A new era for giant cell arteritis

Giant Cell Arteritis in the Third Decade of Life: A Case for Expanded Clinical Suspicion

Giant cell arteritis (GCA), also known as temporal arteritis, is the most common idiopathic systemic vasculitis in middle-aged adults, predominantly involving large and medium-sized arteries. We report an unusual case of a 34-year-old woman with a five-year history of migraines who developed symptoms, including headache, transient vision loss, jaw claudication, and a 5 kg weight loss over two months. Physical examination revealed scalp tenderness, with no other notable findings. Laboratory investigations showed an elevated erythrocyte sedimentation rate (ESR) of 85 mm/hr and a C-reactive protein (CRP) level of 50 mg/L. Ultrasound of the temporal artery demonstrated thickening with the characteristic "halo" sign, and a biopsy confirmed inflammatory changes with multinucleated giant cells. Treatment with high-dose prednisolone resulted in remission, and the patient was discharged with a follow-up plan in place. GCA predominantly affects the superficial temporal arteries, with irreversible vision loss being its most serious complication. Prompt diagnosis and treatment are critical. The diagnosis relies on clinical features, elevated inflammatory markers, imaging studies, and histopathological confirmation. According to the European Alliance of Associations for Rheumatology (EULAR) guidelines, temporal artery ultrasound showing a non-compressible "halo" sign is recommended for diagnosis. Further studies are needed to investigate the potential connection between migraines and GCA. This case underscores the rarity of GCA in individuals under 50 and highlights the possibility of GCA developing in younger patients with a longstanding history of migraines.

Causal genes identification of giant cell arteritis in CD4+ Memory t cells: an integration of multi-omics and expression quantitative trait locus analysis

BACKGROUND

Giant cell arteritis (GCA) is a prevalent artery and is strongly correlated with age. The role of CD4+ Memory T cells in giant cell arteritis has not been elucidated.

METHOD

Through single-cell analysis, we focused on the CD4+ Memory T cells in giant cell arteritis. eQTL analysis and mendelian randomization analysis identified the significant genes which have a causal effect on giant cell arteritis risk. CD4+ Memory T cells were subsequently divided into gene-positive and gene-negative groups, then further single-cell analysis was conducted. Mendelian randomization of plasma proteins, blood-urine biomarkers and metabolites were also performed. Eventually, the PMA induced Jurkat cell lines were used for biological experiments to explore the specific functions of significant causal genes in CD4+ Memory T cells.

RESULTS

Similarity of CD4+ Memory T cells in GCA and old samples were explored. DDIT4 and ARHGAP15 were identified as significant risk genes via mendelian randomization. The CD4+ Memory T cells were then divided into DDIT4 ± or ARHGAP15 ± groups, and further single-cell analysis indicated the differences in aspects involving intercellular communication, functional pathways, protein activity, metabolism and drug sensitivity between positive and negative groups. In vitro experiments, including overexpression and knockdown, demonstrated that DDIT4 leading to a chronic, low-intensity inflammatory state in CD4+ Memory T cells, eventually promoting the development of GCA.

CONCLUSION

DDIT4 and ARHGAP15 have significant causal effects on giant cell arteritis risk. Specifically, DDIT4 exhibit pro-inflammatory effects on GCA via promotes chronic, low-intensity inflammatory in CD4+ Memory T cell.

Optical coherence tomography angiography findings in patients affected by giant cell arteritis, with and without ocular involvement: a pilot study

Purpose

We evaluated the clinical features and retinal and disk perfusion characteristics by using optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) in a subset of giant cell arteritis (GCA) patients who manifested anterior ischemic optic neuropathy (AION), in a subset of GCA patients without ocular involvement, and in a control group composed of healthy controls.

Methods

We performed an observational study on the eyes of GCA patients affected by arteritic AION both in acute and chronic phases, unaffected eyes of AION, eyes of GCA patients without ocular involvement, and in a control group of healthy eyes of healthy individuals. All patients underwent a complete ophthalmic examination and an OCT and OCTA of the macula and the disk.

Results

The study evaluated 10 eyes of GCA patients with AION (AION group), 8 unaffected eyes of GCA patients with AION in another eye (unaffected eyes of AION group), 16 eyes of GCA patients without ocular involvement (non-ocular group), and 22 eyes of healthy patients (healthy group). The ganglion cell complex (GCC) superior and inferior thicknesses were significantly lower in the AION group compared to the unaffected eyes of the AION group (p = 0.045 and p = 0.034, respectively). All OCTA vascular density parameters of the optic disk analyzed in this study (optic nerve head (ONH) whole, superior, inferior, radial peripapillary capillary plexus (RPCP) whole, superior, inferior, lamina cribrosa (LC) whole, superior, inferior) resulted significantly lower in the AION group compared to the unaffected eyes group (p < 0.05 for all the comparisons). The ONH whole and inferior were statistically higher in the healthy group in comparison to the group of GCA patients without ocular involvement (p = 0.008 and p = 0.006, respectively). The ONH inferior was also statistically higher in the unaffected eyes of the AION group in comparison to the non-ocular group (p = 0.045). Regarding the OCTA macular vessel density parameters, the superficial capillary plexus (SCP), whole and inner, were statistically lower in the AION group compared with the unaffected eyes of the AION group.

