Is visual loss due to giant cell arteritis reversible?

Is there a place for cyclophosphamide in the treatment of giant-cell arteritis? A case series and systematic review

OBJECTIVE

To report on the effectiveness of cyclophosphamide (CYC) to treat glucocorticoid (GC)-dependent giant-cell arteritis (GCA) and/or severe GC-related side effects.

METHODS

Fifteen patients with GCA and treated with CYC were retrieved from the computerized patient-record system. Glucocorticoid dependence was defined as a prednisone dose of >20mg/day for 6 months or >10mg/day for 1 year in order not to relapse. Response to CYC was defined as improved clinical and biological findings. Remission was defined as a sustained absence (>12 months) of active signs of vasculitis at a daily GC dose of <7.5mg. A literature review searched PubMed for all patients diagnosed with GCA and who received CYC.

RESULTS

Our 15 patients responded to monthly pulses of CYC, and all experienced a GC-sparing effect, including five patients who discontinued GC long term. At a median follow-up of 43 (range: 14-75) months after CYC, nine (53%) patients were still in remission and six (40%) had relapsed at 6 (3-36) months after the last CYC infusion. Twelve (80%) patients experienced side effects, leading to discontinuation of CYC in two (13%). A literature review retrieved 88 patients who received CYC: 66 for GC-dependent disease, 53 for GC toxicity, and 14 for severe organ involvement. Their median follow-up time was 24 (4-60) months. Among the 88 patients, 74 (84%) were responsive to CYC and 17 (19%) relapsed, although all were receiving a maintenance therapy with immunosuppressive agents (such as methotrexate). Twenty-nine (33%) patients experienced side effects and 11 (12.5%) discontinued treatment.

CONCLUSION

Cyclophosphamide is an interesting option for GCA patients with GC-dependent disease or with severe GC-related side effects, especially when conventional immunosuppressive agents have failed.

An unusual cause of bilateral ophthalmoplegia

The authors present a case of a histologically confirmed giant cell arteritis that presented unusually with bilateral and multiple cranial nerve palsies and resolved following treatment with pulsed cyclophosphamide. The aetiology of the presenting features and the treatment choices are discussed.

Temporal arteritis: report of a case

Temporal arteritis is a rheumatic disease that affects large and medium-sized arteries. It is a severe arteritis involving both the intima and media of the vessel and is a cause of headache that is frequently diagnosed erroneously as "atypical migraine." The patients have a burning or throbbing type of pain. Ultimately, there is localized inflammation or cellulitis over the swollen, tortuous artery. Jaw claudication, eye pain, photophobia, diplopia, and even blindness may accompany the temporal symptoms. As many as 20% to 60% of inadequately treated or untreated patients will lose their vision. Blindness may or may not be preceded by visual symptoms and funduscopic changes. A variety of systemic symptoms are also often present, including nausea, vomiting, chills, dizziness, and loss of weight. Temporal arteritis is not a common diagnosis in maxillofacial practice. We are presenting a case of temporal arteritis diagnosed after a biopsy. The patient eventually lost the vision from one eye.