Giant cell arteritis involving the lower limbs

Giant cell arteritis is an inflammatory disease that can affect the arteries anywhere in the body. Two cases are reported in which the arteries of the lower limbs were involved. Intermittent claudication with a walking distance of only 30 m was the inaugural manifestation in both cases. A biopsy of the superficial femoral artery provided the diagnosis in the first case. Ergotamine toxicity was considered initially in the second case. Acute ischemia and gangrene requiring amputation can complicate giant cell arteritis of the lower limbs and consequently corticosteroid therapy in an effective dose should be given as soon as the diagnosis is made. The inflammatory arterial lesions improve under therapy, but irreversible fibrosis with stenosis can develop if treatment is initiated late.

Risk factors and predictive models of giant cell arteritis in polymyalgia rheumatica

OBJECTIVE

To identify in polymyalgia rheumatica the best set of predictors for a positive temporal artery biopsy and to define predictive models with either a high or low probability of giant cell arteritis (GCA).

PATIENTS AND METHODS

Retrospective study of 227 patients, 137 with polymyalgia rheumatica unassociated with arteritis (group A) and 90 with polymyalgia associated with biopsy-proven giant cell arteritis (group B or training set). Data on demographic features, clinical and laboratory abnormalities were collected. Risk factors for arteritis were estimated by nonlinear logistic regressions. Simple predictive models were constructed with those predictors more related to arteritis by multivariable analysis. These models were then tested in group B and in 89 cases of arteritis without polymyalgia rheumatica (group C or test set).

RESULTS

The best predictors of arteritis were a new headache odds ratio (OR) 13.6 (95% confidence interval [CI] 4.7 to 39.3); age at onset < 70 years OR 0.11 (CI 0.04 to 0.35); abnormal temporal arteries OR 4.2 (CI 1.3 to 13.7); raised liver enzymes OR 2.9 (CI 1.1 to 7.8), and jaw claudication OR 4.8 (CI 1.0 to 22.7). Amaurosis was only observed in patients with arteritis. Three subsets had a very high risk of arteritis: (1) Patients with recent headache, abnormal arteries, and > or = 70 years at disease onset: sensitivity 44%, positive predictive value (PPV) 93%, likelihood ratio (LR) 20.3; (2) patients with a new headache, jaw claudication, and abnormal arteries: sensitivity 34.4%, PPV 96.9%, LR 47.2; and (3) those, that in addition to the last 3 features, were > or = 70 years of age at disease onset: sensitivity 26.7%, PPV 100%. We could also identify a subset with a very low risk of arteritis constituted by patients < 70 years, without headache, and with clinically normal temporal arteries: sensitivity 1.1%, PPV 1.7%, LR 0.03. In group C or the test set, these four predictive models correctly identified 57.3%, 29.2%, 23.6, and 3.4% of patients, respectively.

CONCLUSIONS

In polymyalgia rheumatica it is feasible to identify subsets with a very high likelihood of GCA. Although in some of these subsets the diagnosis of arteritis is almost certain, we suggest that even then it should be confirmed by temporal artery biopsy. By contrast, in those patients with polymyalgia < 70 years and without cranial features of giant cell arteritis, the risk of vasculitis is so low that the biopsy could be initially avoided and the patient treated with low-dose corticosteroids.

Salmon calcitonin nasal spray in the prevention of corticosteroid-induced osteoporosis

The objectives were to determine the efficacy and safety of nasal salmon calcitonin 200 IU daily in the prevention of corticosteroid-induced osteoporosis. A minimized, double-blind, placebo-controlled trial was carried out in corticosteroid-treated patients with polymyalgia rheumatica. The setting was a tertiary care university-affiliated hospital and a total of 31 patients were enrolled. The primary outcome measure was the percentage change in bone mineral density of the lumbar spine in the two treatment groups from baseline to 1 yr of follow-up. The mean +/- S.D. bone mineral density of the lumbar spine in the calcitonin-treated group decreased by 1.29 +/- 6.76% and in the placebo group by 4.95 +/- 3.50% after 12 months. The observed difference of 3.65 +/- 2.10% between groups is statistically significant (P < 0.05). Nasal salmon calcitonin prevented loss of bone in the lumbar spine as measured by dual-energy X-ray absorptiometry.

