Comorbidities in polymyalgia rheumatica: a systematic review

BACKGROUND AND AIM

Comorbidities are known to exist in many rheumatological conditions. Polymyalgia rheumatica (PMR) is a common inflammatory rheumatological condition affecting older people which, prior to effective treatment, causes severe disability. Our understanding of associated comorbidities in PMR is based only on case reports or series and small cohort studies. The objective of this study is to review systematically the existing literature on the comorbidities associated with PMR.

METHODS

MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched for original observational research from inception to November 2016. Papers containing the words 'Polymyalgia Rheumatica' OR 'Giant Cell Arteritis' OR the terms 'PMR' OR 'GCA' were included. Article titles were reviewed based on pre-defined criteria by two reviewers. Following selection for inclusion, studies were quality assessed using the Newcastle-Ottawa tool and data were extracted.

RESULTS

A total of 17,329 papers were reviewed and 41 were incorporated in this review, including three published after the search took place. Wide variations were found in study design, comorbidities reported and populations studied. Positive associations were found between PMR diagnosis and stroke, cardiovascular disease, peripheral arterial disease, diverticular disease and hypothyroidism. Two studies reported a positive association between PMR and overall malignancy rate. Seven studies reported an association between PMR and specific types of cancer, such as leukaemia, lymphoma, myeloproliferative disease and specified solid tumours, although nine studies found either no or negative association between cancer and PMR.

CONCLUSION

Quantification of the prevalence of comorbidities in PMR is important to accurately plan service provision and enable identification of cases of PMR which may be more difficult to treat. This review highlights that research into comorbidities in PMR is, overall, methodologically inadequate and does not comprehensively cover all comorbidities. Future studies should consider a range of comorbidities in patients with a validated diagnosis of PMR in representative populations.

Long-term glucocorticoid treatment in patients with polymyalgia rheumatica, giant cell arteritis, or both diseases: results from a national rheumatology database

The objective of this study was to evaluate glucocorticoid (GC) use in patients with polymyalgia rheumatica (PMR), giant cell arteritis (GCA) or both diseases (PMR + GCA) under rheumatological care. Data from patients with PMR (n = 1420), GCA (n = 177) or PMR + GCA (n = 261) from the National Database of the German Collaborative Arthritis Centers were analyzed regarding GCs and related comorbidities (osteoporosis, diabetes and cardiovascular disease), stratified by disease duration (DD). Longitudinal data were analyzed for all patients with a DD ≤ 2 years at database entry (n = 1397). Three-year data were available for 256 patients. Predictors of GC use ≥ 3 years were examined by logistic regression analyses. A total of 76% received GCs, and 19% (PMR) to 40% (GCA) received methotrexate. Median GC doses were 12.5 mg (PMR), 11.3 mg (GCA), and 20.0 mg/day (PMR + GCA) in a 0-6-month DD. Median GC doses ≤ 5 mg/day were reached at a 13-18-month DD in PMR patients and at a 19-24-month DD in GCA or PMR + GCA patients. In the multivariate analysis, baseline methotrexate (OR 2.03, [95% CI 1.27-3.24]), GCs > 10 mg/day (OR 1.65, [1.07-2.55]), higher disease activity (OR 1.12, [1.02-1.23]) (median 0.6 years DD), and female sex (OR 1.63 [1.09-2.43]) were predictive for GC therapy at ≥ 3 years. Of the examined comorbidities, only osteoporosis prevalence increased within 3 years. GC use for ≥ 3 years was reported in one-fourth of all the patients. A difficult-to-control disease activity within the first year was a good predictor of long-term GC need.

Association between giant cell arteritis and thyroid dysfunction in a "real life" population

PURPOSE

Giant cell arteritis is a systemic autoimmune disorder which involves inflammation of medium to large vessels. The association between giant cell arteritis and autoimmune thyroid disorders has been investigated numerous times in the literature with inconsistent results. Our objective was to evaluate whether a genuine association exists between giant cell arteritis and thyroid dysfunction, which is often due to immune-mediated thyroid disease.

