treatments, follow-up periods, and outcomes (relapse, remission, and adverse drug reactions) in patients with GCA with or without arteritic anterior ischemic optic neuropathy (AAION). RESULTS This study analyzed 18 patients with a median age of 75.5 years that included 12 females (66.7%). Seven patients (38.8%) had AAION. All patients initially received prednisolone treatment, while four (22.2%) underwent adjuvant treatment with methotrexate and azathioprine during prednisolone tapering. During the median follow-up of 3.5 months (interquartile range: 2.0-23.2 months), 4 patients (22.2%) had prednisolone-related adverse reactions, 2 (11.1%) relapsed, and 13 (72.3%) dropped out. Nine patients (50.0%) experienced remission, with this being sustained in four (36.4%). CONCLUSIONS This study observed high dropout rates and short follow-ups. Adverse effects of prednisolone were common, and relapses occurred in approximately one-tenth of Korean patients with GCA. Thus, optimizing GCA treatment necessitates regular monitoring and long-term follow-up.
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Affiliation(s)
- Mi-Kyoung Kang
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Yooha Hong
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Yoo Hwan Kim
- Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Soo-Kyoung Kim
- Department of Neurology, Gyeongsang National University College of Medicine and Gyeonsang National University Hospital, Jinju, Korea
| | - Jong-Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Jiyoung Kim
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Ki-Han Kwon
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
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Kwok L, Wu E, Sheth SJ, Campbell TG, Chakrabarti R. Predictive Factors for Biopsy-Negative Giant Cell Arteritis and Alternative Diagnoses in a Neuro-Ophthalmology Context. Neuroophthalmology 2024; 48:267-271. [PMID: 38933754 PMCID: PMC11197916 DOI: 10.1080/01658107.2024.2311131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/22/2024] [Indexed: 06/28/2024] Open
Abstract
Giant cell arteritis is a challenging diagnosis for patients given the high prevalence of negative temporal artery biopsies (TAB). Despite the lack of histopathological evidence of giant cell arteritis in the TAB, patients can still have TAB-negative giant cell arteritis. The purpose of this paper is to analyse the predictors for TAB-negative giant cell arteritis and the alternative diagnosis of biopsy-negative patients without a giant cell arteritis diagnosis. A retrospective electronic database review of all TABs performed at the Royal Victorian Eye and Ear Hospital from February 2015 to May 2020. Logistic regression analysis was performed to determine predictive factors for a diagnosis of TAB-negative giant cell arteritis. In all cases, a clinical diagnosis of TAB-negative giant cell arteritis was determined by a neuro-ophthalmologist. Alternative diagnoses for negative TABs were identified and explored. A total of 368 TABs were analysed with 287 (78%) negative for histopathological evidence of GCA. Twenty-seven (9.4%) patients were diagnosed and treated as TAB-negative giant cell arteritis. The clinical predictors of a TAB-negative giant cell arteritis diagnosis were the presence of jaw claudication (OR 2.77, 95% CI 1.10-6.98) and CRP (OR 1.02, 95% CI 1.00-1.03). Alternative diagnoses included non-specific headache, non-arteritic anterior ischaemic optic neuropathy, retinal vessel occlusions, and ocular nerve palsies. Predictive factors for a diagnosis of TAB-negative giant cell arteritis were jaw claudication and an elevated CRP. Several alternative diagnoses can be considered for patients with a negative TAB in a neuro-ophthalmology context.
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Affiliation(s)
- Lawrence Kwok
- Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
| | - Emma Wu
- Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
| | - Shivanand J. Sheth
- Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- The Royal Children’s Hospital, Parkville, VIC, Australia
| | - Thomas G. Campbell
- Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia
| | - Rahul Chakrabarti
- Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- Alfred Hospital, Melbourne, VIC, Australia
- Monash University, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
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4
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Jiang Z, Ji H, Dong J. Temporal artery biopsy for suspected giant cell arteritis: A mini review. Indian J Ophthalmol 2023; 71:3299-3304. [PMID: 37787225 PMCID: PMC10683700 DOI: 10.4103/ijo.ijo_3163_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 05/23/2023] [Accepted: 06/16/2023] [Indexed: 10/04/2023] Open
Abstract
Giant cell arteritis (GCA) is a granulomatous inflammation involving medium and large vessels that can lead to serious clinical manifestations associated with tissue ischemia. Temporal artery biopsy (TAB) is currently the gold standard method for the diagnosis of GCA, with a specificity of 100% and a sensitivity of 77%. However, the false-negative rate for TAB ranges from 9% to 61%. False negatives may be related to the timing of biopsy, the length of specimen, and the existence of "skip lesions." We reviewed the relevant evidence for methods to improve the sensitivity and reduce the false-negative rate for TAB. To reduce the false-negative rate for TAB, it is recommended to perform TAB within 1 week of starting corticosteroid therapy. Although there is currently no consensus, we suggest that the temporal artery is cut to a length of 20‒30 mm and to prepare serial pathological sections. It is necessary to attach great importance to patients suspected of having GCA, and complete TAB should be performed as soon as possible while starting corticosteroid therapy promptly. We also discuss the clinical value of non-invasive vascular imaging technologies, such as DUS, CTA, MRA, and 18F-FDG-PET/CT, as auxiliary methods for GCA diagnosis that could partially replace TAB.
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Affiliation(s)
- Zhijian Jiang
- Department of Ophthalmology, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Huiying Ji
- Department of Laboratory, Shanghai Xuhui Central Hospital, Shanghai, China
| | - Jianhong Dong
- Department of Ophthalmology, Shanghai Xuhui Central Hospital, Shanghai, China
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Carreño E, Olivas-Vergara OM. Systemic Vasculitis and Its Association with the Eye. Ophthalmologica 2023; 246:174-180. [PMID: 37331330 DOI: 10.1159/000531395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/30/2023] [Indexed: 06/20/2023]
Abstract
Vasculitis is a group of diseases characterized by the inflammation of the blood vessel walls. They are classified according to the size of the main vessel involved: large vessel, medium vessel, and small vessel vasculitis. Ophthalmic manifestations are quite common in most of these diseases. Episcleritis and scleritis are the most prevalent manifestation of vasculitis. However, there are certain ocular features characteristic of specific vasculitis entities. Given the severity and potential life-threat of these diseases, knowledge of the ocular manifestations is mandatory for the ophthalmologists.
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Affiliation(s)
- Ester Carreño
- Ophthalmology Department, Fundación Jiménez Díaz University Hospital, Madrid, Spain
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Smith LM, Alvarado LA, Dihowm F. The incidence and characteristics of giant cell arteritis in Hispanics and the associated outcomes of ischemic ocular events and stroke. J Investig Med 2023; 71:411-418. [PMID: 36710498 DOI: 10.1177/10815589231152821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Giant cell arteritis (GCA) is a large vessel vasculitis whereby up to half of all patients show ocular involvement, highlighting the importance of treating GCA before it leads to irreversible blindness. Most of the research published for GCA and associated adverse ocular events are based on majority Caucasian populations establishing the current belief that Hispanics have a much lower incident of GCA. We sought to investigate the incidence of GCA in Hispanics and characterize associated ocular events, stroke rates, and comorbid diseases. We conducted a retrospective cohort study of GCA-coded medical records in self-identified Hispanics assessed at the University Medical Center Hospital in El Paso, Texas. From 2000 to 2019, there were 68 new cases of GCA in the Hispanics which represents an average incidence of 0.062% with a 95% confidence interval of [0.05, 0.09] of Hispanics over the age of 50 admitted to University Medical Center hospital. Of the subjects diagnosed with GCA, the majority had ocular involvement such as blurry vision (47.06%), ocular pain (26.47%), and blindness (14.71%). We did not observe a history of stroke had a statistically significant difference associated with GCA with ophthalmic disease compared to GCA without ophthalmic disease. Polymyalgia rheumatica (PMR) was identified in only 2.94% of the Hispanic subjects with GCA. Major conclusions in our study advocate Hispanics with GCA are prevalent and unique in its associations with other comorbid diseases. Unlike non-Hispanic White populations, Hispanic subjects with GCA do not show an association with PMR nor an increased association with stroke.