Diagnostic dilemmas in polymyalgia rheumatica

Polymyalgia rheumatica is a clinical syndrome of proximal muscle pain in older patients that often presents a diagnostic challenge because of the large differential diagnosis, lack of definitive diagnostic criteria, and relatively frequent "atypical" clinical findings, such as peripheral synovitis, distal extremity pain, normal erythrocyte sedimentation rate, and mild weakness. Despite an extensive differential diagnosis that includes endocarditis and steroid-responsive malignant neoplasms, routine laboratory testing should be limited, and a low-dose corticosteroid trial is useful as the final step in the evaluation. The clinical overlap with seronegative rheumatoid arthritis is striking, suggesting that these diagnoses may represent different presentations of a similar disease process. While concurrent asymptomatic temporal arteritis is common, there are no data to support obtaining a temporal artery biopsy in patients with pure polymyalgia rheumatica symptoms.

Giant cell arteritis and polymyalgia rheumatica

Giant cell arteritis and polymyalgia rheumatica are linked conditions that frequently occur in the same patient. They are more common in northern Europe and persons of European descent than in other populations. Recent investigations have begun to provide information about the pathogenesis of both syndromes. Both respond to corticosteroids but at different dose levels. Although a number of vascular complications may occur, the outlook is excellent.

[Thrombocytosis in polymyalgia rheumatica]

BASIC PROBLEM AND OBJECTIVE OF STUDY

The diagnosis of polymyalgia rheumatica is made difficult by the absence of any pathognomonic findings. Erythrocyte sedimentation rate (ESR) and concentration of C-reactive protein are used as diagnostic criteria and to monitor the disease's course. It was the purpose of this study to evaluate prevalence of thrombocytosis and whether there is any correlation between thrombocytosis and ischaemic complications.

PATIENTS AND METHODS

In a retrospective study the data of 23 patients (14 women, 9 men; mean age 67.3 [48-84] years) with polymyalgia rheumatica were analysed: platelet counts, ESR and C-reactive protein had been measured at the time of diagnosis and 7, 14 and 21 days after start of glucocorticoid treatment. At the time of diagnosis 17 of 23 patients (74%) had a thrombocytosis (> 400,000/microliter), at a mean value of 511,000 (418,000-638,000)/microliter. The platelet count decreased more slowly than the inflammatory parameters. On average the platelet count returned to normal on the 14th day. Ischaemic complications developed in three patients (visual disturbances, blindness, cardiac arrhythmias, neurological deficits): all had a high platelet count (462,000-524,000/microliter).

CONCLUSIONS

Thrombocytosis can serve as an additional criterion in the diagnosis and follow-up of polymyalgia rheumatica. An association with ischaemic complications is especially likely in the elderly, in case of immobility and if there is evidence of giant-cell arteritis. Treatment with platelet aggregation inhibitors should be considered.

HLA antigens in polymyalgia rheumatica in northern Sweden

The HLA-A, B and DR antigens were analyzed with serological methods in 75 patients with polymyalgia rheumatica (PMR). In PMR patients the frequency of the HLA-DR4 antigen was significantly higher (62.1%) compared to blood donors (40%), p < 0.05, but did not differ from patients with seropositive rheumatoid arthritis (RA) from the same area (63.1%). In contrast, the frequency of HLA-B27 in the PMR patients (9.3%) was significantly lower compared to RA (27.2%), p < 0.01, but did not differ from blood donors (16.9%). There was no association between DR4 and disease affliction or severity in PMR. The increased frequency of HLA-B27 in RA but not in PMR in the population of northern Sweden suggests an immunogenetic difference between these two HLA-DR4 associated diseases.

Polymyalgia rheumatica, temporal arteritis and malignancy

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[Polymyalgia rheumatica associated with myelodysplasia]

In this paper we describe a patient, female 76 years aged, who showed typical symptomatic, haematologic and instrumental findings of polymyalgia rheumatica. The patient also showed myelodysplastic syndrome and peripheral signs of vasculitis, which some authors refer in association with PMR. The improvement obtained with steroidal therapy confirmed the clinical picture of case.