METHODS

Utilizing the medical database of Clalit Health Services, we compared the proportion of hypo and hyperthyroidisim between patients with giant cell arteritis and age-matched and gender-matched controls in a cross-sectional study. Univariate analysis was performed using Chi-square and student t-test and a multivariate analysis was performed using a logistic regression model.

RESULTS

Five thousand six hundred and sixty three giant cell arteritis patients and 23,308 age-matched and gender-matched controls were included in the study. The proportion of hypothyroidism amongst giant cell arteritis patients was increased in comparison with controls (18.2 vs. 6.91%, respectively, p-value < 0.001), as was hyperthyroidism (2.56 and 1.19% respectively, p-value < 0.001). Giant cell arteritis demonstrated an independent association with hypothyroidism on multivariate analysis (Odd Ratios 1.297, 95% Confidence Intervals 1.19-1.42), yet not with hyperthyroidism.

CONCLUSIONS

Giant cell arteritis patients have a higher proportion of hypothyroidism in comparison with matched controls. Physicians treating giant cell arteritis patients should consider screening for thyroid dysfunction on a regular basis.

Varicella Zoster Virus: A Common Cause of Stroke in Children and Adults

BACKGROUND

Varicella zoster virus (VZV) is a neurotropic, exclusively human herpesvirus. Primary infection causes varicella (chickenpox), after which the virus becomes latent in ganglionic neurons along the entire neuraxis. As cell-mediated immunity to VZV declines with advancing age and immunosuppression, VZV reactivates to produce zoster (shingles). One of the most serious complications of zoster is VZV vasculopathy.

METHODS

We reviewed recent studies of stroke associated with varicella and zoster, how VZV vasculopathy is verified virologically, vaccination to prevent varicella and immunization to prevent zoster, and VZV in giant cell arteritis (GCA).

FINDINGS

We report recent epidemiological studies revealing an increased risk of stroke after zoster; the clinical, laboratory, and imaging features of VZV vasculopathy; that VZV vasculopathy is confirmed by the presence of either VZV DNA or anti-VZV IgG antibody in cerebrospinal fluid; special features of VZV vasculopathy in children; vaccination to prevent varicella and immunization to prevent zoster; and the latest evidence linking VZV to GCA.

CONCLUSION

In children and adults, VZV is a common cause of stroke.

Secondary Antibody Deficiency in Glucocorticoid Therapy Clearly Differs from Primary Antibody Deficiency

PURPOSE

The aim of this study was to identify characteristics of hypogammaglobulinemia secondary to glucocorticoid therapy and their value in the differential diagnosis to primary forms of antibody deficiency.

METHODS

We investigated prevalence and character of hypogammaglobulinemia in a cohort of 36 patients with giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) on glucocorticoid therapy in comparison to a gender- and age-matched cohort of hospital controls. We therefore determined serum immunoglobulin levels as well as B- and T cell-subsets in the peripheral blood of all participants. In addition, prior serum immunoglobulin levels and clinical data of the GCA and PMR patients were extracted from the electronic patient data-base.

RESULTS

21/36 GCA/PMR patients on glucocorticoid treatment developed antibody deficiency. In 19 patients this included IgG and in 13 patients IgG was the only affected isotype. The reduction of IgG was persistent in nearly 50 % of these patients during the observed period. GCA/PMR patients had reduced circulating naive and transitional B cells (p = 0.0043 and p = 0.0002 respectively) while IgM, IgG and IgA memory B cells were preserved. Amongst T-cell subsets, we found a reduction of CD4 memory T cells (p < 0.0001), CD4 regulatory T cells (p = 0.0002) and few CD8 memory T-cell subtypes.

CONCLUSION

Persistent humoral immunodeficiency occurs in about a quarter of GCA/PMR patients under glucocorticoid therapy. Because most patients have isolated IgG deficiency, preserved IgA production and class-switched memory B cells, by these markers this form of secondary hypogammaglobulinemia can be clearly distinguished from common variable immunodeficiency (CVID).