Conclusion

We found a profound vascular impairment in eyes affected by AION and areas of hypoperfusion in the eyes of patients with GCA without ocular involvement, good BCVA, and no clinically significant features. We hypothesized that these areas of lower vessel density might represent areas of subclinical hypoperfusion that cannot be detected ophthalmoscopically.

Intraoperative Frozen Section Diagnosis of Giant Cell Arteritis

Giant cell arteritis (GCA) is a systemic vasculitis of medium and large vessels that is diagnosed using temporal artery biopsy (TAB). In this case report, we explored the benefits of frozen section analysis as a rapid intraoperative diagnostic technique for GCA. We present the cases of two patients who underwent TAB with frozen section analysis, to demonstrate the value of this technique in initiating immediate treatment and potentially avoiding unnecessary contralateral biopsies when the frozen section of the first biopsy confirms GCA. We recommend further investigation into the use of frozen section analysis for patients suspected of having GCA, who might otherwise undergo bilateral TAB.

WHEN THE PICTURE MASKS THE DIAGNOSIS - AN ATYPICAL AND SEVERE GIANT CELL ARTERITIS CASE REPORT

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.

Giant Cell Arteritis

Giant cell arteritis (GCA) is the most common primary vasculitis and is associated with potential bilateral blindness. Neither clinical nor laboratory evidence is simple and unequivocal for this disease, which usually requires rapid and reliable diagnosis and therapy. The ophthalmologist should consider GCA with the following ocular symptoms: visual loss or visual field defects, transient visual disturbances (amaurosis fugax), diplopia, eye pain, or new onset head or jaw claudication. An immediate ophthalmological examination with slit lamp, ophthalmoscopy, and visual field, as well as color duplex ultrasound of the temporal artery should be performed. If there is sufficient clinical suspicion of GCA, corticosteroid therapy should be initiated immediately, with prompt referral to a rheumatologist/internist and, if necessary, temporal artery biopsy should be arranged. Numerous developments in modern imaging with colour duplex ultrasonography, MRI, and PET-CT have the potential to compete with the classical, well-established biopsy of a temporal artery. Early determination of ESR and CRP may support RZA diagnosis. Therapeutically, steroid-sparing immunosuppression with IL-6 blockade or methotrexate can be considered. These developments have led to a revision of both the classification criteria and the diagnostic and therapeutic recommendations of the American College of Rheumatologists and the European League against Rheumatism, which are summarised here for ophthalmology.

A Case of Large Vessel Giant Cell Arteritis Presenting With Cough and Diagnosed Using an FDG-PET Scan

Giant-cell arteritis (GCA) is a type of vasculitis characterised by the presence of granulomas. It is the predominant form of systemic vasculitis in adults and primarily affects the larger arteries in individuals aged ≥ 50 years. GCA affects the major arteries, such as the aorta and its branches, particularly the outer branches of the external carotid artery. Signs and symptoms can be categorised into cranial, extracranial, and systemic manifestations. Patients with headaches, jaw claudication, and vision disturbances usually have extracranial branches of the external carotid artery. Aside from being the prevailing manifestation of GCA, our primary concern regarding this variant is the potential for irreversible vision loss if not properly identified and addressed. Conversely, the GCA can also affect other major blood vessels such as the aorta. Here, we present the case of a 70-year-old Caucasian female patient with cranial GCA who had experienced a temporal headache three years prior. The patient was successfully treated with prednisolone, which was gradually reduced to a very low level with the assistance of methotrexate. Recently, the patient presented with a dry cough that lasted for two months and elevated inflammatory markers. After thorough research, it was determined that there was no evidence of infection, including atypical infections, and that no abnormalities were found in the lungs. Ultimately, via an 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scan, the patient was diagnosed with large vessel giant cell arteritis (LV-GCA). This impacted the aorta, carotid arteries, and subclavian arteries. The patient experienced notable improvement in her cough and a reduction in inflammatory markers after receiving a high dosage of oral prednisolone. This case exemplifies the unusual manifestation of LV-GCA and verifies that recurring symptoms may differ from the original presentation. While dry cough is not commonly listed as a symptom of LV-GCA, it can be present as a manifestation or the sole presentation in certain patients, particularly when inflammatory markers are consistently high and there is no pulmonary disease.

Diagnosis, Treatment, and Follow-Up of Giant-Cell Arteritis: A Retrospective Multicenter Study

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.

Cost-effectiveness analysis of the diagnosis of temporal arteritis

Temporal arteritis (TA) is the most common form of systemic vasculitis. Its diagnosis is based on criteria proposed by the American College of Rheumatology (1990), and its treatment is high-dose corticosteroids. Our objective is to assess the cost of diagnosing TA, and secondarily, cost-effective analysis of different diagnostic strategies (clinical, biopsy, doppler ultrasound) and therapeutic strategies (corticosteroid suspension).

MATERIAL AND METHOD

Observational, retrospective study has been carried out on patients with AT (2012-2021). Demographic data, comorbidities, signs and symptoms suggestive of AT were collected. AT was diagnosed with a score ≥ 3 according to American College of Rheumatoloy criteria (ACR-SCORE). The costs of diagnosis and treatment modification were analysed.