A randomized controlled trial of salmon calcitonin to prevent bone loss in corticosteroid-treated temporal arteritis and polymyalgia rheumatica

Patients treated with high-dose or long-term corticosteroids are at risk of accelerated osteoporosis and spontaneous vertebral and traumatic fractures. To assess the efficacy of salmon calcitonin in preventing corticosteroid- induced osteoporosis, 48 patients with newly diagnosed polymyalgia rheumatica, temporal arteritis, and other vasculitides were enrolled in a 2-year, double-blind, randomized, controlled trial. Patients were randomized to receive subcutaneous injections t.i.w. of either 100 IU of salmon calcitonin (25 patients) or placebo (23 patients). After 2 years, 19 and 21 patients, respectively, were evaluable. All patients also received supplemental calcium carbonate (1500 mg daily in divided doses) and vitamin D3 (400 IU daily). Baseline and serial radiologic assessments included dual-energy X-ray absorptiometry (DXA) of the lumbar spine and hip, and spine radiographs to detect vertebral fractures. There were no significant baseline differences between the two study groups. The mean within-subject percentage change in DXA lumbar spine density in the two groups over the 2-year period of the study was only -0.1% (calcitonin plus calcium) versus -0.2% (placebo plus calcium) a nonsignificant difference despite the high mean cumulative corticosteroid doses of 5371 mg and 4680 mg, respectively (NS). The incidence of vertebral fracture was 12.5% (calcitonin plus calcium: 11%, versus placebo plus calcium: 14%, NS), with four fractures in the first year and one fracture in the second year. Higher cumulative cortico-steroid dose was associated with a greater loss in bone density. In rheumatic disease patients starting high-dose, long-term corticosteroids, salmon calcitonin with calcium and vitamin D3 provided no greater bone preservation than that observed with calcium and vitamin D3 alone.

Distal extremity swelling with pitting edema in polymyalgia rheumatica. Report on nineteen cases

OBJECTIVE

To determine the frequency and clinical characteristics of diffuse distal extremity swelling with pitting edema occurring in polymyalgia rheumatica (PMR).

METHODS

Clinical features and laboratory findings were recorded for all 245 residents of Olmsted County, Minnesota who developed PMR over a 22-year period (1970-1991). Those who exhibited > or = 1 episode of diffuse distal extremity edema with pitting were selected for this study, and were evaluated further.

RESULTS

Thirteen women and 6 men in this incidence cohort of PMR had > or = 1 episode of distal extremity swelling with pitting edema. Giant cell arteritis was also identified in 5 patients. In 11 patients, the swelling and edema development concurrently with proximal PMR symptoms. In 2 patients, the distal swelling was the initial manifestation, and in 6 patients, the distal symptoms developed during relapses or recurrences of PMR. Both upper and lower extremities were affected, usually in a symmetric manner. Other peripheral manifestations were also common. The distal swelling and pitting edema responded promptly to corticosteroids, and slowly or incompletely to nonsteroidal anti-inflammatory drugs; a similar response was observed in the proximal symptoms. The distal swelling appeared to represent tenosynovitis and synovitis of regional structures.

CONCLUSION

Distal extremity swelling with pitting edema represents a manifestation of PMR that has not been well described in previous studies. Awareness of this finding will help facilitate the proper diagnosis and institution of appropriate therapy for this disease.

Synchronous variations of the incidence of temporal arteritis and polymyalgia rheumatica in different regions of Denmark; association with epidemics of Mycoplasma pneumoniae infection

OBJECTIVE

The etiology of temporal arteritis (TA) and polymyalgia rheumatica (PMR) is unknown, but the sudden onset and the wide variation in incidence reported from various parts of the world suggest the existence of environmental and/or genetic factors. We studied the incidence of TA and PMR during a 12 year period in different regions of Denmark.

METHODS

For the period 1982 to 1994, data were obtained on the incidence of PMR and TA prospectively recorded in 2 general hospitals, and for 1982 to 1993 on the incidence reported by legal requirement to the national patient register by all hospitals in 13 of the 16 counties in Denmark. In 2 counties data on all temporal artery biopsies were obtained. Serological epidemiological surveillance data on infections causing epidemics in Denmark were obtained from the Statens Seruminstitut.