A Retrospective Study of Chinese Patients With Giant Cell Arteritis (GCA): Clinical Features and Factors Associated With Severe Ischemic Manifestations

A retrospective study was performed on 70 giant cell arteritis (GCA) patients in Peking Union Medical College Hospital (PUMCH). The aim of this study was to describe the clinical features of these Chinese GCA patients and explore the possible associated factors for severe ischemic manifestations. Medical charts of all patients were reviewed, and the demographic, clinical, and laboratory data were analyzed. The mean age at disease onset was 65.2 years old, and the ratio of male to female was 1:1. Fever and headache were most prominent symptoms at onset, which occurred in 51.4% and 30.0% of patients, respectively. Common manifestations at diagnosis were constitutional symptoms (85.7%), headache (68.8%), visual impairment (38.6%), jaw claudication (30%), scalp tenderness (30%), and concurrent polymyalgia rheumatic (27.1%). No significant difference in clinical manifestations between genders was observed. Comparisons between patients with and without severe ischemic manifestations including jaw claudication, permanent visual loss, or cerebrovascular accident had shown that fever and asthenia were significantly less frequent in patients with severe ischemic manifestations (P = 0.006 and 0.023, respectively), and the mean value of erythrocyte sedimentation rate (ESR) was significantly lower in patients with severe ischemic manifestations than patients without (P = 0.001). History of smoking was more frequent in patients with severe ischemic manifestations (P = 0.038). This is the largest group of GCA patients from China so far. When compared our data with patients reported in the literature, this series of GCA patients were younger and without female predominance. The clinical manifestations of patients in this report were similar to other studies except for a higher prevalence of constitutional symptoms. The results of this study indicated that lower systemic inflammatory response and the history of smoking might be associated with severe ischemic damages.

Venous Thromboembolism and Cerebrovascular Events in Patients with Giant Cell Arteritis: A Population-Based Retrospective Cohort Study

Objective

To investigate the incidence of venous thromboembolism (VTE) and cerebrovascular events in a community-based incidence cohort of patients with giant cell arteritis (GCA) compared to the general population.

Methods

A population-based inception cohort of patients with incident GCA between January 1, 1950 and December 31, 2009 in Olmsted County, Minnesota and a cohort of non-GCA subjects from the same population were assembled and followed until December 31, 2013. Confirmed VTE and cerebrovascular events were identified through direct medical record review.

Results

The study population included 244 patients with GCA with a mean ± SD age at diagnosis of 76.2 ± 8.2 years (79% women) and an average length of follow-up of 10.2 ± 6.8 years. Compared to non-GCA subjects of similar age and sex, patients diagnosed with GCA had a higher incidence (%) of amaurosis fugax (cumulative incidence ± SE: 2.1 ± 0.9 versus 0, respectively; p = 0.014) but similar rates of stroke, transient ischemic attack (TIA), and VTE. Among patients with GCA, neither baseline characteristics nor laboratory parameters at diagnosis reliably predicted risk of VTE or cerebrovascular events.

Conclusion

In this population-based study, the incidence of VTE, stroke and TIA was similar in patients with GCA compared to non-GCA subjects.

The Detection of Rheumatic Disease through Hospital Diagnoses with Examples of Rheumatoid Arthritis and Giant Cell Arteritis: What Are We Missing?

OBJECTIVE

We examined hospitalizations for patients with known rheumatoid arthritis (RA) or giant cell arteritis (GCA) to evaluate whether hospitalization-related diagnoses accurately identified patients with rheumatologic diseases.

METHODS

Diagnosis codes for hospitalizations in 1996-2012 among previously identified population-based cohorts of patients with RA or GCA were examined for RA or GCA mentions.

RESULTS

RA or GCA mention occurred in only 55% of 2407 hospitalizations among patients with RA and 31% of 502 hospitalizations among patients with GCA. RA or GCA was mentioned more often in recent years, younger patients, and rheumatic medication users.

CONCLUSION

Coding for RA or GCA during hospitalizations was often missed. Research using hospital diagnoses alone could be biased.