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Affiliation(s)
- Lisa M Smith
- Paul L. Foster School of Medicine, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Luis A Alvarado
- Biostatistics and Epidemiology and Consulting Lab, Office of Research, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Fatma Dihowm
- Division of General Medicine, Department of Internal Medicine, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
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7
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Atlas IS, Colley SM, Chia MA. Utility of biomarkers and temporal artery biopsy length for investigating giant cell arteritis in Western Australia. Int J Rheum Dis 2023; 26:286-291. [PMID: 36401819 PMCID: PMC10098702 DOI: 10.1111/1756-185x.14488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/20/2022] [Accepted: 10/23/2022] [Indexed: 11/21/2022]
Abstract
AIM To explore demographic characteristics, biopsy length, and blood biomarker performance in an Australian cohort of patients who have undergone temporal artery biopsy (TAB) for giant cell arteritis (GCA). METHODS We extracted data on biopsies performed for GCA between January 2016 and December 2020 at public hospitals in Perth. Sensitivity, specificity, and area under the curve (AUC) were calculated for blood results. We evaluated the proportion of biopsies with post-fixation length less than 15 mm and explored several length associations. RESULTS We retrospectively reviewed biopsies of 360 patients (65.8% female, mean age 72.1 years). Biopsy-positive patients were older (6.0 years, P < 0.01), and had higher C-reactive protein (CRP) (44.5 mg/L, P < 0.01), erythrocyte sedimentation rate (ESR) (18.9 mm/h, P < 0.01), and platelets (86.8 × 103 /μL, P < 0.01) compared with biopsy-negative patients. CRP and platelets had the highest AUCs at 0.76 and 0.71, respectively. Sensitivities for CRP and ESR were 96.2% and 91.5%, respectively. Specificities were comparatively low at 41.3% for CRP and 37.4% for ESR. The proportion of biopsies with sub-optimal length was 55.9% and this varied significantly by site (P < 0.01). Smaller sites performed worse, with a sub-optimal biopsy rate of 87% amongst the three smallest sites. CONCLUSION ESR and CRP are helpful preliminary investigations, especially in identifying low-risk patients, but their specificity is limited. Smaller centers had a higher proportion of biopsies with sub-optimal length. Considering the importance of biopsy length for TAB diagnostic value, reviewing biopsy data may assist services in developing improvement strategies.
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Affiliation(s)
| | | | - Mark A. Chia
- Fremantle HospitalPerthAustralia
- Institute of OphthalmologyUniversity College LondonLondonUK
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8
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Casella AMB, Mansour AM, EC S, do Prado RB, Meirelles R, Wong K, Yassine S, Monteiro MLR. Choroidal ischemia as one cardinal sign in giant cell arteritis. Int J Retina Vitreous 2022; 8:69. [PMID: 36153565 PMCID: PMC9509624 DOI: 10.1186/s40942-022-00422-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose To describe chorioretinal signs in a case series of Giant Cell Arteritis (GCA). Methods This is a multicenter retrospective observational case series with GCA that presented with a headache and an abrupt, unilateral loss in vision. Workup included temporal artery biopsies, intravenous fluorescein angiography, optical coherence tomography (OCT), optical coherence tomography angiography (OCTA), blood levels of erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Results There are a total of 8 GCA instances presented. Average age was 74.5. (Range 68–83 years). The patients reported that one eye's visual loss had suddenly started, along with a fresh headache and other systemic symptoms. Eight patients exhibited choroidal ischemia, five paracentral acute middle maculopathy (PAMM) lesions, five cotton wool spots, four anterior ischemic optic neuropathy, and one central retinal arterial occlusion at the time of presentation. The average ESR at presentation was 68 mm/hr (range 4–110), and 4/6 individuals had a significant increase. The mean CRP level was 6.2 mg/dL (range 2.0–15.4), and the level was always over the normal range. All patients' temporal artery biopsies were positive. Conclusion Alongside PAMM lesions, cotton wool spots, anterior ischemic optic neuropathy, and central retinal artery occlusion, choroidal ischemia is a key angiographic indicator in the diagnosis of GCA. It may be crucial to recognize these typical ischemic chorioretinal signs while diagnosing GCA.
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9
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Ariello LE, de Souza Andrade T, Mello LGM, Oyamada MK, Cunha LP, Monteiro MLR. Simultaneous Unilateral Abducens Nerve Palsy and Contralateral Anterior Ischaemic Optic Neuropathy as the Presenting Signs of Giant Cell Arteritis. Neuroophthalmology 2022; 47:88-92. [PMID: 36891402 PMCID: PMC9988330 DOI: 10.1080/01658107.2022.2107686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 10/14/2022] Open
Abstract
Ischaemic optic neuropathy is the most common, feared, and recognised ocular manifestation of giant cell arteritis (GCA), while extraocular muscle palsy rarely occurs in the disease. Overlooking the diagnosis of GCA in aged patients with acquired diplopia and strabismus is not only sight- but also life-threatening. Here, we present, for the first time, a case of unilateral abducens nerve palsy and contralateral anterior ischaemic optic neuropathy as the presenting signs of GCA in a 98-year-old woman. Prompt diagnosis and treatment prevented further visual loss and systemic complications and allowed for rapid resolution of the abducens nerve palsy. We also aim to discuss the possible pathophysiological mechanisms of diplopia in GCA and to emphasise that acquired cranial nerve palsy must raise suspicion of this severe disease in elderly patients, particularly in association with ischaemic optic neuropathy.
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Affiliation(s)
- Leonardo E. Ariello
- Division of Ophthalmology and the Laboratory of Investigation in Ophthalmology (LIM 33), University of São Paulo Medical School, São Paulo, Brazil
| | - Thais de Souza Andrade
- Division of Ophthalmology and the Laboratory of Investigation in Ophthalmology (LIM 33), University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Guilherme Marchesi Mello
- Division of Ophthalmology and the Laboratory of Investigation in Ophthalmology (LIM 33), University of São Paulo Medical School, São Paulo, Brazil
- Department of Specialized Medicine, Centro de Ciências da Saúde (CCS), Universidade Federal do Espírito Santo, Vitoria, Brazil
| | - Maria Kiyoko Oyamada
- Division of Ophthalmology and the Laboratory of Investigation in Ophthalmology (LIM 33), University of São Paulo Medical School, São Paulo, Brazil
| | - Leonardo Provetti Cunha
- Division of Ophthalmology and the Laboratory of Investigation in Ophthalmology (LIM 33), University of São Paulo Medical School, São Paulo, Brazil
- Department of Surgery, Division of Ophthalmology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Mário L. R. Monteiro
- Division of Ophthalmology and the Laboratory of Investigation in Ophthalmology (LIM 33), University of São Paulo Medical School, São Paulo, Brazil
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Naumovska M, Merdasa A, Hammar B, Albinsson J, Dahlstrand U, Cinthio M, Sheikh R, Malmsjö M. Mapping the architecture of the temporal artery with photoacoustic imaging for diagnosing giant cell arteritis. PHOTOACOUSTICS 2022; 27:100384. [PMID: 36068803 PMCID: PMC9441260 DOI: 10.1016/j.pacs.2022.100384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/02/2022] [Accepted: 07/01/2022] [Indexed: 06/15/2023]
Abstract
Photoacoustic (PA) imaging is rapidly emerging as a promising clinical diagnostic tool. One of the main applications of PA imaging is to image vascular networks in humans. This relies on the signal obtained from oxygenated and deoxygenated hemoglobin, which limits imaging of the vessel wall itself. Giant cell arteritis (GCA) is a treatable, but potentially sight- and life-threatening disease, in which the artery wall is infiltrated by leukocytes. Early intervention can prevent complications making prompt diagnosis of importance. Temporal artery biopsy is the gold standard for diagnosing GCA. We present an approach to imaging the temporal artery using multispectral PA imaging. Employing minimally supervised spectral analysis, we produce histology-like images where the artery wall is clearly discernible from the lumen and further differentiate between PA spectra from biopsies diagnosed as GCA- and GCA+ in 77 patients.