RESULTS

Seventy-five patients have been included, median age 77 (46-87) years. Headache, temporal pain and jaw claudication were significant for the diagnosis of TA. Patients with a halo on Doppler ultrasound and a positive biopsy have significantly elevated ESR and CRP compared to patients who do not. The cost of the AT diagnosis was 414.7 euros/patient. If we use ACR-SCORE ≥ 3-echodoppler it is 167.2 є/patient (savings 59.6%) and ACR-SCORE ≥ 3-biopsy 339.75 є/patient (savings 18%). If the corticosteroid was removed and a biopsy was performed, 21.6 є/patient (94.7% savings), if the corticosteroid was removed and Doppler ultrasound was performed, 10.6 є/patient (97.4% savings).

CONCLUSIONS

Headache, temporary pain and jaw claudication are predictors of AT. Elevated ESR and CRP are predictors of positive biopsy and presence of halo on ultrasound. The uses of ACR-SCORE ≥ 3 with Doppler ultrasound or biopsy, and with corticosteroid suspension, are cost-effective.

Oxidative stress in the eye and its role in the pathophysiology of ocular diseases

Oxidative stress occurs through an imbalance between the generation of reactive oxygen species (ROS) and the antioxidant defense mechanisms of cells. The eye is particularly exposed to oxidative stress because of its permanent exposure to light and due to several structures having high metabolic activities. The anterior part of the eye is highly exposed to ultraviolet (UV) radiation and possesses a complex antioxidant defense system to protect the retina from UV radiation. The posterior part of the eye exhibits high metabolic rates and oxygen consumption leading subsequently to a high production rate of ROS. Furthermore, inflammation, aging, genetic factors, and environmental pollution, are all elements promoting ROS generation and impairing antioxidant defense mechanisms and thereby representing risk factors leading to oxidative stress. An abnormal redox status was shown to be involved in the pathophysiology of various ocular diseases in the anterior and posterior segment of the eye. In this review, we aim to summarize the mechanisms of oxidative stress in ocular diseases to provide an updated understanding on the pathogenesis of common diseases affecting the ocular surface, the lens, the retina, and the optic nerve. Moreover, we discuss potential therapeutic approaches aimed at reducing oxidative stress in this context.

Giant cell arteritis: reviewing the advancing diagnostics and management

Giant Cell Arteritis (GCA) is well known to be a critical ischaemic disease that requires immediate medical recognition to initiate treatment and where one in five people still suffer visual loss. The immunopathophysiology has continued to be characterised, and the influencing of ageing in the development of GCA is beginning to be understood. Recent national and international guidelines have supported the directed use of cranial ultrasound to reduce diagnostic delay and improve clinical outcomes. Immediate high dose glucocorticoids remain the standard emergency treatment for GCA, with a number of targeted agents that have been shown in clinical trials to have superior clinical efficacy and steroid sparing effects. The aim of this review was to present the latest advances in GCA that have the potential to influence routine clinical practice.

Oxidative Stress: A Suitable Therapeutic Target for Optic Nerve Diseases?

Optic nerve disorders encompass a wide spectrum of conditions characterized by the loss of retinal ganglion cells (RGCs) and subsequent degeneration of the optic nerve. The etiology of these disorders can vary significantly, but emerging research highlights the crucial role of oxidative stress, an imbalance in the redox status characterized by an excess of reactive oxygen species (ROS), in driving cell death through apoptosis, autophagy, and inflammation. This review provides an overview of ROS-related processes underlying four extensively studied optic nerve diseases: glaucoma, Leber's hereditary optic neuropathy (LHON), anterior ischemic optic neuropathy (AION), and optic neuritis (ON). Furthermore, we present preclinical findings on antioxidants, with the objective of evaluating the potential therapeutic benefits of targeting oxidative stress in the treatment of optic neuropathies.

Giant Cell Arteritis With Chronic Bronchitis Successfully Treated With Tocilizumab

Giant cell arteritis (GCA) causes systemic symptoms; however, involvement of the lungs is relatively rare compared to other rheumatic diseases such as rheumatoid arthritis and systemic sclerosis. Diagnosis and treatment of GCA complicated by chronic lung diseases can be challenging. In this case, an 87-year-old male presented with the chief complaints of systemic muscular pain and cough. The patient was eventually diagnosed with GCA complicated by chronic bronchitis. Although GCA treatment with chronic bronchitis is uncertain, we treated the patient with tapering doses of prednisolone and tocilizumab, which were effective. In older patients with systemic muscular pain and cough, GCA can be considered a differential diagnosis, and tocilizumab can be a reliable treatment in cases complicated by lung diseases, similar to other rheumatic diseases.

Giant Cell Arteritis: State of the Art in Diagnosis, Monitoring, and Treatment

Giant cell arteritis (GCA) is the most prevalent subtype of vasculitis in adults. In recent years, there has been substantial improvement in the diagnosis and treatment of GCA, mainly attributed to the introduction of highly sensitive diagnostic tools, incorporation of modern imaging modalities for diagnosis and monitoring of large-vessel vasculitis, and introduction of highly effective novel biological therapies that have revolutionized the field of GCA. This article reviews state-of-the-art approaches for the diagnosis, monitoring, and treatment options of GCA.