Association of HLA-DRB1 amino acid residues with giant cell arteritis: genetic association study, meta-analysis and geo-epidemiological investigation

INTRODUCTION

Giant cell arteritis (GCA) is an autoimmune disease commonest in Northern Europe and Scandinavia. Previous studies report various associations with HLA-DRB1*04 and HLA-DRB1*01; HLA-DRB1 alleles show a gradient in population prevalence within Europe. Our aims were (1) to determine which amino acid residues within HLA-DRB1 best explained HLA-DRB1 allele susceptibility and protective effects in GCA, seen in UK data combined in meta-analysis with previously published data, and (2) to determine whether the incidence of GCA in different countries is associated with the population prevalence of the HLA-DRB1 alleles that we identified in our meta-analysis.

METHODS

GCA patients from the UK GCA Consortium were genotyped by using single-strand oligonucleotide polymerization, allele-specific polymerase chain reaction, and direct sequencing. Meta-analysis was used to compare and combine our results with published data, and public databases were used to identify amino acid residues that may explain observed susceptibility/protective effects. Finally, we determined the relationship of HLA-DRB1*04 population carrier frequency and latitude to GCA incidence reported in different countries.

RESULTS

In our UK data (225 cases and 1378 controls), HLA-DRB1*04 carriage was associated with GCA susceptibility (odds ratio (OR) = 2.69, P = 1.5×10(-11)), but HLA-DRB1*01 was protective (adjusted OR = 0.55, P = 0.0046). In meta-analysis combined with 14 published studies (an additional 691 cases and 4038 controls), protective effects were seen from HLA-DR2, which comprises HLA-DRB1*15 and HLA-DRB1*16 (OR = 0.65, P = 8.2×10(-6)) and possibly from HLA-DRB1*01 (OR = 0.73, P = 0.037). GCA incidence (n = 17 countries) was associated with population HLA-DRB1*04 allele frequency (P = 0.008; adjusted R(2) = 0.51 on univariable analysis, adjusted R(2) = 0.62 after also including latitude); latitude also made an independent contribution.

CONCLUSIONS

We confirm that HLA-DRB1*04 is a GCA susceptibility allele. The susceptibility data are best explained by amino acid risk residues V, H, and H at positions 11, 13, and 33, contrary to previous suggestions of amino acids in the second hypervariable region. Worldwide, GCA incidence was independently associated both with population frequency of HLA-DRB1*04 and with latitude itself. We conclude that variation in population HLA-DRB1*04 frequency may partly explain variations in GCA incidence and that HLA-DRB1*04 may warrant investigation as a potential prognostic or predictive biomarker.

Cardiovascular risk and acute coronary syndrome in giant cell arteritis: a population-based retrospective cohort study

OBJECTIVE

To assess the occurrence of acute coronary syndrome (ACS) in patients with giant cell arteritis (GCA) compared to subjects without GCA.

METHODS

We retrospectively reviewed a population-based incidence cohort of Olmsted County, Minnesota residents with GCA diagnosed in 1950-2009. We compared this cohort with a cohort of patients without GCA of similar age, sex, and calendar year from the same population.

RESULTS

The study included 245 patients with GCA and 245 non-GCA subjects. The mean ± SD Framingham cardiovascular risk score was 30% ± 19% in GCA patients and 34% ± 23% in non-GCA subjects (P = 0.096) at the incidence/index date. Diabetes mellitus was significantly less common in GCA patients than non-GCA subjects at the index date. The mean high-density lipoprotein was higher and triglycerides were lower, with fewer patients taking lipid-lowering medications in the GCA cohort compared to the non-GCA cohort at the index date. During followup, no difference between the 2 cohorts was noted in the overall rate of ACS events (hazard ratio 0.74, 95% confidence interval 0.44-1.26). Overall thrombosis in myocardial infarction scores were similar in both cohorts. Revascularization procedures were done less frequently in GCA than in non-GCA subjects (19% versus 50%; P = 0.015). Post-ACS hospital length of stays and complications were similar in both cohorts.

CONCLUSION

Multiple cardiovascular risk factors are less atherogenic at incidence of GCA. There is no overall increased risk of ACS in patients with GCA.

Epidemiological study of primary systemic vasculitides among adults in southern Spain and review of the main epidemiological studies

OBJECTIVES

To study the incidence and prevalence of primary systemic vasculitides (PSV) in the Costa del Sol region (southern Spain) and to compare the major epidemiological studies in PSV with the results obtained in our area.