RESULTS

We analyzed data on 10,818 patients from 13 counties and 2651 temporal artery biopsies from two counties. The incidence rate for TA for the population aged 50 years and older was 20.4/100,000 (95% CI, 19-23), the rate for PMR was 41.3/100,000 (95% CI, 30-67). Significantly higher incidence rates were found in locations with high population density. Median number of temporal artery biopsies performed was 109/100,000 population aged 50 years and older, and the number increased linearly with time; a positive biopsy result was observed in 15.0%; the incidence rate of histologically proven TA in 2 counties was 15.1/100,000 population aged 50 years and older (95% CI, 11-20). Pronounced quarterly and annual variations of the incidence of TA and PMR were found in each of the 13 counties, and in the 2 hospital regions, with a clustering in 5 peaks. These cyclic fluctuations were seen simultaneously in several regions irrespective of the origin (hospital based, register derived, or temporal artery biopsy) of the data. Distinct peak incidences of TA and PMR occurred in close association with 2 epidemics of Mycoplasma pneumoniae infection. Two peaks were seen, partly related to 2 epidemics of parvovirus B19 and to an epidemic of Chlamydia pneumoniae.

CONCLUSION

The synchronous variations in the incidences of TA and PMR recorded in several regions of Denmark strongly indicate that an environmental infectious factor influences the frequencies. The close concurrence with epidemics of M. pneumoniae and the coincidence of 2 epidemics of parvovirus B19 and of one epidemic of C. pneumoniae in some locations with peak incidences of TA and PMR suggest that TA and PMR may be triggered by certain virus and/or bacterial agents.

[Giant cell arteritis. A study of 191 patients]

BACKGROUND

The aim of the present was to study the clinical features of a wide series of patients with giant cell arteritis (GCA) diagnosed with accurate criteria and to evaluate the sensitivity of the criteria proposed by the ACR for classification of GCA.

METHODS

A retrospective analysis of 191 patients with GCA, 184 of whom were diagnosed by biopsy and 7 due to their clinical manifestations was carried out.

RESULTS

The age was 73 +/- 7 years with the most frequent symptoms being headache (87%), abnormalities in the temporal arteries (75%), general malaise (60%), rheumatic polymyalgia (49%) and mandibular claudication (40%). The frequency of GCA was equal in both genders although the most complex syndrome was observed in women with a greater frequency of polymyalgia (p < 0.005), jaw claudication (p < 0.01) and anemia (p < 0.01). The patients with polymyalgia were characterized by a predominance of the polymyalgic syndrome in the initial phases and a higher frequency of amaurosis. Out of 47 patients with amaurosis, 23 remained with permanent unit or bilateral blindness. Unilateral biopsy of the temporal artery was diagnosed in 91% of the cases (CI 95%; 86 to 95%) increasing to 96.3% (CI 95%; 92 to 98%) on biopsy of both arteries. Ninety-eight percent of the patients (CI 95%; 95 to 99%) had 3 or more GCA criteria for classification as GCA.

CONCLUSIONS

The clinical manifestations of giant cell arteritis in Spain, with the exception of an equal frequency in both sexes, are similar to that described in other series of patients selected with strict criteria. The present data confirm the sensitivity of the criteria proposed by the ACR for the classification of giant cell arteritis although its application does not avoid the need for temporal artery biopsy for diagnosis. Unilateral biopsy is usually suffice in most of the cases.

[Giant-cell temporal arteritis. Anatomo-clinical study of 2 cases]

The Authors describe two cases of giant cell arteritis in male and elderly patients 72 and 82 years old. In both cases the early symptoms and signs of disease (headache, fever, weight loss and sedimentation rate raised) were associated to classical histology of temporal arteritis (granulomatous inflammation with giant cells). In case 1 there was impaired vision, while in case 2 coexisted polymialgia rheumatica (pain and stiffness in the muscles of the neck, back and proximal portions of the limbs).

Polymyalgia rheumatica and temporal arteritis: a retrospective study of 111 patients

There is no unanimity as to whether polymyalgia rheumatica (PMR) and temporal arteritis (TA) are two distinct diseases or different features of one disease. The objective of this study was to assess the value of histological findings of temporal artery biopsy and the efficacy and complications of drug therapy as well as the frequency of malignancies. It was carried out as a retrospective follow-up study. One hundred eleven patients (89 PMR, 14 TA and 8 PMR+TA) were studied. In 56 patients with PMR a temporal artery biopsy was performed; in none of these biopsies was active arteritis found. Of the 19 patients with TA or PMR+TA, where a temporal artery biopsy was performed, arteritis was found in 15 patients. Reactivation occurred in 27 patients: 4 patients using NSAIDs and 23 patients using corticosteroids. Side effect of the medication included vertebral compression in 10 patients, most of whom were using corticosteroids. Malignancies were diagnosed in 12 of the 111 patients. Most malignancies were diagnosed long before or after the diagnosis of PMR. In case of a PMR diagnosed by the clinician a biopsy of the temporal artery has no value, while the yield of this diagnostic procedure is high in TA. Reactivation was seen quite often and warrants a prolonged period of medical treatment.