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Affiliation(s)
- Magdalena Naumovska
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Aboma Merdasa
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Björn Hammar
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - John Albinsson
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ulf Dahlstrand
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Magnus Cinthio
- Department of Biomedical Engineering, Faculty of Engineering, Lund University, Lund, Sweden
| | - Rafi Sheikh
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Malin Malmsjö
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
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11
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Lacy A, Nelson R, Koyfman A, Long B. High risk and low prevalence diseases: Giant cell arteritis. Am J Emerg Med 2022; 58:135-140. [DOI: 10.1016/j.ajem.2022.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/16/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022] Open
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Loricera J, Castañeda S, Moriano C, Narváez J, Aldasoro V, Maiz O, Melero R, Villa I, Vela P, Romero-Yuste S, Callejas JL, de Miguel E, Galíndez-Agirregoikoa E, Sivera F, Fernández-López JC, Galisteo C, Ferraz-Amaro I, Sánchez-Martín J, Sánchez-Bilbao L, Calderón-Goercke M, Casado A, Hernández JL, González-Gay MA, Blanco R. Tocilizumab in visual involvement of giant cell arteritis: a multicenter study of 471 patients. Ther Adv Musculoskelet Dis 2022; 14:1759720X221113747. [PMID: 35898567 PMCID: PMC9310329 DOI: 10.1177/1759720x221113747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Visual involvement is the most feared complication of giant cell arteritis
(GCA). Information on the efficacy of tocilizumab (TCZ) for this
complication is scarce and controversial. Objective: We assessed a wide series of GCA treated with TCZ, to evaluate its role in
the prevention of new visual complications and its efficacy when this
manifestation was already present before the initiation of TCZ. Design: This is an observational multicenter study of patients with GCA treated with
TCZ. Methods: Patients were divided into two subgroups according to the presence or absence
of visual involvement before TCZ onset. Visual manifestations were
classified into the following categories: transient visual loss (TVL),
permanent visual loss (PVL), diplopia, and blurred vision. Results: Four hundred seventy-one GCA patients (mean age, 74 ± 9 years) were treated
with TCZ. Visual manifestations were observed in 122 cases (26%), of which
81 were present at TCZ onset: PVL (n = 60;
unilateral/bilateral: 48/12), TVL (n = 17;
unilateral/bilateral: 11/6), diplopia (n = 2), and blurred
vision (n = 2). None of the patients without previous
visual involvement or with TVL had new episodes after initiation of TCZ,
while only 11 out of 60 (18%) patients with PVL experienced some
improvement. The two patients with diplopia and one of the two patients with
blurred vision improved. Conclusion: TCZ may have a protective effect against the development of visual
complications or new episodes of TVL in GCA. However, once PVL was
established, only a few patients improved.
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Affiliation(s)
- Javier Loricera
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
| | - Santos Castañeda
- Department of Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, Catedra UAM-Roche, EPID-Future, UAM, Madrid, Spain
| | - Clara Moriano
- Department of Rheumatology, Complejo Asistencial Universitario de León, León, Spain
| | - Javier Narváez
- Department of Rheumatology, Hospital de Bellvitge, Barcelona, Spain
| | - Vicente Aldasoro
- Department of Rheumatology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Olga Maiz
- Department of Rheumatology, Hospital Universitario de Donostia, San Sebastián, Spain
| | - Rafael Melero
- Department of Rheumatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Ignacio Villa
- Department of Rheumatology, Hospital Sierrallana, Torrelavega, Spain
| | - Paloma Vela
- Department of Rheumatology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Susana Romero-Yuste
- Department of Rheumatology, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - José L Callejas
- Unit of Systemic Autoimmune Diseases, Hospital San Cecilio, Granada, Spain
| | | | | | - Francisca Sivera
- Department of Rheumatology, Hospital Universitario de Elda, Alicante, Spain
| | | | - Carles Galisteo
- Department of Rheumatology, Hospital Parc Taulí, Barcelona, Spain
| | - Iván Ferraz-Amaro
- Department of Rheumatology, Complejo Hospitalario Universitario de Canarias, Tenerife, Spain
| | | | - Lara Sánchez-Bilbao
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
| | - Mónica Calderón-Goercke
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
| | - Alfonso Casado
- Department of Ophthalmology, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Valdecilla (IDIVAL), Santander, Spain
| | - José L Hernández
- Internal Medicine Division, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, ES-39008 Santander, Spain
| | - Miguel A González-Gay
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Valdecilla (IDIVAL), Avda. Valdecilla s/n, ES-39008 Santander, Spain
| | - Ricardo Blanco
- Rheumatology Division, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Valdecilla (IDIVAL), Avda. Valdecilla s/n, ES-39008 Santander, Spain
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13
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Dentel A, Clavel G, Savatovsky J, Vignal C, Senè T, Charbonneau F, Zuber K, Lecler A, Hage R. Use of Retinal Angiography and MRI in the Diagnosis of Giant Cell Arteritis With Early Ophthalmic Manifestations. J Neuroophthalmol 2022; 42:218-225. [PMID: 35051984 DOI: 10.1097/wno.0000000000001517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is a vasculitis often revealed by visual signs. Diagnosis is challenging and urgent. Retinal angiography (RA) and MRI allow effective diagnosis. We compared those and proposed an imaging-based approach to diagnose GCA in ophthalmological practice. METHODS We conducted a retrospective study based on the data collected from patients suspected to have GCA on ophthalmological findings. Fluorescein (FA) and indocyanine green (ICG) RAs and MRI were performed and compared with final diagnosis. RESULTS Among the 41 patients included, 25 were diagnosed with GCA. Sensitivities and specificities of FA and ICG were not different. MRI showed a higher sensitivity and specificity. The approach consisting in performing RA followed by MRI provided a better accuracy. CONCLUSION Our study shows that RA can be supplemented by MRI in a specialized center to provide the most accurate diagnosis in GCA revealed by visual signs.
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Affiliation(s)
- Alexandre Dentel
- Department of Ophthalmology (AD, CV, RH), Foundation Adolphe de Rothschild Hospital, Paris, France; Department of Internal Medicine (GC, TS), Foundation Adolphe de Rothschild Hospital, Paris, France; Department of Neuroradiology (JS, FC, AL), Foundation Adolphe de Rothschild Hospital, Paris, France ; and Department of Clinical Research (KZ), Foundation Adolphe de Rothschild Hospital, Paris, France
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14
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Naumovska M, Sheikh R, Albinsson J, Hammar B, Dahlstrand U, Malmjsö M, Erlöv T. Ultrasound centre frequency shifts as a novel approach for diagnosing giant cell arteritis. Scand J Rheumatol 2022:1-8. [PMID: 35549812 DOI: 10.1080/03009742.2022.2056979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Giant cell arteritis (GCA) is a treatable, but potentially sight- and life-threatening form of systemic vasculitis. Prompt and correct diagnosis is therefore important. Temporal artery biopsy (TAB) is the gold standard for diagnosing GCA, but is associated with risks. There is no reliable non-invasive technique for the diagnosis of GCA. Ultrasound centre frequency shift (CFS) is a novel technique that uses high-frequency ultrasound and the analysis of the centre frequency of the ultrasound pulse, which is dependent on the size of the microstructures in the tissue. This provides an objective measure of the scattering microstructures in the tissue, and thus has the potential to discriminate changes due to disease. The aim of this study was to assess ultrasound CFS as a means of discriminating arteries affected by GCA from healthy arteries. METHOD TAB specimens from 68 subjects, 53 female and 15 male, with a mean age of 73 (range 52-87) years, with suspected GCA were examined using ultrasound ex vivo and the CFS was analysed. The temporal arteries were then examined histopathologically. RESULTS Histopathological examination revealed that 25 of the 68 biopsies of the temporal artery showed inflammatory changes in the vessel wall compatible with GCA. The ultrasound CFS decreased less in TAB-positive than in TAB-negative temporal arteries (p < 0.05). CONCLUSIONS This proof-of-principle study indicates that ultrasound CFS has the potential to detect GCA in temporal arteries. Further technical development will be needed before in vivo examination can be performed and the clinical applicability can be assessed.
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Affiliation(s)
- M Naumovska
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - R Sheikh
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - J Albinsson
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - B Hammar
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - U Dahlstrand
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - M Malmjsö
- Department of Clinical Sciences Lund, Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - T Erlöv
- Department of Biomedical Engineering, Faculty of Engineering, LTH, Lund University, Lund, Sweden
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15
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González-Gay M, Ortego-Centeno N, Ercole L. Práctica clínica en la arteritis de células gigantes a partir de una encuesta a especialistas. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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16
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Rose EC, Carroll LS, Evans S, Mason A. Giant cell arteritis complicated by tongue necrosis and bilateral cerebellar ischaemic stroke. BMJ Case Rep 2021; 14:e244948. [PMID: 34880035 PMCID: PMC8655573 DOI: 10.1136/bcr-2021-244948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/04/2022] Open
Abstract
Giant cell arteritis (GCA) typically presents with headache, scalp tenderness or visual disturbance. Other symptoms include orofacial pain, constitutional symptoms and ischaemic stroke. An 81-year-old woman with a background of type-2 diabetes and hypertension presented with headache, oral pain and right visual loss. Examination showed hypertension, nodular temporal arteries, reduced visual acuity and suspected oral candida. Inflammatory markers were raised and she was diagnosed with GCA and commenced on corticosteroids. During treatment she developed tongue ulceration, then acute vertigo and incoordination with nystagmus and ataxia. Neuroimaging confirmed bilateral, cerebellar ischaemic strokes and temporal artery biopsy was consistent with GCA. With corticosteroids and secondary prevention of stroke measures she is now functionally independent. Oral pain is an uncommon symptom of GCA and delays in recognition may lead to catastrophic consequences. Clinicians should be aware of uncommon presentations and to optimise additional ischaemic stroke risk-factors.