METHODS

Retrospective study including permanent residents ≥14 years (or older) diagnosed with PSV at the Hospital Costa del Sol (Marbella, Spain) between 1994 and 2010. Epidemiological data were collected and the annual incidence rate during the study period and the prevalence in 2010 were calculated per million population, except for GCA, which was estimated per 100,000 population >50 years.

RESULTS

Seventy-four adult patients were diagnosed with PSV, representing an annual incidence of 15.8 (95%CI 12.2-19.4) patients/million population. These diagnoses included 29 (39.1%) giant cell arteritis (GCA), 5 (6.7%) Takayasu's arteritis (TKA), 3 (4%) poly-arteritis nodosa (PAN), 29 (39.1%) antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) [10 (13.5%) granulomatosis with polyangiitis (GPA) (Wegener), 16 (21.6%) microscopic polyangiitis (MPA) and 3 (4%) eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss)], 7 (9.4%) IgA vasculitis (Henoch-Schönlein) (IgAV) and one (1.3%) cryobulinaemic vasculitis (CV). The annual incidence and 2010 prevalence for each of the PSV, respectively, were: GCA: 2.2/12.2; TKA: 1.1/10.5; PAN: 0.6/2.6; AAV: 6.2/44.8 (GPA: 2.1/15.8; MPA: 3.4/23.8; EGPA: 0.6/5.3); IgAV: 1.5/7.9; and CV: 0.2/0.

CONCLUSIONS

The first epidemiological study of PSV in southern Spain corroborates their infrequency, with GCA and AAV as the PSV most often diagnosed. In southern Spain, the incidence and prevalence of PSV are lower than in northern Spain and in countries in the Northern Hemisphere.

[Bilateral loss of vision in temporal arteriitis--a preventable condition?]

BACKGROUND

Bilateral loss of vision (BLV) is one of the most feared complications of temporal arteriitis (TA).

AIM

Analysis of factors contributing to BLV.

PATIENTS AND METHODS

Observational study in 301 TA patients in- cluding 23 (8%) suffering from BLV.

RESULTS

Diagnosis of TA was unknown in all patients before BLV. Total blindness of both eyes occurred in 10 and in one eye in 5 patients. BLV evolved simultaneously in 7, sequentially in 12, and time latency remained undetermined in 4 patients. Loss of vision occurred during hospital treatment in 5 patients. Progressive loss of vision despite glucocorticoid treatment was observed in 2 patients with bilateral AION. Warning signs of TA were absent due to atypical manifestation of the disease in 11 patients, and transient visual disturbances preceded BLV only in 5 patients. Typical abnormalities of the temporal artery on palpation were lacking in 11 patients, and ESR was below 50 mm in 5 patients. Co-morbidities were present in all patients, including diseases mimicking TA, other vascular disease and dementia, as an obstacle to correct analysis of the course of the disease. Medical malpractice was claimed and recognised in 2 patients and could not be excluded in other patients.

CONCLUSION

Prevention of BLV due to TA and ischemia of the anterior visual pathways is not pos- sible in all patients because it may occur suddenly and simultaneously without any preceding clinical warning signs.

[Clinical manifestations, diagnosis and treatment of patients with temporal arteritis in Clinical Hospital Center Rijeka]

Temporal arteritis is middle and large vessel vasculitis, that affects parts of carotid arteries. First symptoms are headache, weakness and tiredness. Later occur scalp sensitivity, lack of pulse and temporal nodes, visual disturbances, and claudications of jaw and limbs. Diagnosis is based on clinical symptoms, laboratory findings, and biopsy of the temporal artery. First choice for treatment are glucocorticoids. The aim of the study was to show the clinical characteristics, laboratory findings, treatment and its side effects in patients with temporal arteritis in KBC Rijeka, using retrospective analysis. During the analyzed period 18 patients with an average age of 73 years were treated. 100% of patients had headache as a symptom, 78% weakness, fatigue and fever, 61% scalp sensitivity, 56% vision problems, 39% claudication, 27% nodes in the field of temporal artery, and 23% dizziness. In 62% of patients the diagnosis was confirmed by biopsy of the temporal artery. The initial therapy for all patients were glucocorticoids. Steroid side effects occurred in 67% of treated.

