Aortic aneurysm and dissection in patients with biopsy-proven giant cell arteritis from northwestern Spain: a population-based study

Most classical manifestations of giant cell arteritis (GCA) are the result of occlusive vascular involvement. However, unlike ischemic manifestations, aortic aneurysmal disease in patients with GCA has been less well described. We assessed the incidence and predictors of aortic aneurysm and dissection in patients with biopsy-proven GCA from the Lugo region of northwestern Spain and compared the results with those in a 2003 report from Olmsted County, MN. We performed a retrospective study of biopsy-proven GCA patients diagnosed from 1981 to 2001 at the single hospital for a well-defined population of almost 250,000 people. Twenty (9.5%) of the 210 biopsy-proven GCA patients diagnosed during the study period developed aortic aneurysmal disease. Sixteen of the 20 patients had thoracic aneurysms and 6 had abdominal aneurysms. The incidence of aortic aneurysm and/or dissection in Lugo (18.9 per 1000 person years at risk) was similar to that reported in Olmsted County (18.7 per 1000 person years at risk). Hypertension (hazard ratio: 4.73) and polymyalgia rheumatica with a marked acute inflammatory response at the time of diagnosis of GCA (hazard ratio: 3.71) were the best predictors of aortic aneurysmal disease. Our present observations suggest that a severe inflammatory response associated with hypertension at the time of diagnosis of GCA may promote the development of aortic aneurysmal disease. GCA patients having these features should be monitored for the existence of aortic aneurysm and dissection.

Influence of traditional risk factors of atherosclerosis in the development of severe ischemic complications in giant cell arteritis

Because the prognosis of giant cell arteritis (GCA) is related to the development of ischemic complications, we sought to assess the possible influence of traditional risk factors of atherosclerosis in the development of severe ischemic complications of GCA. We conducted a retrospective study of patients with biopsy-proven GCA diagnosed from 1981 to 2001 at the single hospital for a well-defined population of almost 250,000 people. Patients were considered to have severe ischemic manifestations if they suffered visual manifestations, cerebrovascular accidents, jaw claudication, or signs of occlusive changes in large arteries of the extremities. Patients were assessed for the presence of hypercholesterolemia, hypertension, diabetes mellitus, and heavy smoking at the time of GCA diagnosis. The presence of traditional risk factors of atherosclerosis at the time of GCA diagnosis in this series of 210 patients increased significantly the risk of developing at least 1 of the severe ischemic complications (odds ratio [OR], 1.79; 95% confidence intervals [CI], 1.03-3.11; p = 0.04). Patients with traditional atherosclerosis risk factors had fever less commonly than the rest of GCA patients (5.2% vs. 16.0%; p = 0.01). GCA patients with hypertension exhibited a significantly increased risk of developing severe ischemic complications (OR, 1.80; 95% CI, 1.00-3.25; p = 0.05). The current study suggests that the presence of atherosclerosis risk factors at the time of diagnosis of GCA may influence the development of severe ischemic manifestations of the disease.

[Analysis of a series of 55 patients with biopsy proven giant cell temporal arteritis]

INTRODUCTION

Our main aim with this study is to establish the epidemiologic and clinical features, treatment response and complications of a group composed of 55 patients with biopsy proven temporal arteritis in a local hospital.

MATERIAL AND METHODS

Retrospective study based on clinical records revision of patients diagnosed of giant cell arteritis (GCA) made by temporal artery biopsy between 1989 and 2001.

RESULTS

The approximated annual incidence of GCA in our area is 4.1 cases per 100,000 persons over the age of 50. The mean age at diagnostic was 74 years and the 78,2% were women. The most common symptom at diagnostic was headache (81.5%) followed by systemic manifestations (74.1%) and later we found jaw claudication (32,7%), visual impairment (30.2%), isquemic manifestations (17%). Polymyalgia rheumatica was associated to GCA in 49.1% of cases. The temporal artery explorations was abnormal in the 76.9% of patients. The mean initial dose of corticoids was 69 mg prednisone per day, with a half dose reduction time of .5 months. In spite of that, 24,1% of patients relapsed during the first year. The 38% of patients did some complications during the corticosteroid treatment. The ESR was lower 50 mm in 12.7% of patients; it was anaemia in the 37.7% and thrombocytosis in 32,1%. In these last patients we detected a relation between thrombocytosis and specific visual impairment.

