Lymphocyte proliferation to artery antigen as a positive diagnostic test in polymyalgia rheumatica

The relationship of anti-endothelial cell antibodies to anti-phospholipid antibodies in patients with giant cell arteritis and/or polymyalgia rheumatica

Sera from patients with giant cell arteritis and/or polymyalgia rheumatica were tested for the presence of IgG, IgM and IgA antibody to endothelial cells (AEC), cardiolipin (ACL) and phosphatidylethanolamine (APE) using enzyme-linked immunosorbent assays. There were strong correlations between ACL and APE, but also between AEC and ACL IgM (p < 0.02) and between AEC and APE IgA (p < 0.003). Inhibition of AEC binding was achieved by absorption onto EC, but ACL and APE binding was also significantly reduced. In contrast, the binding of AEC antibody could not be inhibited by incubation with CL. Our data suggest that AEC constitute a heterogeneous population of autoantibodies.

Familial calcification of aorta and calcific aortic valve disease associated with immunologic abnormalities

We report three patients of the same family with linear calcification of the ascending aorta, severe calcific mixed aortic valve disease associated with increased levels of globulins, lambda-chain gammopathy, an increased T4/T8 lymphocyte ratio, and other immunologic abnormalities. None of the patients had syphilis, atherosclerosis, abnormalities of calcium or phosphorus metabolism, lymphadenopathy, or other systemic diseases. It is postulated that these cases and some previously reported in the literature as idiopathic represent a distinct pathologic entity, familial or sporadic, in which localized vascular and valvular calcific disease is associated with an underlying immunologic disorder or autoimmune process.

Giant-cell (temporal) arteritis following a bypass operation for cerebral infarction

A 61-year-old man was referred to us with linear and indurated erythemas and severe tenderness on the scalp, neck, tongue, and scrotum which had gradually spread over the previous six months. He had a history of an intracranial bypass operation for cerebral infarction. Histologic and ultrastructural examinations revealed giant-cell arteries in the skin as well as inflammatory cells infiltrating into nerves. Carotid angiograms indicated stenosis of cranial arteries. It is suggested that the bypass operation may be related to the occurrence of the giant-cell arteritis and that the inflammatory cell infiltrate into nerves may have caused the severe tenderness of this disease.

Collagen fibril structure of normal, aging, and osteoarthritic cartilage

The collagen architecture in normal, aging, and osteoarthritic articular cartilage was studied optically using a new silver staining technique based on specimens from 50 autopsy cases, four amputated limbs, and six osteoarthritic knees. In the normal articular cartilage, the collagen fibrils in the superficial zone were compactly arranged into layers of decussating flat ribbons mostly parallel to the artificial split lines. The fibrils showed a tendency to condense into vertical arcade columns undergirded by tangential bundles in the intermediate zone. In the deep zone, the fibrils formed a random meshwork with a slight preponderance of vertical fibrils in the perilacunar region. Three types of early degradative lesions involving the collagen network were identified. Type I lesions consisted of focal superficial disruptions related to age and friction. Type II lesions consisted of focal disruptions of tangential fibrils in the intermediate zone leading to cyst formation, probably representing a form of local stress failure. Type III lesions were found in the patella and consisted of marked swelling of the superficial zone, the cause of which was unknown. Lesions of varying severity were seen within each of the three types; the morphological changes of the more severe lesions overlapped with those of clinically overt osteoarthritis.

Immunological studies in giant cell arteritis

The results of investigations on the humoral immunological mechanisms are conflicting in giant cell arteritis (GCA) and have not been able to explain the pathological findings in the inflamed arterial wall. Altogether, immunological studies suggest that a cell-mediated immune reaction, possibly against an autologous antigen, occurs locally in the arteritic lesions of GCA. The excellent effect of treatment with glucocorticosteroids on the inflammation in GCA can also be explained by this model. The glucocorticosteroids inhibit the synthesis of interleukin-1 (IL-1) by the macrophages and suppress the IL-2 production from the T cells (Palacios, 1982). The observed HLA-DR expression in the arterial wall can be accounted for by the sum of macrophages and activated T cells, the macrophages being the most probable antigen-presenting cells. The interdigitating reticulum cells observed in some of the GCA patients may also be involved in antigen presentation. What the antigen(s) may be is, however, still unknown, as are the factors initiating the inflammatory process. It has recently been possible to extract T lymphocytes from the inflamed tissue and to culture these cells in vitro. After culture, it is possible to study the gene for the T-cell receptor, and probably even the antigenic specificity of the T cells. I hope that this approach may lead to a better understanding of the pathogenic mechanisms in GCA.