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Affiliation(s)
- Emily Charlotte Rose
- Department of Rheumatology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Liam Stuart Carroll
- Department of Neurology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sue Evans
- Department of Stroke Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alice Mason
- Department of Rheumatology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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17
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González-Gay MA, Ortego-Centeno N, Ercole L. Clinical practice in giant cell arteritis based on a survey of specialists. Rev Clin Esp 2021; 222:266-271. [PMID: 34620581 DOI: 10.1016/j.rceng.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this study was to learn about the clinical practice of specialists who care for patients with giant cell arteritis, to verify whether they follow the diagnosis and treatment recommendations for this disease, and to identify areas for improvement. METHODS A cross-sectional survey on clinical practice in 2019. The survey was completed by 167 physicians (64% rheumatologists, 27% internal medicine specialists, and 9% other specialists) who attended a course on updating giant cell arteritis treatment. We compared the clinical practice collected in the study with the latest recommendations approved by the European League Against Rheumatism (EULAR). RESULTS The physicians surveyed cared for a median of 10 patients (interquartile range 6-30) with giant cell arteritis during their practice. As a diagnostic method, respondents used temporal artery biopsy (84%), temporal artery ultrasound (61%) or other imaging techniques (37%). As first-line therapy, respondents used high-dose glucocorticoids (at least 40 mg of prednisone, or equivalent, per day) (84%), glucocorticoids with methotrexate (7%) and glucocorticoids with tocilizumab (5%). The most frequent drugs used for relapse were methotrexate (37%) and tocilizumab (58%). CONCLUSION Our results indicate that the medical specialists surveyed follow the recent EULAR recommendations for giant cell arteritis diagnosis and therapy.
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Affiliation(s)
- M A González-Gay
- Servicio de Reumatología y Grupo de Investigación sobre la Epidemiología, Genética y Aterosclerosis en Enfermedades Inflamatorias Sistémicas, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain; Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - N Ortego-Centeno
- Unidad de Enfermedades Autoinmunes, Hospital Universitario San Cecilio, Instituto de Investigación Biosanitaria de Granada (IBS. Granada), Servicio de Medicina Interna, Universidad de Granada, Granada, Spain
| | - L Ercole
- Departamento Médico, Roche Pharma, Madrid, Spain
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18
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Farrukh H, VandenBerg C, Ertel E, Griffith H, Kelly B. Retinal Detachment and Temporal Artery Dissection: An Elusive Case of Giant Cell Arteritis. Cureus 2021; 13:e16703. [PMID: 34513351 PMCID: PMC8412197 DOI: 10.7759/cureus.16703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Giant cell arteritis (GCA), also known as temporal arteritis, is the most common systemic inflammatory vasculitis occurring in the elderly. Patients usually present with vision loss, headache, jaw claudication, diplopia, myalgia and constitutional symptoms. The most common ocular manifestations are anterior ischemic optic neuropathy (AION), choroidal ischemia and central retinal artery occlusion. Here we describe a case of GCA presenting with vision changes secondary to retinal detachment and vitreous hemorrhage. Upon temporal artery biopsy, GCA was confirmed and it was found to be accompanied by temporal artery dissection as well. Patient was treated with pulse dose intravenous steroids after which her symptoms improved. Based on our literature review, this is the first reported case of GCA presenting in this manner.
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Affiliation(s)
- Hina Farrukh
- Internal Medicine, AtlantiCare Regional Medical Center, Atlantic City, USA
| | | | - Elisabeth Ertel
- Department of Medicine, Temple University, Philadelphia, USA
| | - Heidi Griffith
- Internal Medicine, AtlantiCare Regional Medical Center, Atlantic City, USA
| | - Brendan Kelly
- Internal Medicine, AtlantiCare Regional Medical Center, Atlantic City, USA
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19
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Ling ML, Yosar J, Lee BW, Shah SA, Jiang IW, Finniss A, Allende A, Francis IC. The diagnosis and management of temporal arteritis. Clin Exp Optom 2021; 103:572-582. [DOI: 10.1111/cxo.12975] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/08/2019] [Accepted: 08/07/2019] [Indexed: 12/22/2022] Open
Affiliation(s)
- Melvin Lh Ling
- Faculty of Medicine, The University of New South Wales, Sydney, Australia,
| | - Jason Yosar
- Faculty of Medicine, The University of Queensland, Brisbane, Australia,
| | - Brendon Wh Lee
- Faculty of Medicine, The University of New South Wales, Sydney, Australia,
| | - Saumil A Shah
- Faculty of Medicine, The University of New South Wales, Sydney, Australia,
| | - Ivy W Jiang
- Faculty of Medicine, The University of New South Wales, Sydney, Australia,
| | | | - Alexandra Allende
- Medical Testing Laboratory, Douglass Hanly Moir Pathology, Sydney, Australia,
| | - Ian C Francis
- Faculty of Medicine, The University of New South Wales, Sydney, Australia,
- Ocular Plastics Unit, Department of Ophthalmology, Prince of Wales Hospital, Sydney, Australia,
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20
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Jang JH, Kim ES, Lee JY. Temporal Arteritis with Diagnostic Brain Magnetic Resonance Imaging. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2021. [DOI: 10.3341/jkos.2021.62.3.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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21
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Simon S, Ninan J, Hissaria P. Diagnosis and management of giant cell arteritis: Major review. Clin Exp Ophthalmol 2021; 49:169-185. [PMID: 33426764 DOI: 10.1111/ceo.13897] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/06/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
Giant cell arteritis is a medical emergency because of the high risk of irreversible blindness and cerebrovascular accidents. While elevated inflammatory markers, temporal artery biopsy and modern imaging modalities are useful diagnostic aids, thorough history taking and clinical acumen still remain key elements in establishing a timely diagnosis. Glucocorticoids are the cornerstone of treatment but are associated with high relapse rates and side effects. Targeted biologic agents may open up new treatment approaches in the future.
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Affiliation(s)
- Sumu Simon
- Department of Ophthalmology and South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jem Ninan
- Department of Rheumatology, Modbury Public Hospital, Modbury, South Australia, Australia
| | - Pravin Hissaria
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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22
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Koçak N, Yeter V, Güngör I. Monocyte to High-Density Lipoprotein Ratio in Patients with Arteritic and Non-Arteritic Anterior Ischaemic Optic Neuropathy. Neuroophthalmology 2020; 44:294-298. [PMID: 33012918 DOI: 10.1080/01658107.2020.1733618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The purpose of this study was to evaluate the monocyte to high-density lipoprotein (HDL) ratio (MHR) in patients with arteritic anterior ischaemic optic neuropathy (A-AION) and non-arteritic anterior ischaemic optic neuropathy (NA-AION). A total of 98 subjects were included in the study. Patients were divided into three groups: 16 patients with A-AION regarded as group one; 41 patients with NA-AION regarded as group two and 41 healthy subjects regarded as the control group. The MHR was calculated in all participants and compared between the patient and control groups. The mean age of subjects with A-AION, NA-AION and the control group were 75.9 ± 8.9 years, 67.1 ± 9.2 years, and 66.6 ± 6.7 years, respectively. Baseline clinical characteristics, such as diabetes mellitus and hypertension, were similar among groups. The mean MHR was significantly higher only in the A-AION group compared with the NA-AION and control group (p < .001), whereas there was no difference between NA-AION group and control group (p = .110). On receiver operating characteristic analysis, the area under the curve was 0.755, and the best cut- off value was 12.2 with a sensitivity of 72% and a specificity of 80%. An elevated MHR ratio is significantly associated with A-AION and MHR might be used to differentiate A-AION from NA-AION.
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Affiliation(s)
- Nurullah Koçak
- Ophthalmology Department, Ondokuz Mayis University Hospital, Samsun, Turkey
| | - Volkan Yeter
- Ophthalmology Department, Ondokuz Mayis University Hospital, Samsun, Turkey
| | - Inci Güngör
- Ophthalmology Department, Ondokuz Mayis University Hospital, Samsun, Turkey
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23
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Dattilo M, Tian T, Peragallo JH, Newman NJ, Biousse V. Very Poor Visual Acuity in Non-Arteritic Anterior Ischaemic Optic Neuropathy. Neuroophthalmology 2020; 45:23-28. [PMID: 33762784 DOI: 10.1080/01658107.2020.1785509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Very poor (hand motion or worse) visual acuity at presentation is highly unusual in non-arteritic anterior ischaemic optic neuropathy. We retrospectively reviewed the medical records of 151 consecutive non-arteritic anterior ischaemic optic neuropathy patients seen at our institution between July 2014 and April 2016 to evaluate the frequency and characteristics of patients with very poor visual acuity in non-arteritic anterior ischaemic optic neuropathy. Hand motion or worse visual acuity was documented in 17 patients (11%); all patients had at least one vascular risk factor and 14 (82%) had at least two vascular risk factors. Although severe vision loss at presentation does occur in non-arteritic anterior ischaemic optic neuropathy, an extensive workup should be obtained to rule out another cause, especially arteritic anterior ischaemic optic neuropathy.