Giant Cell Arteritis in an Elderly Female With Pulmonary Tuberculosis

Giant cell arteritis (GCA) is a type of systemic vasculitis that primarily affects people over the age of 50 and affects the medium to large arteries. GCA's clinical manifestations can be varied and non-specific, similar to those observed in atherosclerosis. Here, the authors present a case of an elderly woman with pulmonary tuberculosis with GCA masquerading as atherosclerosis.

Giant cell arteritis with adventitial pattern in a 51-year-old man: A case report

Clinical presentation as well as histological or biological findings can sometimes make the diagnosis of giant cell arteritis difficult. Histopathological features of temporal artery biopsy from giant cell arteritis patients are also challenging because of the various described appearances or even finding of clinically normal temporal artery biopsy does not rule out the diagnosis. We here describe the case of a 51-year-old man with temporal artery biopsy showing lymphocytes infiltrates in the adventitia corresponding to the so-called adventitial pattern of giant cell arteritis according to Hernandez-Rodriguez et al.

Horton's disease in Michelangelo Buonarroti (1475-1564): the origin of his neurological debilitations in old age

BACKGROUND

Based on portraits of the time, this description provides novel evidence that the celebrated Renaissance artist and genius of human anatomy, Michelangelo Buonarroti (1475-1564), suffered from a vascular disorder known as giant cell arteritis or Horton's disease.

METHODS

Two portraits and a bronze sculpture produced between 1535 and the second half of the sixteenth century, in which Michelangelo was represented at over 60 years of age, reveal dilation of his superficial temporal artery consistent with that found in patients with Horton's disease or even with chronic arteriosclerosis. In addition, specialized authors indicate Michelangelo showed some of the neurological symptoms of this disease (blindness in old age, depression, and fever).

RESULTS

These findings, at least in part, may explain the origin of the neurological debilitations Michelangelo faced in old age and that may even have contributed to his death.

CONCLUSION

This description can serve as an important tool for analyzing his state of health during this period of his life.

Comparison of temporal artery ultrasound versus biopsy in the diagnosis of giant cell arteritis

BACKGROUND/OBJECTIVES

Giant cell arteritis (GCA) is a medical and ophthalmological emergency due to risk of stroke and sudden irreversible loss of vision. Fast and accurate diagnosis is important to prevent complications and long-term high dose glucocorticoids toxicity. Temporal artery biopsy is gold standard for diagnosing GCA. However, temporal artery ultrasound is a fast and non-invasive procedure which may provide a supplement or an alternative to biopsy. This study assesses the diagnostic performance of ultrasound and biopsy in the diagnosis of GCA.

SUBJECTS/METHODS

Examination results of patients suspected of having GCA in the period from August 2018 to June 2019 were reviewed. Patients underwent clinical examination and blood tests. Within a few days of starting glucocorticoid treatment, temporal ultrasound and unilateral biopsy were performed. Experienced physicians established the final clinical diagnosis at 6-months follow-up.

RESULTS

Seventy-eight patients underwent both ultrasound and biopsy. Thirty-five (45%) received the final clinical diagnosis of GCA. Compared with the final clinical diagnosis, biopsy had a sensitivity of 69% (51-83%) and a specificity of 100% (92-100%), and ultrasound a sensitivity of 63% (45-79%) and a specificity of 79% (64-94%). Area under the receiver operating characteristics curves were 0.84 and 0.71 for biopsy and ultrasound respectively (p = 0.048). False negative rate of ultrasound was 4 out of 78 (5%).

CONCLUSION

Sensitivity of ultrasound is almost on par with that of biopsy although the overall diagnostic accuracy of ultrasound was slightly lower. We find that ultrasound is a reliable tool for first line diagnosis of GCA.

Longitudinal Trends of Hospitalizations for Giant Cell Arteritis: A 21-Year Longitudinal National Population-Based Study

Background Long-term longitudinal studies on giant cell arteritis (GCA) hospitalizations are limited. Here we aim to fill gaps in knowledge by analyzing longitudinal trends of GCA hospitalizations over the last two decades in the United States (U.S.). Materials and methods We performed a 21-year longitudinal trend analysis of GCA hospitalizations using data obtained from the National Inpatient Sample (NIS) database between 1998 and 2018. Using the NIS database, we searched for hospitalizations for patients aged ≥ 50 years with a principal diagnosis of GCA using ICD billing codes. The principal diagnosis was the main reason for hospitalization. We used all hospitalizations in patients without GCA aged ≥50 years as the control population. Multivariable logistic and linear regression analysis was utilized to calculate the adjusted p-trend for outcomes of interest. Results The incidence of GCA hospitalization remained stable at about one per 100,000 U.S. persons throughout the study period. There was no statistically significant change in the inpatient mortality for the GCA group during the study period (adjusted p-trend=0.111). In comparison, inpatient mortality reduced from 4.4% to 3.1% from 1998 to 2018 (adjusted p-trend <0.0001) in the control group. The proportion of whites reduced, while the proportion of racial minorities increased over time in both the GCA and control groups. Conclusion The non-GCA control population saw significant reductions in mortality over time, but unfortunately, the GCA group did not see such improvements. More research into additional treatment modalities for inpatient GCA management may help improve mortality.