Temporal arteritis: cell composition and the possible pathogenetic role of cell-mediated immunity

A biopsy specimen exhibiting the typical morphologic characteristics of temporal arteritis was studied by using light immunofluorescent, and electron microscopy and immunohistochemical techniques. The granulomatous lesion consisted of clusters of macrophages, epithelioid cells, giant cells, and the peripheral lymphocyte mantle, and was localized mainly in the media. Neutrophils were rare, and fibrinoid necrosis was absent. In immunofluorescent and immunohistochemical studies, no significant deposition of immunoglobulins or complement was observed. Immunohistochemical study with monoclonal antibodies to leukocyte surface antigens demonstrated that the central aggregated granulomatous infiltrate consisted of OKTM1+, Leu-M3+, HLA-DR+ epithelioid macrophages and multinucleated giant cells, whereas OKT8+, HLA-DR+ (suppressor/cytotoxic) T cells predominated in the peripheral lymphocyte mantle. These findings suggest that cell-mediated immunity, especially T cell-regulated granulomatous reaction, may play an important role in the pathogenesis of temporal arteritis. By electron microscopy, smooth muscle cells often exhibited closely attached macrophages, epithelioid cells, and giant cells, and displayed a variety of cell injuries. It therefore seems likely that smooth muscle cells are a primary target of the granulomatous reaction.

Temporal arteritis and renal disease. Case report and review of the literature

Renal abnormalities have been described in a small percentage of patients with temporal arteritis. Transient microscopic hematuria is the most common finding. In rare instances, widespread vasculitis involving renal arteries or microscopic polyarteritis nodosa can be seen. This case report describes the association of temporal arteritis with membranous glomerulonephropathy and the nephrotic syndrome in an elderly patient, an occurrence not previously reported. Whether this association is coincidental or pathogenetically linked remains to be determined.

Polymyalgia rheumatica and temporal arteritis in a married couple

A husband suffering from temporal arteritis and his wife afflicted with polymyalgia rheumatica are reported. The possibility of the existence of an environmental factor rather than a genetic etiology is discussed.

Decrease of the OKT8 positive T cell subset in polymyalgia rheumatica. Lack of correlation with disease activity

Peripheral T cell populations were investigated in 35 patients suffering from polymyalgia rheumatica. The total number of T cells was low compared with those of a control group of similar age (P less than 10(-3). This decrease was demonstrated by using both classic E-rosette and monoclonal antibody techniques (OKT3, and OKT4 + OKT8) and was shown to be secondary to a selective T8 defect (P less than 10(-9). There was no correlation between the decrease in T8 (a cytotoxic suppressor T cell subset) and steroid therapy, disease activity, and temporal arteritis, nor between this decrease and the T gamma percentage and the presence of circulating immune complexes (CIC). The T gamma cell percentage was low in the patient group (P less than 10(-5) and correlated with the presence of detectable CIC (P less than 0.05). In contrast to the T8 and T gamma defects, concanavalin A-stimulated cells from 5 selected patients were found capable of suppressing in vitro anti-trinitrophenyl response. This suppression was found in both autologous and allogeneic experiments. From these data one can assume that an immune anomaly (T8 defect) could be the origin of CIC and the disease occurrence.

Serologic and immunopathologic findings in temporal arteritis

In 104 patients undergoing biopsies for temporal arteritis, lymphocyte characterization identified both T4 helper/inducer and T8 cytotoxic/suppressor lymphocytes in approximately equal numbers. B lymphocytes were absent. Deposition of IgM and IgG was observed in three of 16 positive biopsy specimens. Antinuclear antibodies were present in ten of 16 biopsy-proven cases of temporal arteritis compared with 19 of 55 in the control group with negative biopsy specimens. Anti-smooth-muscle, anti-DNA, and antimitochondrial antibodies were not useful in distinguishing between the two groups.

Giant-cell arteritis. Signs and symptoms

Giant-cell arteritis is a polysymptomatic disease of the elderly. Systemic symptomatology includes headaches, arthralgias, myalgias, tender temporal arteries, jaw claudication, low-grade fever, anemia, anorexia, malaise, and weight loss. Visual loss from anterior ischemic optic neuropathy and diplopia resulting from ischemia of the ocular muscles represents the major ocular manifestations of giant cell arteritis. When the diagnosis is suspected, blood for a sedimentation rate should be drawn, and, if it confirms the clinical impression, high dose prednisone should be started immediately and a temporal artery biopsy performed at a later date. Only by asking the proper questions and suspecting the diagnosis will this preventable form of blindness receive the prompt attention it deserves.