CONCLUSIONS

The incidence of GCA in our area is low. The results of our series aren't different from others publicated before in clinical manifestations, there is a prevalence of female sex and there is a relation between specific visual impairment and the presence of thrombocytosis.

Fever in biopsy-proven giant cell arteritis: Clinical implications in a defined population

OBJECTIVE

To assess the frequency and clinical features of biopsy-proven giant cell arteritis (GCA) patients who had fever at the time of diagnosis of the disease, and the relationship between fever, ischemic complications, and the systemic inflammatory response in GCA.

METHODS

A retrospective study of biopsy-proven GCA patients diagnosed between 1981 and 2001 was performed at the single referral hospital for a well-defined population in the Lugo region of northwest Spain. Patients were considered as having fever if the axillary temperature at the time of admission or during the followup prior to the onset of corticosteroid therapy was > or =38 degrees C.

RESULTS

During the period of study, 21 (10%) of the 210 biopsy-proven GCA patients had fever. Two of them fulfilled criteria for fever of unknown origin. Patients with fever had a lower frequency of severe ischemic manifestations than the rest of biopsy-proven GCA patients. They also exhibited a more severe inflammatory disease, with significant abnormality in most laboratory variables, including higher elevation of erythrocyte sedimentation rate, lower values of hemoglobin, and higher proportion of patients with increased alkaline phosphatase. By logistic regression analysis, we observed that patients with fever had an increased risk of developing anemia (odds ratio [OR] 12.24). In contrast, a negative association between severe ischemic manifestations and fever was found (OR 0.41).

CONCLUSION

Biopsy-proven GCA patients with fever constitute a subgroup of patients with more severe inflammatory response and less ischemic disease.

HLA-DRB1 allele distribution in polymyalgia rheumatica and giant cell arteritis: Influence on clinical subgroups and prognosis

OBJECTIVE

To evaluate HLA-DRB1 associations in patients with polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) in the Spanish population, especially those alleles that include the disease-linked sequence motif DRYF (positions 28 to 31 of the HVR2).

METHODS

We performed a PCR based HLA-DRB1 genotyping in 89 PMR patients, 44 GCA patients, and 99 unrelated healthy controls from the same geographic area.

RESULTS

We did not find any significant difference between the whole group of PMR/GCA patients (n = 133) compared with the healthy controls with the exception of a lower frequency of HLA-DRB1*0405 in the patient group (odds ratio [OR], 0.1 [CI0.02 to 1.2]; P =.04). The distribution of DRB1 alleles was very similar between PMR patients and controls. However, DRB1*0401 (OR, 3.1 [1.1 to 8.6]; P =.02) and DRB1*0404 (OR, 3.5 [0.97 to 12.9]; P =.04) were overrepresented in patients with GCA compared with the control group. DRB1*04 (OR, 1.9 [0.96 to 3.8]; P =.06), especially *0401 (OR, 2.8 [1 to 7.7]; P =.04), and DRB1*07 (OR, 2.3 [1.2 to 4.6]; P =.01) were more frequent in GCA than in PMR. Frequency of the DRYF 28-31 motif was similar among GCA (79.5%), PMR (89.9%), and controls (87.9%) and did not confer any significant risk of the development of systemic vasculitis. We also compared the DRB1 allele distribution in patients with classic PMR (n = 58) and those with an erythrocyte sedimentation rate (ESR) <40 mm/hour (n = 31). Patients with classic PMR expressed DRB1*07 less frequently (OR, 0.4 [0.1 to 1]; P =.04) and had a higher frequency of the DRYF 28-31 motif (94.8% vs 80.6%; P =.03) than patients with ESR < 40. Within the GCA group, DRB1 alleles were not predictive for the development of severe ischemic complications. However, the development of relapses in patients with PMR was associated with a higher frequency of DRB1*09 (5.6% vs 0%; P =.04).

CONCLUSIONS

Our data suggest that the HLA-DRB1 alleles associated with susceptibility for developing PMR and GCA are different. Whether PMR with low ESR represents a different clinical subset of the disease should be clarified in a larger sample of patients. HLA-DRB1 genes might predict the presence of relapses in PMR, but they do not seem to be indicators of severe disease in GCA patients.

Are polymyalgia rheumatica and giant cell arteritis the same disease?

OBJECTIVE

To summarize the evidence about the relationship between polymyalgia rheumatica (PMR) and giant cell arteritis (GCA).