Atypical giant cell arteritis presentations diagnosed with FDG-18 whole body PET imaging

Two male patients aged above 70 years were investigated for chronic non-specific symptoms and evidence of significant systemic inflammation, but without classic 'cranial symptoms' of giant cell arteritis (GCA). Each patient had multiple non-diagnostic investigations, but finally extensive large-vessel vasculitis was revealed by whole body positron emission tomography/CT imaging. Both cases were confirmed to have GCA on temporal artery biopsy and responded well to initial high-dose prednisolone therapy. The patients successfully completed 12 months of steroid-sparing therapy with tocilizumab and achieved remission of their condition.

Sudden-onset unilateral painless vision loss

A 75-year-old Caucasian woman presented with sudden-onset multifocal scotomas in her right eye's central vision for 1 day. There were subtle white intraretinal foveal lesions that correlated with patchy inner retinal hyperreflectivity on optical coherence tomography, suggestive of paracentral acute middle maculopathy. Initial cerebrovascular work-up was negative. Review of systems was positive for lethargy and jaw claudication. The sedimentation rate and c-reactive protein were elevated, but platelet count was normal. The patient was started on 60 mg oral prednisone daily and underwent bilateral temporal artery that confirmed the diagnosis of giant cell arteritis.

A study of temporal artery biopsy for the diagnosis of giant cell arteritis

OBJECTIVE

This large, retrospective, multicenter study examines the Mayo Clinic experience with temporal artery biopsies over an 11-year period to help form guidelines that would lead to optimal performance of the technique.

METHODS

Pathology records were identified from all patients at all three Mayo Clinic sites (Rochester, MN; Jacksonville, FL; and Scottsdale, AZ) who underwent temporal artery surgery over an 11-year period, from January 1, 1994, to December 31, 2004. From each report, we extracted demographic information, the length of the temporal artery removed in the biopsy from each side, and the pathologic findings in each specimen. We used logistic regression to assess whether biopsy positivity may be associated with the following factors: biopsy length, age, sex, type (unilateral vs. bilateral), and year of study.

RESULTS

Our data set included 3817 temporal artery biopsies performed on 2539 patients at Mayo Clinic. Overall, 681 patients (27%) had a positive biopsy on at least one side. Biopsy length was uniformly noted to have no significant effect on biopsy positivity. Of the 603 patients with a bilateral biopsy, 43 (7%) had a negative initial biopsy followed by a positive result on the contralateral side.

CONCLUSION

Our results support that one can recommend any length of biopsy, within the range our study, without affecting the rate of positivity. Furthermore, we conclude that if a unilateral biopsy is negative on frozen section, then we recommend a second biopsy on the contralateral side to avoid possible missed diagnoses. Key Points • Our paper is a large retrospective study over all 3 Mayo Clinic campuses investigating the association between temporal artery biopsy length and the positivity rate of biopsies. • We also determined the value of performing bilateral biopsies in which the first biopsy was negative on frozen section. • We believe the strength of our study is having one of the largest sample sizes of biopsies in the literature to date including 3817 biopsies. • The sum of our research supports that we found biopsy positivity is not a function of length and, second, bilateral biopsies diagnose up to 7% of disease not otherwise picked up by unilateral approaches.

From Temporal Cell Arteritis to Giant Cell Aortitis Presenting as a Constitutional Syndrome: A Case Report

Giant cell arteritis (GCA) is the most common form of systemic vasculitis in adults, especially in patients over the age of 50. It manifests most commonly with an intense headache and visual symptoms. Although constitutional symptoms are also frequent in GCA, these can be dominant in 15% of patients at first presentation and 20% of patients when relapsing. Treatment with high-dose steroids should be initiated as soon as possible to rapidly control the inflammatory symptoms and prevent ischemic complications, the most feared being blindness from anterior ischemic optic neuropathy. We present a case of a 72-year-old man who presented to the emergency department with a right temporal headache with retroocular radiation associated with scalp hyperesthesia, without any visual symptoms. The patient also reported low-grade fever, night sweats, anorexia, and weight loss over the last two months. The physical exam revealed a tortuous and indurated right superficial temporal artery, which was tender to palpation. The ophthalmological examination was normal. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated, and he also had inflammatory anemia with a hemoglobin of 11.7 g/L. Due to this clinical presentation as well as the elevation of inflammatory markers, the diagnosis of temporal arteritis was suspected, and the patient was started on prednisolone (1 mg/kg). A right temporal artery biopsy was performed on the first week after the initiation of corticotherapy and was negative. After treatment initiation, there was a remission of symptoms accompanied by a decrease and normalization of inflammatory markers. However, after steroid tapering, there was a reappearance of constitutional symptoms but without any other organ-specific symptoms, such as headache, visual loss, arthralgia, or other. The corticosteroid dose was increased to the initial dosage, but there was no improvement in the symptoms this time. After the exclusion of other causes of the constitutional syndrome, a positron-emission tomography (PET) scan was performed, which showed a grade 2 aortitis. The diagnosis of giant cell aortitis was assumed, and given the lack of clinical response to corticotherapy, tocilizumab was initiated with a resolution of constitutional symptoms as well as a normalization of inflammatory markers. In conclusion, we report a case of temporal cell arteritis that further progressed to aortitis manifesting solely with constitutional symptoms. Furthermore, there was no optimal response to corticotherapy and no improvement with tocilizumab, therefore making this a case with a unique and infrequent clinical course. GCA is characterized by a wide variety of symptoms and organ involvement, and although it most frequently affects temporal arteries, it can be associated with aortic involvement that can cause life-threatening structural complications, highlighting the need for a high suspicion index for this condition.