Pathogenesis of rheumatoid arthritis: a vascular hypothesis

Past research into the pathogenesis of RA has generally concerned itself with established inflammation. The present review summarizes alterations in microvascular anatomy and function which occur during the hypoxic state, in various experimental and disease conditions. It further shows that tissue hypoxia is a common finding in RA and that the microvascular alterations of RA are similar to those produced by experimental hypoxia. The available data suggest that microcirculatory compromise, concomitant with an increase in metabolic needs of synovial tissue, may initiate tissue injury via anoxia and acidosis, resulting in hydrolytic enzyme release, increased vascular permeability and acceleration of inflammatory processes. It is further believed that the microcirculatory abnormality may be generalized, accounting for the systemic manifestations often seen in RA. Factors effecting arteriolar blood flow obstruction are reviewed to identify areas for future investigation in RA and other disorders involving microvasculopathy. The multitude of longknown and newly recognized factors predisposing to vasospasm and vasodilatation have been outlined as a guide to possible mechanisms which may be operative in RA. An attempt has been made to gather and synthesize the available data in the hope that it may stimulate other investigators to pursue more definitive research into specific areas which may show early microvascular abnormalities in the pathophysiology of RA. Identification of factors operative early in the pathogenesis of RA, before it becomes self-perpetuating, may well be a step in the direction of preventing the ravages of this disease, or providing insight to more effective control.

Polymyalgia rheumatica syndrome

Eleven (14%( of 80 patients with polymyalgia rheumatica syndrome (PMR-S) recovered spontaneously within one year; two of them had received repeated injections of depot steroids before remission occurred. The remaining 69 patients, including 14 with giant cell arteritis (GCA), were all treated with systemic glucocorticoids for an average of 30 months (range 3-81 months). Nine of the patients developed side effects from the treatment, which in seven cases were severe osteoporosis and spinal compression. None suffered from loss of vision. The patients' mortality rate and causes of death did not differ from those of the population at large. The diagnostic criteria are discussed, with the omission of those applied for exclusion. Use of the common term PMR-S is preferred, as GCA and polymyalgia rheumatica (PMR) are clinically indistinguishable. Systemic glucocorticoids are urgently needed when arteritis or ocular manifestations are detected or even suspected. In uncomplicated cases of PMR we recommend that trials be made with repeated injections of depot steroids. This procedure could also be used in patients suffering from severe subjective recurrences after cessation of treatment with systemic glucocorticoids, thereby reducing the number of cases where steroid treatment is unquestionably maintained for too long.

Immunohistochemical findings in cranial arteritis

The cause of cranial arteritis is unknown, but the demonstration of immunoglobulin and complement in temporal artery biopsies by immunofluorescence suggest that it may be a disease of disordered immunity. Because of the inevitable problems of histologic interpretation associated with the fluorescent technique, 15 temporal artery biopsies from patients with active arteritis were examined by an immunoperoxidase method. Varying amounts of IgA, IgG, and IgM were identified in plasma cells and macrophages. Extracellular IgG was identified in 1 case, but there was no staining for complement. These findings provide no support for the concept of cranial arteritis as a form of immune complex vasculitis.

In vitro cytotoxicity of human endothelial cells in polymyalgia rheumatica and giant cell arteritis

We studied sera from 20 patients with polymyalgia rheumatica (PMR)/giant cell arteritis (GCA), 15 patients with systemic lupus erythematosus (SLE), 15 patients with the CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangietasia) and 33 age and sex matched controls for cytotoxicity against human endothelial cells using a 51Cr release assay. We observed increased levels of endothelial cytotoxic activity in the PMR/GCA sera compared with controls (P less than 0.001). This cytotoxicity was predominantly found in the GCA group, where 7 out of 10 patients (70%) demonstrated significant cytotoxicity. Sequential studies showed that the cytotoxic activity returned to normal when the disease was under control. Although 7 SLE and 3 CREST sera had significant cytotoxic activity, as a group they did not differ from controls (P less than 0.05). Pre-incubation with soybean trypsin inhibitor suppressed the cytotoxic activity in the positive sera suggesting the cytotoxicity is mediated via a protease mechanism. Our results demonstrate the presence of a cytotoxic factor in the serum of patients with PMR/GCA which may play an important role in the pathogenesis of the vascular lesions observed in these disorders.