The prevalence of soft tissue rheumatism. A who-ilar copcord study

The prevalence of various forms of soft tissue rheumatism, including painful low back syndrome (PLBS), painful restricted shoulder syndrome (PRSS), and epicondylitis without an underlying specific rheumatic disease, and the resultant loss of time from work were determined in a total population of 4,683 rural and 1,103 urban subjects aged 15 years and over in Central Java, Indonesia. In the rural study, 763 respondents with, and 355 respondents without complaints were examined. The urban survey evaluated 925 subjects. Prevalence rates in the rural and urban subjects were 20.0% and 25.8%, respectively, for PLBS, 14.5% and 16.2%, respectively, for PRSS, and 5.8% and 7.5%, respectively, for epicondylitis. Lost time from work in the rural and urban subjects was 9% and 2.2%, respectively, for PLBS, 5% and 1.1%, respectively for PRSS, and 2% and 1.3%, respectively for epicondylitis. The mean number of lost work days per year in the rural and urban subjects were 15.3 and 21.1, respectively, for PLBS, 8.1 and 15.2, respectively, for PRSS, and 3.9 and 2.3, respectively for epicondylitis. Thus, these forms of soft tissue rheumatism exerted significant effects on community life, apart from causing pain and discomfort. Work days lost directly means diminished income in populations lacking any form of unemployment benefits.

A longitudinal study of anticardiolipin antibody in polymyalgia rheumatica and giant cell arteritis

OBJECTIVE

To determine the incidence of elevated levels of anticardiolipin antibody (aCL) in patients with newly diagnosed polymyalgia rheumatica (PMR) and/or giant cell arteritis (GCA); and to determine the relationship between these antibodies at diagnosis and subsequent course of the disease over a period of 2 yrs.

METHODS

Ninety-eight consecutive patients with PMR and/or GCA were examined for the presence of aCL, at presentation and every 6 mo for 2 yrs. Sixty-four patients had PMR alone, 22 had coexistent PMR and GCA, and 12 presented with pure GCA. Patients presenting with suspected clinical diagnosis, overt or covert, of GCA were subjected to temporal artery biopsy from the symptomatic side within 3 days of presentation. Appropriate serological, biochemical, and hematological investigations were undertaken at presentation and subsequently at times of periodic assessments. One hundred healthy age and sex matched elderly subjects were also screened for the presence of aCL as a control group.

RESULTS

Elevated levels of aCL were detected in 20 patients at presentation. These included 9 patients with PMR/GCA and 11 patients with pure PMR. During followup, 10 patients with pure PMR at presentation developed GCA. These comprised 5 of the 11 patients with high aCL at presentation and 5 of the 53 patients with normal levels of aCL at presentation. This was statistically significant with relative risk (4.82, 95% CI, 1.72-13.51) of developing GCA in the presence of PMR and a high aCL at presentation. Furthermore, 3 of the 5 patients with pure GCA and high aCL at presentation progressed to severe vascular complications (stroke, 2; anterior ischemic optic neuritis, 1) compared to none of the other patients in the study. Elevated levels of antineutrophilic cytoplasmic antibody were also analyzed and detected in only 4 patients, 3 with pure PMR and one with biopsy proven GCA.

CONCLUSION

This prospective study suggests that a significant number of patients with PMR and/or GCA with elevated levels of aCL at presentation have increased risk of developing GCA or other major vascular complications. It is possible that aCL may be an independent prognostic marker for future vascular complications in patients with PMR and/or GCA.

Glucocorticoid-induced osteoporosis

High-dose treatment of more than three months' duration reduces bone mass, regardless of the patient's age, sex, or race. Because bone loss is most severe during the first six to 12 months of treatment, prophylaxis to preserve bone--with calcium, vitamin D, a bisphosphonate, and exercise--should begin as soon as the clinical situation permits rather than after the disease has been brought under control.