Can a Giant Cell Arteritis (GCA) Risk Stratification Score Be Helpful in Clinical Practice?

INTRODUCTION

Giant cell arteritis (GCA) is the most common type of large vessel vasculitis. The diagnosis of GCA is often challenging and there is a difficult balance of over- and underinvestigation. There have been several proposed scoring systems to help clinicians risk stratify patients who may present with suspected GCA.

METHODS

A retrospective cohort study was performed using electronic medical records of patients referred for a temporal artery biopsy (TAB) and temporal artery ultrasound scan (USS) for suspected GCA. All TABs performed at the Royal Wolverhampton NHS Trust between June 2014 and June 2018 and all USS procedures performed between January 2015 and January 2019 were analysed. Patients who undergo a USS for suspected GCA at our centre routinely have scanned bilateral temporal and axillary arteries. Patients were excluded if they already had a previous diagnosis of GCA (and the clinical question was suspected flare), or if there was insufficient information available.

RESULTS

The total number of patients who underwent a confirmatory diagnostic test (either TAB or USS) for suspected GCA was 187. Thirteen of these patients met the exclusion criteria, the remaining 174 patients were included for analysis. A total of 126 of 174 patients underwent a TAB and 63 of 174 had a USS performed; 15 of 174 who had both these were included in the USS cohort because for all these patients, the ultrasound was the first diagnostic test performed. Our results appear to closely mirror the original multi-centre results with regard to the prediction of biopsy-positive GCA, with the centiles closely following those in the inception cohort. Also, 0% of the 'low' risk probability biopsy cohort were misclassified; none had a positive biopsy. However, 8% of the low-risk-probability ultrasound cohort were misclassified, as two had a positive ultrasound.

CONCLUSION

 Our study highlights that a probability score for GCA derived from a large multi-centre cohort of patients who were biopsy positive predicts ultrasound positivity with similar accuracy. Our work reveals that scoring systems are not infallible but can be helpful in guiding clinical decision making.

Giant Cell Arteritis Presenting as Bilateral Cotton Wool Spots

An 81-year-old Afro-Caribbean woman presented with a two-week history of a dull headache in her temples, jaw claudication especially when chewing food, and reduced vision in her eyes, more pronounced in the right eye. There was no past medical or family history of hypothyroidism or autoimmunity. On examination, the vision was counting fingers in the right eye and 6/36 in the left eye, best corrected. Dilated fundus examination revealed multiple peripapillary cotton wool spots in both eyes though more pronounced in the right. Her erythrocyte sedimentation rate (ESR) was 120 mm/h, and her C-reactive protein (CRP) level was 79 mg/L. A temporal artery ultrasound scan was undertaken immediately which demonstrated a halo sign around both temporal arteries and so a giant cell arteritis (GCA) diagnosis was made. The patient was commenced on daily high-dose IV methylprednisolone 1 g for three days and referred to the rheumatology team. Her vision improved to 1/60 right and 6/9 left eye best corrected at three days post-treatment. At 12 months after the initial presentation, her vision stabilized at 6/60 in the right and 6/6 with complete visual fields in the left eye. Cotton wool spots can be a sign of GCA. Their appearance with or without characteristic systemic symptoms should prompt urgent evaluation.

Optical Coherence Tomography of Peripapillary Vessels in Giant Cell Arteritis and Ischaemic Ocular Disease

With normal retinal blood flow, cross-sectional optical coherence tomography (OCT) of retinal vessels shows a structured intravascular reflectivity profile, resembling a 'figure-of-8'. Altered profiles have been reported in vascular occlusive and haematological diseases. Giant cell arteritis (GCA) can cause visual loss, usually due to anterior ischaemic optic neuropathy (AION) or retinal artery occlusion. Our aim was to extend the assessment of OCT vascular profiles to patients with suspected GCA and to determine if any abnormalities were related to GCA per se or to ischaemic ocular conditions. This nested retrospective study included 61 eyes of 31 patients (13 with GCA). Six eyes had arteritic and seven eyes non-arteritic AION, three eyes had non-arteritic retinal artery occlusion, 11 eyes had other ocular conditions and 34 were unaffected control eyes. For each eye the appearance of structured intravascular profiles on peripapillary OCT was graded as present, partial, absent or uncertain. Non-presence of structured intravascular profiles was more frequent in AION and retinal artery occlusion than in other ocular conditions or unaffected eyes (Fisher's test, p = .0047). Based on follow-up of 25 eyes, reflectivity profiles normalised in three out of four eyes after 85 (35-245) days. Vessel profiles were not associated with GCA (p = .32) and were similar in arteritic and non-arteritic AION (p = .66). In conclusion, absence of structured intravascular reflectivity profiles may be a marker of acute ischaemia in the anterior optic nerve or inner retina. However, it did not seem specific for GCA. The prognostic value warrants further studies.