Immune complexes, rheumatoid factors, and cellular immunological parameters in patients with giant cell arteritis

Circulating immune complexes were found in 2 of 15 patients with giant cell arteritis (GCA) by using a solid phase Clq enzyme linked immunoabsorbent assay (ELISA). The prevalence in controls was 5%. Rheumatoid factor could be demonstrated in 2 out of 27 patients and in 11% of the controls by using a similar ELISA technique. The prevalence of T cells in blood was similar in 25 patients with GCA and in controls. The blood lymphocyte blastogenic response to the mitogens, phytohaemagglutinin, concanavalin-A, and pokeweed mitogen did not differ in 25 untreated patients compared with controls. Stimulation of lymphocytes by arterial homogenates was tested in 8 patients. In no case could a significant simulation by obtained. We conclude that immune complexes and rheumatoid factors are present in the same low frequency in GCA patients as in the normal population, and that the studied parameters of cellular immunity appear to be normal.

Circulating immune complexes in giant cell arteritis and polymyalgia rheumatica

Sera from 74 patients with polymyalgia rheumatica or giant cell arteritis or both were tested for immune complexes by using the Raji cell radioimmunoassay. Levels in patients with active disease were higher than in patients whose disease had become inactive. There was no difference in levels of immune complex-like materials between patients with polymyalgia rheumatica alone and those with giant cell arteritis. Density gradient analysis of one serum showed immune complex-like materials mainly in the 19S region. Immune complexes may be important in the pathogenesis of these conditions.

Bullous pemphigoid, polymyalgia rheumatica and thyroid disease

This paper describes the occurrence of bullous pemphigoid in a 71-year-old female patient who subsequently developed polymyalgia rheumatica and hyperthyroidism. The association of bullous pemphigoid with other autoimmune disorders is discussed.

Aortic valve replacement for severe aortic regurgitation caused by idiopathic giant cell aortitis

Giant cell aoritis occurred in a 25-year-old woman, with absent pulses in the left arm and severe aortic regurgitation from dilatation of the valvar annulus. The aortic valve was replaced by a Starr-Edwards prosthesis, and the patient was treated with steroids. Five years later, she continues asymptomatic and haemodynamically stable. The left brachial and radial pulses have returned.

Cellular immunity in polymyalgia rheumatica and giant cell arteritis: lack of response to muscle or artery homogenates

Peripheral blood lymphocyte functions were evaluated in 20 patients with active polymyalgia rheumatica (PMR) and/or giant cell arteritis (GCA) by determining the percent of E-rosette-forming cells and by measuring the uptake of tritiated thymidine by peripheral blood lymphocytes after exposure to common infectious antigens and to homogenates of homologous and heterologous artery, muscle, and elastin. Although lymphocytes from patients with PMR and/or GCA were stimulated slightly by artery and muscle homogenates, no differences in lymphocyte responses were found when the results were compared with 22 normal controls and 16 patients with rheumatoid arthritis. The hypothesis that GCA results from a cellular immune reaction to normal or diseased arterial wall antigens is not supported by these studies.

Polymyalgia arteritica: a clinical review

In a series of thirty-seven consecutive patients with polymyalgia arteritica, twenty-five had polymyalgia rheumatica and twelve had cranial arteritis. Some failed to respond promptly to low doses of prednisolone and it is recommended that the initial dose should be in the order of 40 mg daily. An ESR above 40 mm in the first hour was present in four patients 3 months after admission; three were found to have rheumatoid disease and one pulmonary tuberculosis. Symptomatic relapses occurred in fourteen patients on twenty-one occasions and all responded to an increase in the daily dose of maintenance prednisolone. Most occurred in the first year and were attributable to an excessively rapid reduction in steroid therapy. Relapses occurring in patients on a stable dose of prednisolone were commonly associated with the development of rheumatoid disease. In elderly patients who have relapsed, or who have had arteritic complications, life-long prednisolone therapy appears justifiable.

Giant cell arteritis (cranial arteritis, polymyalgia rheumatica)

Giant cell arteritis, which is probably due to disturbed immune mechanisms, has a spectrum of clinical symptoms in elderly people. In nearly all cases such general signs as loss of appetite, loss of weight and fever are present. The sedimentation rate is almost without exception about 100 mm in the first hour. The two most frequent and typical clinical syndromes are polymyalgia rheumatica and cranial arteritis. The polymyalgia rheumatica is characterized by periarticular pain which is mostly symmetrical and accentuated in the shoulder girdle. Increasingly severe temporal headache and ocular distrubances are found with cranial arteritis in more than 50% of cases. A combination of both diseases is frequent. Other arterial branches are rarely involved. The course of the disease is over a period of 1 1/2 to 2 years. Treatment with corticosteroids is indicated mainly because of the severe ocular complications with blindness. It should begin immediately, be intensive and last over a long period. Regular followup is necessary over several years in order to avoid relapses.