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Affiliation(s)
- Michael Dattilo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tian Tian
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jason H Peragallo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nancy J Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
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24
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Harky A, Fok M, Howard C, Bashir M. Current Controversies in Large-Vessel Inflammatory Vasculitis and Thoracic Aortic Aneurysm Disease. Int J Angiol 2019; 28:215-225. [PMID: 31787819 PMCID: PMC6882665 DOI: 10.1055/s-0039-1692448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Large-vessel vasculitis encompasses the spectrum of vasculitides, which pathologically cause chronic granulomatous inflammatory changes, primarily in the aorta and its major branches. These patients are at risk of developing life-threatening aortic lesions that, without recognition and prompt treatment, can cause detrimental effects. Many provocative issues surrounding large-vessel vasculitis and its surgical treatment still remain, spanning from recognition to management. In this review, we discuss the main large-vessel vasculitides, Takayasu's arteritis and giant cell arteritis. We include the key points and current controversies surrounding diagnostic imaging, timing of interventions, and patient outcomes.
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Affiliation(s)
- Amer Harky
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, United Kingdom
| | - Matthew Fok
- Department of General Surgery, Royal Liverpool Hospital, Liverpool, United Kingdom
| | - Callum Howard
- Department of Aortovascular Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Mohamad Bashir
- Department of Aortovascular Surgery, Manchester Royal Infirmary, Manchester, United Kingdom
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25
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The role of vascular ultrasound in managing giant cell arteritis in ophthalmology. Surv Ophthalmol 2019; 65:218-226. [PMID: 31775013 DOI: 10.1016/j.survophthal.2019.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 11/20/2022]
Abstract
Giant cell arteritis is the most common systemic vasculitis in the elderly and is a potentially life-threatening ophthalmic emergency that can result in irreversible blindness. Blindness is most commonly associated with acute onset, irreversible arteritic ischemic optic neuropathy. Without treatment, second eye involvement may occur, resulting in bilateral blindness. Patients with established visual loss are treated with high-dose steroids and generally undergo a temporal artery biopsy to confirm their diagnosis. A significant number of patients are, however, referred for urgent ophthalmology assessment from concerns about "incipient" arteritic ischemic optic neuropathy. Before visual loss, patients may experience a range of ocular symptoms related to ischemia. This generally leads to treatment with high-dose systemic steroid and an urgent request for a temporal artery biopsy. Temporal artery biopsy is considered as the standard investigation for confirmatory diagnosis. It is generally arranged as soon as possible, although it is often not carried out for several days, and there may also be delays in histopathological reporting. It is often perceived that the patient is "safe" while on corticosteroids, in that they are being treated to avoid visual loss. What is not acknowledged, however, is that, if patients do not have giant cell arteritis and are being treated "just in case," they will often require a tapering of oral steroids over several weeks, exposing them to unnecessary and significant side effects. In the rheumatology setting, vascular ultrasound has emerged as a safe and reliable alternative to temporal artery biopsy as a point of care diagnostic tool in the management of giant cell arteritis. Given an experienced sonographer and optimal equipment, a rapid diagnosis can be established in a fast-track clinic setting, taking into consideration clinical assessment, scoring, and ultrasound findings. A huge advantage of ultrasound is that it provides immediate information that can be used to inform treatment decisions. We explore the evidence that supports the incorporation of vascular ultrasound into the ophthalmology repertoire to make a more efficient diagnosis that is cost-effective and associated with better patient outcomes, including a potential reduction in loss of sight and avoidance of unnecessary long-term steroid treatment by early exclusion of mimics.
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26
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Ciofalo A, Gulotta G, Iannella G, Pasquariello B, Manno A, Angeletti D, Pace A, Greco A, Altissimi G, de Vincentiis M, Magliulo G. Giant Cell Arteritis (GCA): Pathogenesis, Clinical Aspects and Treatment Approaches. Curr Rheumatol Rev 2019; 15:259-268. [DOI: 10.2174/1573397115666190227194014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/30/2019] [Accepted: 02/13/2019] [Indexed: 11/22/2022]
Abstract
:
Giant Cell Arteritis (GCA), or Horton’s Arteritis, is a chronic form of vasculitis of the
large and medium vessels, especially involving the extracranial branches of the carotid arteries, in
particular, the temporal artery, with the involvement of the axillary, femoral and iliac arteries too.
Arterial wall inflammation leads to luminal occlusion and tissue ischemia, which is responsible for
the clinical manifestations of the disease.
:
A substantial number of patients affected by GCA present head and neck symptoms, including ocular,
neurological and otorhinolaryngological manifestations.
:
The aim of this article is to present pathogenesis, clinical aspects and treatment approaches of GCA
manifestations.
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Affiliation(s)
- Andrea Ciofalo
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Giampiero Gulotta
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Giannicola Iannella
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Benedetta Pasquariello
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Alessandra Manno
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Diletta Angeletti
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Annalisa Pace
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Antonio Greco
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Giancarlo Altissimi
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Marco de Vincentiis
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
| | - Giuseppe Magliulo
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 151 - 00161, Rome, Italy
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27
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Choi JH, Shin JH, Jung JH. Arteritic Anterior Ischemic Optic Neuropathy Associated with Giant-Cell Arteritis in Korean Patients: A Retrospective Single-Center Analysis and Review of the Literature. J Clin Neurol 2019; 15:386-392. [PMID: 31286712 PMCID: PMC6620454 DOI: 10.3988/jcn.2019.15.3.386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose The aim of this study is to report the relative incidence of arteritic anterior ischemic optic neuropathy (AAION) associated with giant-cell arteritis (GCA) in a single-center and evaluate the clinical features of AAION in Korean patients. Methods The medical records of patients with presumed AION who visited our hospital from January 2013 to August 2018 were examined retrospectively. The patients were divided into two groups: AAION associated with GCA, and non AION (NAION). We additionally reviewed the literature and identified all cases of AAION in Korean and Caucasian patients. We evaluated the clinical data including the initial and final best-corrected visual acuities, fundus photographs, visual field tests, fluorescein angiography, and contrast-enhanced MRI, and compared the data with those for Caucasian patients in the literature. Results Of the 142 patients with presumed AION, 3 (2.1%) were diagnosed with AAION and 139 (97.9%) were diagnosed with NAION. Seven Korean patients with AAION associated with GCA were identified in our data and the literature review. We found no difference in any clinical features other than laterality: four of the seven Korean patients had bilateral involvement. Moreover, the optic nerve sheath was enhanced in two of our Korean patients. Conclusions AAION associated with GCA is a very rare condition compared to NAION in Korea. However, GCA should be considered in all cases of ischemic optic neuropathy because AAION is associated with poor visual outcome, and sometimes presents bilaterally.
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Affiliation(s)
- Jae Hwan Choi
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jong Hoon Shin
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Ophthalmology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae Ho Jung
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.
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28
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Na S, Lee ES, Kim YD. Teaching NeuroImages: Pterygoid myositis mimicking giant cell arteritis. Neurology 2019; 92:e2297. [DOI: 10.1212/wnl.0000000000007465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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29
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Abstract
Giant cell arteritis (GCA) is an inflammatory vasculitis typically affecting elderly that can potentially cause vision loss. Studies have demonstrated that early recognition and initiation of treatment can improve visual prognosis in patients with GCA. This review addresses the benefits of early diagnosis and treatment, and discusses the available treatment options to manage the disease.