Simultaneous Unilateral Abducens Nerve Palsy and Contralateral Anterior Ischaemic Optic Neuropathy as the Presenting Signs of Giant Cell Arteritis

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.

Giant Cell Arteritis: A Case-Based Narrative Review of the Literature

Purpose of Review

Giant cell arteritis (GCA) is a chronic, inflammatory condition, primarily affecting the medium and larger arteries. The purpose of this narrative review is to describe GCA in the context of headache and facial pain, based on a case and the available current literature. Understanding the etiology, pathophysiology, the associated conditions, and the differential diagnoses is important in managing GCA.

Recent Findings

In a patient presenting with unilateral facial/head pain with disturbances of vision, GCA should be considered in the differential diagnosis. There is an association of GCA with several comorbid conditions, and infections including coronavirus-19 (COVID-19) infection. Management of GCA primarily depends upon the identification of the affected artery and prompt treatment. Permanent visual loss and other serious complications are associated with GCA.

Summary

GCA is characterized by robust inflammation of large- and medium-sized arteries and marked elevation of systemic mediators of inflammation. An interdisciplinary approach of management involving the pertinent specialties is strongly recommended.

Use of Retinal Angiography and MRI in the Diagnosis of Giant Cell Arteritis With Early Ophthalmic Manifestations

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.

An update on the clinical approach to giant cell arteritis

Recent national and international guidance from rheumatology societies have reflected the advances in evidence for both the investigation and management of giant cell arteritis. Cranial ultrasound reduces diagnostic delay and improves clinical outcomes. Immediate high-dose glucocorticoids remain the standard treatment for giant cell arteritis. Randomised controlled trial evidence using tocilizumab, an interleukin-6 receptor antagonist, has been shown to have good clinical efficacy with glucocorticoid sparing effects. Overall patient outcomes appear to be improved by formalising pathways for diagnosis to include clinical experts' opinion early in decision making.

Large-Vessel Vasculitis in Ophthalmology: Giant Cell Arteritis and Takayasu Arteritis

ABSTRACT

Giant cell arteritis and Takayasu arteritis are large-vessel vasculitides that share multiple common features but also have significant differences in epidemiology, demographics, clinical presentation, evaluation, and treatment. Giant cell arteritis is more common in elderly patients of Caucasian descent versus Takayasu arteritis, which is more prevalent in younger patients of Asian descent. Although traditionally age has been the main criterion for differentiating the 2 etiologies, modifications in the diagnostic criteria have recognized the overlap between the 2 conditions. In this monograph, we review the diagnostic criteria for both conditions and describe the epidemiology, pathogenesis, histology, evaluation, and management for large-vessel vasculitis in ophthalmology. Additionally, we describe ocular imaging techniques that may be utilized by ophthalmologists to identify manifestations of large-vessel vasculiti- des in patients. Lastly, we compare and contrast the key clinical, laboratory, and pathologic features that might help ophthalmologists to differentiate the 2 entities.

Role of temporal artery resection in Horton's arteritis (Review)

Horton's arteritis is found in the literature under various names, such as temporal arteritis, Horton's disease senile arteritis, granulomatous arteritis or giant cell arteritis (GCA). The pathogenic mechanism is the result of an inflammatory cascade triggered by a still unknown factor that causes dendritic cells in vessels to recruit T cells and macrophages, which form granulomatous infiltrates. The clinical picture consists of a daily headache with temporal localization, with moderate to severe intensity, unilateral or bilateral, with a history of months, years. Other changes may include pain in the cheek or tongue during chewing (claudication), weight loss, generalized fatigue, low-grade fever, and frequent pain in the limbs, in the context of coexisting rheumatic polymyalgia. Visual symptoms represent a special category, involving blurred vision, scotomas, and even sudden blindness. Histopathological examination of the temporal artery biopsy reveals focal thickening of the intima, with interruption of the lamina propria, with transmural inflammatory infiltrates, sometimes with multinucleated giant cells. In this article, we aim to review the role of temporal artery resection in the diagnosis of Horton's arteritis, but we also discuss the hypothesis of a potential therapeutic benefit of this procedure. However, there are also clinical situations in which there has been a considerable improvement in clinical symptoms and especially in vision deficit, with the improvement of the visual field after surgery performed for biopsy. It is difficult to estimate the influence of temporal artery resection alone, given that most patients also have concomitant cortisone treatment. However, in some cases, the rapid improvement of symptoms immediately after surgery, with the improvement of visual acuity and visual field, along with the disappearance of the headaches, can create the premises for future studies on a therapeutic contribution of temporal artery resection in GCA.

Current advances in giant cell arteritis

PURPOSE OF REVIEW

The aim of this study was to present the latest advances in giant cell arteritis (GCA) care, and recent national and international rheumatology societies guidance which influences clinical practice.

RECENT FINDINGS

Cranial ultrasound reduces diagnostic delay and improves clinical outcomes. Immediate high dose glucocorticoids remain the standard treatment for GCA. Controlled trial evidence using Tocilizumab, an interleukin-6 receptor antagonist, shows good clinical efficacy with steroid-sparing effects.