Relapses in patients with giant cell arteritis: prevalence, characteristics, and associated clinical findings in a longitudinally followed cohort of 106 patients

Giant cell arteritis (GCA) is a relapsing disease. However, the nature, chronology, therapeutic impact, and clinical consequences of relapses have been scarcely addressed. We conducted the present study to investigate the prevalence, timing, and characteristics of relapses in patients with GCA and to analyze whether a relapsing course is associated with disease-related complications, increased glucocorticoid (GC) doses, and GC-related adverse effects. The study cohort included 106 patients, longitudinally followed by the authors for 7.8 ± 3.3 years. Relapses were defined as reappearance of disease-related symptoms requiring treatment adjustment. Relapses were classified into 4 categories: polymyalgia rheumatica (PMR), cranial symptoms (including ischemic complications), systemic disease, or symptomatic large vessel involvement. Cumulated GC dose during the first year of treatment, time required to achieve a maintenance prednisone dose <10 mg/d (T10), <5 mg/d (T5), or complete prednisone discontinuation (T0), and GC-related side effects were recorded. Sixty-eight patients (64%) experienced at least 1 relapse, and 38 (36%) experienced 2 or more. First relapse consisted of PMR in 51%, cranial symptoms in 31%, and systemic complaints in 18%. Relapses appeared predominantly, but not exclusively, within the first 2 years of treatment, and only 1 patient developed visual loss. T10, T5, and T0 were significantly longer in patients with relapses than in patients without relapse (median, 40 vs 27 wk, p  < 0.0001; 163 vs 89.5 wk, p = 0.004; and 340 vs 190 wk, p = 0.001, respectively). Cumulated prednisone dose during the first year was significantly higher in relapsing patients (6.2 ± 1.7 g vs 5.4 ± 0.78 g, p = 0.015). Osteoporosis was more common in patients with relapses compared to those without (65% vs 32%, p = 0.001). In conclusion, the results of the present study provide evidence that a relapsing course is associated with higher and prolonged GC requirements and a higher frequency of osteoporosis in GCA.

Analysis of two autoimmunity genes, IRAK1 and MECP2, in giant cell arteritis

OBJECTIVES

The Xq28 region, containing IRAK and MECP2, represent a common susceptibility locus for a high number of autoimmune diseases. Our aim in the present study was to evaluate the influence of the IRAK1 and MECP2 autoimmunity-associated genetic variants in the giant cell arteritis (GCA) susceptibility and its clinical subphenotypes.

METHODS

We analysed a total of 627 female biopsy-proven GCA patients and 1,520 female healthy controls of Spanish Caucasian origin. Two polymorphisms, rs1059702 and rs17345, located at IRAK1 and MECP2, respectively, were genotyped using TaqMan® allelic discrimination assays.

RESULTS

No association with any of the analysed polymorphisms was evident when genotype and allele frequencies were compared between GCA patients and controls (rs1059702: allelic p-value=0.699, OR=0.96, CI 95% 0.80-1.17; rs17435: allelic p-value=0.994, OR=1.00, CI 95% 0.84-1.19). Likewise, the subphenotype analysis yield similar negative results.

CONCLUSIONS

We have assessed for the first time the possible role of IRAK1 and MECP2 autoimmune disease-associated polymorphisms in GCA. Our data suggest that IRAK1 rs1059702 and MECP2 rs17435 genetic variants do not play a significant role in GCA susceptibility or severity.

Isolated aortitis versus giant cell arteritis: are they really two sides of the same coin?

OBJECTIVES

The aim of the study was to compare epidemiological data, clinical findings and results of investigations in patients with isolated aortitis and those with giant cell arteritis (GCA) to establish whether patients with isolated aortitis differ from those with GCA.

METHODS

We reviewed the medical notes of all patients consecutively seen in two Rheumatology centres in the last two decades with a suspicion of GCA, searching for cases characterised by abnormal [18F] fluorodeoxyglucose (FDG) PET uptake of the aorta. 'Isolated aortitis' was defined as increased FDG uptake in the aorta not explained by atherosclerosis in the absence of FDG uptake in other large vessels.