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Affiliation(s)
- Iyza F Baig
- McGovern Medical School, The University of Texas Health Science Center in Houston, Houston, TX, USA
| | - Alexis R Pascoe
- McGovern Medical School, The University of Texas Health Science Center in Houston, Houston, TX, USA
| | - Ashwini Kini
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA,
| | - Andrew G Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA, .,Department of Ophthalmology, Baylor College of Medicine,Houston, TX, USA, .,Department of Ophthalmology, .,Department of Neurology, .,Department of Neurosurgery, Weill Cornell Medical College, Houston, TX, USA, .,The University of Texas Medical Branch, Galveston, TX, USA, .,The Universityof Texas MD Anderson Cancer Center, Houston, TX, USA, .,Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA,
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Skanchy DF, Vickers A, Prospero Ponce CM, Lee AG. Ocular manifestations of giant cell arteritis. EXPERT REVIEW OF OPHTHALMOLOGY 2019. [DOI: 10.1080/17469899.2018.1560265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- David F. Skanchy
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aroucha Vickers
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
| | | | - Andrew G. Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- Department of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, USA
- Division of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Ophthalmology, Texas A and M College of Medicine, College Station, TX, USA
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31
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Mascarenhas RJ, Hapangama ND, Mews PJ, Burlakoti A, Ranjitkar S. Orofacial neuralgia associated with a middle cerebral artery aneurysm. Aust Dent J 2018; 64:106-110. [PMID: 30525205 DOI: 10.1111/adj.12668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2018] [Indexed: 12/01/2022]
Abstract
Chronic orofacial pain of neuropathic origin can present diagnostic and management dilemmas to dental practitioners and also affects the patient's quality of life. Intracranial aneurysms are a potential cause of stroke (e.g. sub-arachnoid haemorrhage) that is usually associated with, high rates of mortality and morbidity. A patient who had been previously managed for symptoms of temporomandibular joint disorder (TMD) presented with sharp, shooting pain of moderate intensity. It was precipitated by swallowing, and radiated to the right throat, posterior border of the mandible, ear and temporomandibular joint. Clinical and radiological investigations ruled out odontogenic pain, TMD and other more common types of facial pain. Magnetic resonance imaging revealed a 7 × 6 mm aneurysm in the right middle cerebral artery (MCA) which was subsequently surgically clipped. Interestingly, the facial pain resolved after this procedure. Compression of the insular region of the brain innervated by the trigeminal, glossopharyngeal and vagus nerves provides a plausible explanation for the pain reported. To our knowledge, this is the first case of facial neuralgia associated with an aneurysm in the MCA which emphasizes the importance of a multidisciplinary approach in the diagnosis and management of unusual cases of chronic orofacial pain.
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Affiliation(s)
- R J Mascarenhas
- School of Dentistry and Health Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - N D Hapangama
- Oral and Maxillofacial Surgery Unit, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - P J Mews
- ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - A Burlakoti
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - S Ranjitkar
- Adelaide Dental School, University of Adelaide, Adelaide, South Australia, Australia
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Oh LJ, Wong E, Andrici J, McCluskey P, Smith JEH, Gill AJ. Full blood count as an ancillary test to support the diagnosis of giant cell arteritis. Intern Med J 2018; 48:408-413. [PMID: 29236347 DOI: 10.1111/imj.13713] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/31/2017] [Accepted: 12/03/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Temporal artery biopsy is considered the investigation of choice to diagnose definitively giant cell arteritis (GCA) in patients with compatible symptoms. However it is invasive and not completely sensitive. Serum markers, particularly erythrocyte sedimentation rate (ESR), can be supportive, but are not definitive in individual cases. AIMS To investigate whether indices derived from the full blood count, including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were associated with a positive biopsy in patients with suspected GCA. METHODS The clinical and pathological details of 537 patients undergoing temporal artery biopsy at our institution from 1992 to 2015 were reviewed. RESULTS In univariate analysis high platelets (odds ratio (OR) 4.44, P < 0.001), NLR (OR 1.81, P = 0.02), PLR (OR 3.25, P < 0.001), C-reactive protein (CRP) (OR 3.00, P < 0.001), ESR (OR 3.62, P < 0.001) and increased age (OR 1.03, P = 0.006) were strongly associated with a positive biopsy. In multivariate modelling only high platelets (P < 0.001) and ESR (P = 0.049) maintained significance. CONCLUSIONS We conclude that the presence of thrombocytosis and high NLR, PLR, ESR and CRP can all be used clinically to support the diagnosis of GCA prior to biopsy. Of particular note, in multivariate modelling the presence of thrombocytosis is a stronger predictor of a positive temporal artery biopsy than ESR. Therefore, careful consideration of the findings in a full blood count can be used to predict the likelihood of a positive temporal artery biopsy in patients with suspected GCA.
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Affiliation(s)
- Lawrence J Oh
- Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Eugene Wong
- Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Juliana Andrici
- Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Peter McCluskey
- Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Ophthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - James E H Smith
- Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Ophthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Sezgin Y. The Acupuncture Therapeutic Approach in Temporal Arteritis Vasculitis: A Case Report. J Acupunct Meridian Stud 2018; 11:116-118. [PMID: 29436372 DOI: 10.1016/j.jams.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 12/15/2017] [Indexed: 11/30/2022] Open
Abstract
Temporal arteritis is a form of vasculitis that involves the large- and medium-diameter arteries and leads to progressive headache. Symptoms may be accompanied by vision disorder, subfebrile temperature, fatigue, lack of appetite, weight loss, sweating, and joint pains. While cortisone therapy reduces the symptoms, its effects in terms of improving quality of life are limited. We opted to benefit from the effects of acupuncture to reduce symptoms and increase quality of life in a case of temporal arteritis, a chronic disease. A 75-year-old woman presented with pain on both sides of the head. The pain occurred in the form of agonizing attacks 2-3 times a week. Accompanying neck pain was present, together with continuous lethargy and fatigue. Physical examination revealed decreased cutaneous elasticity and muscle mass, and a depressive mood state was present. The patient was first administered six sessions of acupuncture therapy directed toward the migraine etiology. When no response was achieved, we investigated temporal and parietal region points associated with headache in the literature. Points GB1,8,18, ST8, SI19, and BL8 were added to the treatment. The pain attacks and their frequency decreased following acupuncture therapy. In conclusion, while cortisone is the first preference in the treatment of temporal arteritis, we think that acupuncture aimed at the cause of accompanying symptoms can also be useful.
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Affiliation(s)
- Yılmaz Sezgin
- Department of Family Medicine, University of Health Science, I˙stanbul Educational Research Hospital, I˙stanbul, Turkey.
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Papakostas TD, Jakobiec FA, Stagner AM, Eliott D, Kim LA. Small-Caliber Retinal Vasculitis Associated With Giant Cell Arteritis: A New Finding. Ophthalmic Surg Lasers Imaging Retina 2017; 47:1054-1056. [PMID: 27842201 DOI: 10.3928/23258160-20161031-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 09/16/2016] [Indexed: 11/20/2022]
Abstract
Giant cell arteritis (GCA) can present with cotton-wool spots in the retina and usually affects medium and large vessels. The authors present herein a 75-year-old man with GCA manifesting with cotton-wool spots and widespread retinal vasculitis affecting small-size retinal arterioles. The retinal vasculitis and the cotton-wool spots resolved after initiation of systemic corticosteroids and his vision returned to normal. GCA can uncommonly present with retinal vasculitis affecting small-size arterioles. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1054-1056.].
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Wang AL, Raven ML, Surapaneni K, Albert DM. Studies on the Histopathology of Temporal Arteritis. Ocul Oncol Pathol 2017; 3:60-65. [PMID: 28275606 PMCID: PMC5318845 DOI: 10.1159/000449466] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/25/2016] [Indexed: 11/19/2022] Open
Abstract
AIMS The aim of this paper was to identify the location and to grade the severity of most significant inflammation within positive temporal artery biopsies along with other key clinical and histologic characteristics. METHODS Charts and pathology slides for 70 patients diagnosed with temporal arteritis at the University of Wisconsin (UW) Hospital and Clinics from 1989 to 2015 were reviewed. A subset of 48 specimens was immunostained for CD68 and graded on a scale from 0 to +++; the location of staining was recorded. RESULTS The most severe granulomatous inflammation was in the media and adventitia in 13% (9/70) of the biopsies; the remaining had uniform full thickness inflammation. Of the slides that were stained with CD68, 94% (45/48) were positive. In 42% (19/45), the stained cells were found mainly in the muscularis and adventitia. Seven percent (3/45) of the slides had staining solely around the internal elastic lamina, and 2% (1/45) had staining limited to the intima. CONCLUSIONS With a few exceptions, granulomatous inflammation in positive temporal artery biopsies is most evident at the media and adventitia or is uniform throughout the layers of the artery. Our study lends support to the theory that the muscularis and adventitia may play an inciting role in the pathogenesis of temporal arteritis.