SUMMARY

Improved patient outcomes require formalizing pathways to diagnosis and closer liaison with rheumatology for long-term management with second-line therapies.

Diagnosing Giant Cell Arteritis: A Comprehensive Practical Guide for the Practicing Rheumatologist

Giant cell arteritis (GCA) is the most common large vessel vasculitis in the elderly population. In recent years, advanced imaging has changed the way GCA can be diagnosed in many locations. The GCA fast-track clinic (FTC) approach combined with ultrasound (US) examination allows prompt treatment and diagnosis with high certainty. FTCs have been shown to improve prognosis while being cost effective. However, all diagnostic modalities are highly operator dependent, and in many locations expertise in advanced imaging may not be available. In this paper, we review the current evidence on GCA diagnostics and propose a simple algorithm for diagnosing GCA for use by rheumatologists not working in specialist centres.

Impact of Climate Change on Eye Diseases and Associated Economical Costs

Climate change generates negative impacts on human health. However, little is known about specific impacts on eye diseases, especially in arid and semi-arid areas where increases in air temperatures are expected. Therefore, the main goals of this research are: (i) to highlight the association between common eye diseases and environmental factors; and (ii) to analyze, through the available literature, the health expenditure involved in combating these diseases and the savings from mitigating the environmental factors that aggravate them. Mixed methods were used to assess the cross-variables (environmental factors, eye diseases, health costs). Considering Southern Spain as an example, our results showed that areas with similar climatic conditions could increase eye diseases due to a sustained increase in temperatures and torrential rains, among other factors. We highlight that an increase in eye diseases in Southern Spain is conditioned by the effects of climate change by up to 36.5%; the economic burden of the main eye diseases, extrapolated to the rest of the country, would represent an annual burden of 0.7% of Spain's Gross Domestic Product. In conclusion, the increase in eye diseases has a strong economic and social impact that could be reduced with proper management of the effects of climate change. We propose a new concept: disease sink, defined as any climate change mitigation action which reduces the incidence or morbidity of disease.

Monckeberg's Medial Sclerosis as a Cause for Headache and Facial Pain

PURPOSE OF REVIEW

Mönckeberg's medial sclerosis (MMS) is a chronic, non-inflammatory degenerative condition affecting primarily the tunica media of muscular arteries resulting in their calcification. The purpose of this comprehensive review is to describe MMS as it appears in the literature, in the context of headache and facial pain. Understanding the etiopathology, the associated conditions, and the differential diagnoses is important in managing MMS.

RECENT FINDINGS

Management of MMS primarily depends upon identification of its associated conditions and their treatment. Due to the rare incidence and inadequate literature on MMS presenting with headaches, the diagnosis of the pain and the entity itself is challenging. MMS is characterized by associated systemic conditions and absence of inflammatory markers. It can mimic giant cell arteritis (GCA) and other pain entities. An interdisciplinary approach involving appropriate specialties is recommended.

Headache for ophthalmologists: current advances in headache understanding and management

Patients with headache and head pain are often referred to ophthalmologists. These symptoms can either be associated with underlying ophthalmic conditions, or more often are headache disorders unrelated to the eyes. Understanding the phenotype of the headache is critical for advice, safe discharge or onward referral. This review will provide an update on the criteria for common headache disorders that are often seen by ophthalmology and embrace disorders associated with ophthalmic diseases. It will also describe the changing management of migraine and outline recent therapies that are currently available.

Utility of Doppler ultrasound for the study of ocular vascular disease

Ocular vascular problems represent an emerging pathology within the activity of the internist. Ocular ultrasound is a widely used technique to evaluate a variety of eye conditions. Specifically, Doppler ultrasound of the ophthalmic vessels has become a very useful tool in diagnosing various eye diseases. Doppler ultrasound allows for examining blood flow in the eye even in the presence of eye opacities that impede viewing the posterior segment of the eye. In this review, we describe the principles and techniques of an ocular vascular Doppler ultrasound examination in clinical practice and provide a general approach to the ultrasound characteristics of the most important vascular eye disorders for internists. These include central retinal artery and vein occlusions, chronic retinal ischemic syndrome, anterior optic ischemic neuropathy, and diabetic retinopathy.

Diagnosis and management of giant cell arteritis: Major review

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.

Large vessel vasculitis and the rising role of FDG PET-CT: A case report and review of literature

Giant cell arteritis (GCA) is a rare form of large and medium vessel vasculitis affecting about 20 cases per 100,000 persons older than the age of 50 years. GCA results in inflammation and constriction of the temporal arteries, cranial arteries, the aorta, and its major branches. Patients often present with vague constitutional symptoms and fever of unknown origin. GCA is a medical emergency requiring prompt diagnosis and early treatment with glucocorticoids which is essential to avoid irreversible end organ damage such as loss of vision, stroke and aneurysm formation. We report a case of a 63-year-old male patient presenting to our healthcare facility with sudden loss of vision and an ischemic brain infarct to be finally diagnosed as a case of giant cell arteritis with positron emission tomography-computed tomography imaging used to evaluate the full extent of the involved vasculature. Diagnostic imaging with FDG positron emission tomography-computed tomography can play a crucial role in the diagnosis, evaluation of the full burden of the disease and follow up to the response of therapy.