RESULTS

Comparing the epidemiological and clinical data of patients with isolated arteritis with those with GCA, we observed many statistical significant differences. First of all, the male/female ratio was reversed, with a predominant male involvement in isolated arteritis. Moreover, the mean age of patients with isolated arteritis was significantly lower than that of GCA patients (62 vs. 78.4 yrs; p<0.0001). None of the patients with isolated aortitis presented at any time of the disease course the typical symptoms of GCA, while in a low percentage of cases constitutional symptoms represented the only clinical features. Beside the aortic arch, the sites more frequent involved were the thoracic and abdominal tracts, in all cases without an uptake of the aortic branches.

CONCLUSIONS

It is not known whether our patients with isolated aortitis represent variants of GCA or TA, nor is it known how they will evolve, but we can certainly conclude that these patients have a different epidemiologic and clinical profile, and do not necessarily represent two sides of the same coin.

Large-vessel involvement in giant cell arteritis and polymyalgia rheumatica

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related disorders that affect people of middle age and older, and frequently occur together. With the widespread use of newer vascular imaging modalities, large-vessel involvement (LVI) has increasingly been recognised in patients with GCA and less often in those with PMR. LVI in GCA can result in complications such as aortic aneurysm and dissection, aortic arch syndrome, and limb arteries stenosis, while vascular complications in PMR are exceedingly rare. It is still controversial which patients should be investigated for LVI, and how LVI should be diagnosed, monitored and managed. In this review, we will try to address six important issues regarding LVI in GCA and PMR.

TLR4 polymorphism is not associated with biopsy proven giant cell arteritis

OBJECTIVES

Giant cell arteritis (GCA) is a systemic inflammatory vasculitis affecting the elderly. It primarily affects medium and large arteries of the head and neck and can cause stroke and blindness. The cause of GCA is unknown; however both genetic and environmental factors are likely to be involved. TLR4 is implicated in the pathogenesis of GCA, however previous studies, examining the association between GCA and two TLR4 single nucleotide polymorphisms (SNPs), have reported conflicting results. The aim of this study was to determine the association between GCA and range of SNPs spanning the TLR4 gene sequence.

METHODS

A case-control genetic study was performed using DNA from Australian biopsy proven GCA patients (n=139) and population controls (n=130). Samples were genotyped for 8 SNPs tagging common variation across TLR4. These SNPs included rs4986790 (+896A/G, Asp299Gly) and rs4986791 (+1196C/T) which have been previously studied in GCA. Allelic and haplotypic variation was analysed by logistic regression assuming an additive genetic model. A random effects meta-analysis of the association between GCA and rs4986790 was performed utilising data from three previous studies.

RESULTS

rs4986790 and rs4986791 are in strong linkage disequilbrium and tag one of the five common TLR4 haplotypes identified. No associations were observed between TLR4 SNPs and/or haplotypes and GCA. A meta-analysis, comprising 577 GCA patients and 1153 controls, did not confirm an association between GCA and rs4986790 (OR 1.29, 95% CI 0.86, 1.92, p=0.22).

CONCLUSIONS

There is no evidence of an association between TLR4 polymorphism and susceptibility to GCA.

[SHOULD PATIENTS WITH GIANT CELL ARTERITIS BE TESTED FOR AORTIC ANEURYSMS?]

Aortitis is one of the manifestations of giant cell arteritis (GCA) and is included in its definition. There is a significantly increased risk of aortic aneurysm formation in GCA patients. In some GCA patients aortic aneurysm dissection is diagnosed only in autopsy. Monitoring of these patients, especially in long lasting disease, requires a doctor's awareness of the possibility of aneurysm formation and aortic aneurysm dissection. Based on the available reports it cannot be confirmed whether intensification of aortitis treatment in GCA prevents the development of aneurysms. This article presents an overview of the available literature and our own experience on a rational diagnosis of inflammation and aneurysms of the aorta in GCA, as well as the prospects for its prevention.