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Affiliation(s)
- Angeline L. Wang
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Wis., USA
| | - Meisha L. Raven
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Wis., USA
- McPherson Eye Research Institute, Madison, Wis., USA
| | - Krishna Surapaneni
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Wis., USA
- McPherson Eye Research Institute, Madison, Wis., USA
| | - Daniel M. Albert
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Wis., USA
- McPherson Eye Research Institute, Madison, Wis., USA
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Oh LJ, Wong E, Gill AJ, McCluskey P, Smith JEH. Value of temporal artery biopsy length in diagnosing giant cell arteritis. ANZ J Surg 2016; 88:191-195. [PMID: 27800647 DOI: 10.1111/ans.13822] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/05/2016] [Accepted: 09/20/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is considered an ophthalmological emergency with severe sight and life-threatening sequelae. Temporal artery biopsy (TAB) is the current gold standard for the diagnosis of GCA; however, the required length of biopsy remains an issue of contention in the literature. METHODS Retrospective case-control study of a consecutive cohort of 545 patients who had undergone TABs across five hospitals between 1 January 1992 and 1 January 2016. In patients with either positive or negative TABs, we collected age, sex, biopsy length and erythrocyte sedimentation rate (ESR). RESULTS A total of 538 patients were included in the final analysis. Of these, 23.4% of TABs were positive, with the average length being 17.6 mm. There was a significant difference in means for positive (19.9 mm) and negative (16.8 mm) biopsies (P = 0.0009). Each millimetre increase in TAB length increased the odds of a positive TAB by 3.4% (P = 0.024). A cut-off point of ≥15 mm increased the odds of a positive TAB by 2.25 compared with a TAB <15 mm (P = 0.003). We also found that ESR ≥50 mm/h was a very strong predictor for a positive TAB result (P < 0.0001). CONCLUSION Biopsy length and ESR were significant predictors of a pathological diagnosis of GCA. We also found that the optimal length threshold predictive for GCA was 15 mm in order to avoid a false-negative GCA diagnosis. Although TAB remains the gold standard for diagnosis, clinicians should refer to both clinical and pathological data to guide their management.
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Affiliation(s)
- Lawrence J Oh
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia
| | - Eugene Wong
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia.,Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Peter McCluskey
- Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia.,Department of Opthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - James E H Smith
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia
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Toren A, Weis E, Patel V, Monteith B, Gilberg S, Jordan D. Clinical predictors of positive temporal artery biopsy. CANADIAN JOURNAL OF OPHTHALMOLOGY 2016; 51:476-481. [PMID: 27938961 DOI: 10.1016/j.jcjo.2016.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 05/11/2016] [Accepted: 05/17/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We investigated the ability of known clinical signs and symptoms, as well as common laboratory tests, to correctly predict a positive temporal artery biopsy. DESIGN A prospective cohort study. PARTICIPANTS Consecutive patients in a tertiary referral centre undergoing temporal artery biopsy. METHODS Clinical information was collected using a predesigned questionnaire. Pathology results and laboratory information were collected from digital patient records. MAIN OUTCOME MEASURE The predictive value of clinical signs, symptoms, and laboratory values of a positive temporal artery biopsy. RESULTS Over a 3-year period, 259 patients were enrolled and 251 patients were analyzed. Sixty-one patients had a positive biopsy. Clinical features most predictive of a positive biopsy were jaw claudication (positive likelihood ratio [LR+] 2.31) and abnormal temporal artery pulse (LR+ 2.62). Receiver operating characteristic curves generated for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and platelets values showed an area under curve (AUC) value of 0.71, 0.75, and 0.76, respectively. The initiation of steroids decreased the diagnostic utility of the ESR, CRP, and platelets values (AUC = 0.58, 0.61, and 0.63, respectively). CONCLUSIONS A variety of clinical signs and symptoms were observed in patients referred for a temporal artery biopsy. Clinical signs and symptoms were less accurate in predicting a positive biopsy than laboratory tests. No combination of clinical signs and symptoms tested was able to predict giant cell arteritis with the certainty necessary to justify or withhold long-term steroid therapy.
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Affiliation(s)
- Andrew Toren
- Department of Ophthalmology, Faculty of Medicine, University of Laval, Quebec, Que
| | - Ezekiel Weis
- Department of Ophthalmology, University of Alberta, Edmonton, Alta
| | - Vivek Patel
- USC Eye Institute, Keck School of Medicine, University Southern California, Los Angeles, Calif
| | - Bethany Monteith
- Department of General Internal Medicine, Faculty of Medicine, Queen's University, Kingston, Ont
| | - Steven Gilberg
- Department of Ophthalmology, University of Ottawa Eye Institute, Ottawa, Ont
| | - David Jordan
- Department of Ophthalmology, University of Ottawa Eye Institute, Ottawa, Ont.
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Caignard A, Leruez S, Milea D. Urgences en neuro-ophtalmologie. J Fr Ophtalmol 2016; 39:716-728. [DOI: 10.1016/j.jfo.2016.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 04/27/2016] [Accepted: 05/25/2016] [Indexed: 11/30/2022]
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Histologisch nachgewiesene Riesenzellarteriitis und Sehverlust. SPEKTRUM DER AUGENHEILKUNDE 2016. [DOI: 10.1007/s00717-016-0304-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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De Smit E, O’Sullivan E, Mackey DA, Hewitt AW. Giant cell arteritis: ophthalmic manifestations of a systemic disease. Graefes Arch Clin Exp Ophthalmol 2016; 254:2291-2306. [DOI: 10.1007/s00417-016-3434-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/19/2016] [Accepted: 06/27/2016] [Indexed: 11/30/2022] Open
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Chen JJ, Leavitt JA, Fang C, Crowson CS, Matteson EL, Warrington KJ. Evaluating the Incidence of Arteritic Ischemic Optic Neuropathy and Other Causes of Vision Loss from Giant Cell Arteritis. Ophthalmology 2016; 123:1999-2003. [PMID: 27297405 DOI: 10.1016/j.ophtha.2016.05.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/09/2016] [Accepted: 05/10/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To determine the incidence of permanent visual loss from giant cell arteritis (GCA). DESIGN Retrospective, population-based cohort. PARTICIPANTS All residents of Olmsted County, Minnesota, diagnosed with GCA between January 1, 1950, and December 31, 2009. METHODS All cases of GCA were identified using the Rochester Epidemiology Project (REP), which is a record-linkage system of medical records for all patient-physician encounters among Olmsted County, Minnesota, residents. The medical records were reviewed to identify and determine the cause of permanent vision loss among patients with GCA. Systemic symptoms of GCA and visual outcomes also were determined. MAIN OUTCOME MEASURES Incidence and outcomes of permanent vision loss from GCA. RESULTS Among the 245 new cases of GCA over the 60-year period, 20 patients (8.2%) had permanent vision loss due to GCA. The frequency of arteritic ischemic optic neuropathy (A-ION) was 6.9% (95% confidence interval [CI], 4.0-11.1) accounting for 85% of cases of permanent vision loss. The frequency of central retinal artery occlusion (CRAO) was 1.6% (95% CI, 0.4-4.2), and the frequency of cilioretinal artery occlusion was 0.4% (95% CI, 0.01-2.3). The population-based age- and sex-adjusted annual incidence of A-ION from GCA among persons aged ≥50 years was 1.3 (95% CI, 0.7-2.0) per 100 000 population. Some 20% of patients with permanent vision loss from GCA had vision loss without constitutional symptoms of GCA. Overall, there was no significant difference between presenting and final visual acuities. CONCLUSIONS These population-based data provide the most accurate incidence of permanent vision loss from GCA. This study confirms that visual outcomes from GCA-related vision loss are poor and that 20% of patients with permanent visual loss from GCA can present without systemic symptoms of GCA.
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Affiliation(s)
- John J Chen
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.
| | | | - Chengbo Fang
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota; Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Eric L Matteson
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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42
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Kang YS, Park SW, Lee HK, Choi YD, Heo H. Arteritic Anterior Ischemic Optic Neuropathy Associated with Giant Cell Arteritis in an Elderly Korean Man. KOREAN JOURNAL OF OPHTHALMOLOGY 2016; 30:239-41. [PMID: 27247526 PMCID: PMC4878987 DOI: 10.3341/kjo.2016.30.3.239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yeon-Soo Kang
- Department of Ophthalmology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Sang-Woo Park
- Department of Ophthalmology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Ho-Kyun Lee
- Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Yoo-Duk Choi
- Department of Pathology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Hwan Heo
- Department of Ophthalmology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Au CP, Sharma NS, McCluskey P, Ghabrial R. Increase in the length of superficial temporal artery biopsy over 14 years. Clin Exp Ophthalmol 2016; 44:550-554. [DOI: 10.1111/ceo.12733] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 02/09/2016] [Accepted: 02/17/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Cheryl P Au
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Neil S Sharma
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Peter McCluskey
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Raf Ghabrial
- Royal Prince Alfred Hospital; Sydney New South Wales Australia
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Abstract
PURPOSE OF REVIEW Giant cell arteritis (GCA) remains a potentially blinding inflammatory vasculitis of the elderly. Because prolonged doses of corticosteroids remain the best established treatment, side-effects during treatment are common and potentially serious. This review addresses the challenges clinicians face in managing this disease. RECENT FINDINGS High-dose corticosteroids with slow tapering and close monitoring are the mainstay of treatment. Investigations into adjunctive treatment have yet to establish other agents as beneficial, but further research is ongoing with some promising results. SUMMARY GCA represents a challenging illness to clinicians because of its potential for causing blindness and the need for prolonged high doses of corticosteroids with their many complications.