Immunological and histological study of temporal arteries

Sixty-four temporal arteries were studied. 36 were from patients with clinically active temporal arteritis or polymyalgia rheumatica; 22 showed histological changes of temporal arteritis, 12 of which were in an active stage. 28 arteries, none of which showed histological changes, were taken at necropsy or from patients with unrelated disease. Extracellular immunoglobulin and complement deposition was seen in the artery biopsies showing active arteries and in 1 of the 10 biopsies with inactive arteritis. There was no immunoglobulin or complement deposition in the 14 patients with clinically active temporal arteritis and/or polymyalgia rheumatica, but with a normal artery biopsy. Patients with clinically active temporal arteritis were more likely to have a positive biopsy. Our results support the suggestion that the immune deposition is concurrent with an active histologically proven arteritis. Immunofluorescent examination does not appear to be a better diagnostic test than histological examination.

Neutrophil chemotaxis in ankylosing spondylitis, Reiter's disease, and polymyalgia rheumatica

Neutrophil chemotaxis was found to be normal in 14 patients with ankylosing spondylitis, in 10 patients with Reiter's disease, and in 8 patients with polymyalgia rheumatica.

Giant cell arteritis. Clinical features and involvement of different organs

Sixty-eight patients with giant cell arteritis (GCA) are described. In 42, histological evidence of arteritis was recorded at biopsy of a temporal artery. Twenty-six patients were included according to clinical criteria. In 20 patients the onset of illness was associated with an infection. The first symptom was: in 30 patients, muscle pains; in 14, fever; in 11, headache with temporal localization, and in 13 patients, tiredness and anorexia. In all, 50 patients had muscular symptoms and 30 had symptoms of localized temporal arteritis. In 5 patients neither muscular symptoms nor localized arteritis were found. A high erythrocyte sedimentation rate was seen in all cases and elevated platelet count was found in 24 patients. Abnormal liver function was a common finding, whereas impaired renal function was not observed. In 8 cases reversible eye symptoms were noted and reduced hearing capacity was demonstrated in 5 patients.

A concept of diffuse actinic arteritis. The role of actinic damage to elastin in 'age change' and arteritis of the temporal artery and in polymyalgia rheumatica

Actinic damage (actinic elastosis) affecting the internal elastic lamina appears to be the prime cause of 'age change' and arteritis of the temporal artery. Resorption and removal of altered elastin (elastolysis) is an integral part of the pathology of actinic damage. Actinic irradiation is probably responsible for the destruction and disappearance of a vast number of arterioles in elastotic skin. The intimate connection between temporal arteritis and polymyalgia rheumatica prompts the belief that the vascular and other internal malign components of the temporal arteritis/polymyalgia rheumatica syndrome might likewise be due, albeit indirectly, to the same actinic cause. Actinic elastotic damage at the body surface could have this effect by provoking a state of systemic elastolysis. Although ultraviolet (uv) light is often regarded as the sole cause of actinic elastosis, penetrating infrared (heat) irradiation may deserve a large or even a dominant share of the blame.

Circulating immunoblasts in polymyalgia rheumatica

The percentage of immunoblasts circulating in the peripheral blood has been examined in a group of 29 patients with polymyalgia rheumatica (PMR). Less than 0.5% of immunoblasts were found in healthy young controls, but 18 of 29 unselected patients with PMR were positive when first tested, a similar proportion to that found in rheumatoid arthritis. Raised immunoblasts were found in only one of 12 elderly controls. The presence of circulating immunoblasts correlated with the activity of polymyalgia both as assessed by the erythrocyte sedimentation rate (ESR) and as assessed by an independent clinical observer. This was true in the group overall and in those patients where serial studies were made. Patients studied from the time of disease presentation showed a concurrent fall in ESR and in immunoblasts on starting steroid therapy. Detection of circulating immunoblasts can be a useful additional test in the assessment of disease activity in PMR, especially in cases with a low ESR. The presence of circulating immunoblasts supports the concept of an immunological aetiology for PMR. This is strengthened by the finding that raised immunoglobulins were more common in patients with circulating immunoblasts.