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Frohman L, Wong ABC, Matheos K, Leon-Alvarado LG, Danesh-Meyer HV. New developments in giant cell arteritis. Surv Ophthalmol 2016; 61:400-21. [PMID: 26774550 DOI: 10.1016/j.survophthal.2016.01.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 01/05/2016] [Accepted: 01/08/2016] [Indexed: 12/01/2022]
Abstract
Giant cell arteritis (GCA) is a medium-to-large vessel vasculitis with potentially sight- and life- threatening complications. Our understanding of the pathogenesis, diagnosis, and treatment of GCA has advanced rapidly in recent times. The validity of using the American College of Rheumatology guidelines for diagnosis of GCA in a clinical setting has been robustly challenged. Erythrocyte sedimentation rate, an important marker of inflammation, is lowered by the use of statins and nonsteroidal anti-inflammatory drugs. Conversely, it may be falsely elevated with a low hematocrit. Despite the emergence of new diagnostic modalities, temporal artery biopsy remains the gold standard. Evidence suggests that shorter biopsy lengths and biopsies done weeks to months after initiation of steroid therapy are still useful. New imaging techniques such as positron emission tomography have shown that vascular inflammation in GCA is more widespread than originally thought. GCA, Takayasu arteritis, and polymyalgia rheumatica are no longer thought to exist as distinct entities and are more likely parts of a spectrum of disease. A range of immunosuppressive drugs have been used in conjunction with corticosteroids to treat GCA. In particular, interleukin-6 inhibitors are showing promise as a therapy.
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Affiliation(s)
- Larry Frohman
- Department of Ophthalmology, Rutgers-New Jersey Medical School, New Jersey, USA; Department of Neurosciences, Rutgers-New Jersey Medical School, New Jersey, USA
| | - Aaron B C Wong
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | - Kaliopy Matheos
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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Assad M, Coffin-Pichonnet S, Billotte C, Denion É. [Acute unilateral arteritic anterior ischemic optic neuropathy becoming bilateral despite corticosteroid therapy]. J Fr Ophtalmol 2015; 39:e13-5. [PMID: 26552759 DOI: 10.1016/j.jfo.2015.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 01/07/2015] [Accepted: 01/28/2015] [Indexed: 11/17/2022]
Affiliation(s)
- M Assad
- Service d'ophtalmologie, CHU de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - S Coffin-Pichonnet
- Service d'ophtalmologie, CHU de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - C Billotte
- Service d'ophtalmologie, CHU de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France
| | - É Denion
- Service d'ophtalmologie, CHU de Caen, avenue de la Côte-de-Nacre, 14000 Caen, France.
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Muller G, Devilliers H, Besancenot JF, Manckoundia P. Giant cell arteritis (Horton's disease) in very elderly patients aged 80 years and older: A study of 25 cases. Geriatr Gerontol Int 2015; 16:679-85. [PMID: 26081629 DOI: 10.1111/ggi.12536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/29/2022]
Abstract
AIM Analysis of the characteristics of very elderly patients with giant cell arteritis (GCA). METHODS Patients aged 80 years and older diagnosed with GCA in our department between 1 January 2002 and 31 July 2008 were retrospectively included. For each patient, we recorded general characteristics, reason(s) for hospitalization, specialty of the physician or department that referred the patient to us, medical history, treatment at admission, GCA clinical features, time to diagnosis of GCA, biological screening and GCA treatment. RESULTS We analyzed 25 clinical records, 18 women and seven men with a mean age of 83.9 years. General weakness, visual loss and inflammatory syndrome were the principal reasons for hospitalization. Patients were mainly referred by general practitioners or ophthalmological departments. At diagnosis, headache and musculoskeletal disorders were the most frequent signs (52% each), before general weakness and visual disorders. Time to diagnosis was 2.2 months. Inflammatory syndrome was very frequent (92%). Biopsy of the temporal artery confirmed GCA in 16 cases. Corticosteroid therapy (CST) mean dose was 0.9 mg/kg/day. Because of the positive evolution, CST was stopped in nine patients after 22.7 ± 15 months. A total of 22 patients received a preventive osteoporosis treatment. After 3 months of CST, clinical signs and IS vanished in 22 patients. CST complications, mainly infection, appeared in 17 patients. CONCLUSION Clinical and biological features of GCA in the very elderly patients of the present study were comparable with those described in the literature in younger patients. However, it must be pointed out that our patients were not compared with a younger population in this study. Geriatr Gerontol Int 2015; ●●: ●●-●●.
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Affiliation(s)
- Géraldine Muller
- Department of Internal Medicine and Systemic Diseases, University Hospital, Dijon, France
| | - Hervé Devilliers
- Department of Internal Medicine and Systemic Diseases, University Hospital, Dijon, France
| | | | - Patrick Manckoundia
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France.,Inserm/U1093 Motricity-Plasticity, University of Burgundy, Dijon, France
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Attaseth T, Vanikieti K, Poonyathalang A, Preechawat P, Jindahra P, Wattanatranon D. Anterior ischemic optic neuropathy due to biopsy-proven giant cell arteritis in Thai patients. Clin Ophthalmol 2015; 9:1071-5. [PMID: 26109841 PMCID: PMC4472068 DOI: 10.2147/opth.s82898] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Giant cell arteritis is a systemic granulomatous vasculitis affecting medium to large arteries. An arteritic anterior ischemic optic neuropathy is the most common cause of permanent visual loss. Giant cell arteritis is very rare among Asians. We report six patients with biopsy-proven arteritic anterior ischemic optic neuropathy. Demographic data, clinical manifestations, laboratory findings, treatment, and visual outcome are described in detail and compared with Caucasian patients. We found no differences in any clinical features except for sex preference. Moreover, perioptic nerve sheath enhancement was observed in half of our patients.
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Affiliation(s)
| | - Kavin Vanikieti
- Department of Ophthalmology, Mahidol University, Bangkok, Thailand
| | | | - Pisit Preechawat
- Department of Ophthalmology, Mahidol University, Bangkok, Thailand
| | | | - Duangkamon Wattanatranon
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Palmer VE, Young-Zvandasara T, Vusirikala B. Forehead necrosis, one of the many facades of giant cell arteritis. BMJ Case Rep 2015; 2015:bcr-2014-207804. [PMID: 25953578 DOI: 10.1136/bcr-2014-207804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Giant cell arteritis (GCA) is known to be a potentially blinding condition. Swift diagnosis can aid in preventing permanent visual loss and, more importantly, protect the contralateral eye. Classical symptoms include jaw claudication, myalgia and new-onset headache. We present two cases of GCA with scalp necrosis, a rare feature associated with this condition. In the first case, forehead necrosis preceded the visual symptoms by 2 days. In the second case it was noted a few weeks after the patient presented with profound unilateral loss of vision. Scalp necrosis is an important sign that should prompt those approached by these patients to consider GCA.
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Vasudevan S, Palle AR, Sylvia DS, Renuka V, Challa R. A rare case of temporal arteritis with rheumatoid arthritis and interstitial lung disease mimicking pulpo-periodontal pathology. J Indian Soc Periodontol 2014; 18:531-5. [PMID: 25210275 PMCID: PMC4158602 DOI: 10.4103/0972-124x.138764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/21/2014] [Indexed: 11/30/2022] Open
Abstract
A 75-year-old male patient was planned for dental treatment due to pain of suspected pulpo-periodontal origin in relation to right maxillary first molar. Careful evaluation revealed the pain to be non-odontogenic in nature and led to the diagnosis of temporal arteritis with rheumatoid arthritis along with interstitial lung disease (ILD). Characteristic findings of temporal arteritis include headache, jaw claudication, visual loss, and constitutional symptoms (malaise, fever, weight loss, loss of appetite). Temporal artery biopsy (TAB) remains the gold standard for diagnosis. Additional diagnostic tests include blood tests (ESR, CRP). This article reports and discusses how the orofacial manifestations can lead to misdiagnosis of temporal arteritis. Hence, temporal arteritis should be included in the differential diagnosis of orofacial pain in the elderly especially to prevent complications like vision loss.
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Affiliation(s)
- Sanjay Vasudevan
- Department of Periodontics, Army College of Dental Sciences, Secunderabad, Andhra Pradesh, India
| | - Ajay Reddy Palle
- Department of Periodontics, Army College of Dental Sciences, Secunderabad, Andhra Pradesh, India
| | - Dulapalli Sharon Sylvia
- Department of Periodontics, Army College of Dental Sciences, Secunderabad, Andhra Pradesh, India
| | - Valli Renuka
- Department of Periodontics, Army College of Dental Sciences, Secunderabad, Andhra Pradesh, India
| | - Radhika Challa
- Department of Periodontics, Army College of Dental Sciences, Secunderabad, Andhra Pradesh, India
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