METHODS

Review of relevant articles from the English-language literature.

RESULTS

Epidemiologic studies suggest that PMR and GCA are closely related conditions affecting people over 50 years and frequently occurring in the same patient. PMR symptoms have been observed in 40 to 60 percent of GCA clinical series. Also, temporal artery biopsy may yield positive results for GCA in patients with isolated PMR. Conflicting HLA-DRB1 genotype results have been reported, and recent studies have shown that PMR and GCA have different expression of RANTES, TNFalpha microsatellite, and IL-6 promoter genetic polymorphisms. Search for a possible common infectious agent have yielded disappointing results. Although parvovirus B19 DNA is present in the artery wall of patients with GCA, this virus may be only an innocent bystander. Cytokine studies on a limited number of temporal artery biopsy specimens have shown that interferon-gamma is produced in GCA and not in PMR, suggesting that this cytokine may be crucial to the development of overt vasculitis.

CONCLUSIONS

PMR and GCA frequently occur together but no definitive conclusions can be drawn about the nature of this association.

Geographical and genetic factors do not account for significant differences in the clinical spectrum of giant cell arteritis in southern europe

OBJECTIVE

To investigate whether genetic and geographical differences may influence the clinical spectrum of giant cell arteritis (GCA), we compared the demographic and clinical features of patients with biopsy-proven GCA from Reggio Emilia (Northern Italy) and Lugo (Northwest Spain) during a 15-year period.

METHODS

We performed a retrospective review of the case records of all patients diagnosed with biopsy-proven GCA at Hospital Xeral-Calde (Lugo, Spain) and Hospital Santa Maria Nuova (Reggio Emilia, Italy) between 1 January 1986 and 31 December 2001. Both hospitals are the only referral centers for populations living in central Galicia and central Emilia Romagna, respectively.

RESULTS

During the period of study, 194 Lugo residents and 126 Reggio Emilia residents were diagnosed with biopsy proven GCA. Reggio Emilia patients were more likely to be female (74% vs 54%; p = 0.0001). Although Lugo patients complained of headache (86%) more commonly than did those from Reggio Emilia (77%), the difference was only marginally significant (p = 0.05). The proportion of patients with visual manifestations or visual loss was remarkably similar (22% for visual manifestations and 17% for visual loss in Lugo and 29% and 21% for Reggio Emilia residents). The mean erythrocyte sedimentation rate prior to the onset of therapy was also similar.

CONCLUSION

Apart from differences in sex, the clinical spectrum of GCA in these 2 Southern European regions was similar.

Predictors of cerebrovascular accidents in giant cell arteritis in a defined population

OBJECTIVE

To examine the frequency and predictors of cerebrovascular accidents (CVA) in giant cell arteritis (GCA) patients from a defined population.

METHODS

Retrospective study of biopsy-proven GCA patients diagnosed from 1981 through 2001 at the single hospital for the population of Lugo (Northwest Spain).

RESULTS

Thirty (14.3%) of the 210 biopsy-proven GCA patients had CVA, 5 of them (16.7%) involving the vertebrobasilar territory. Five patients (4 of them involving the carotid territory) had CVA within the 2 years prior to the onset of GCA symptoms. Four patients had CVA within the first month after the diagnosis of the disease. Of these, 3 involved the vertebrobasilar territory. Another 5 patients suffered carotid stroke between the 4th and the 12th month after the disease diagnosis. The remaining 16 GCA patients had CVA (all but one involving the carotid territory) at least 1 year after the diagnosis of vasculitis. No differences in the clinical and laboratory features at the time of diagnosis between patients who had CVA and the rest of the biopsy-proven GCA patients were observed. However, hypertension and hyperlipidemia at the time of diagnosis of GCA were associated with the development of CVA (p < 0.05 for both). Also, anemia at the time of diagnosis (hemoglobin < 12 g/dL) [hazard ratio = 0.34 (95% CI 0.12 - 1.00; p = 0.05)] was negatively associated with CVA within the first 10 years after the diagnosis of the disease. Mortality in GCA patients with CVA was not significantly higher than that in patients without CVA (hazard ratio = 1.53; p = 0.14).

CONCLUSION

The present study confirms that CVA may occur in GCA. Vertebrobasilar accidents are more common than carotid accidents at the time of diagnosis of the disease. Vascular risk factors should be carefully controlled in the follow-up of GCA patients.

Giant cell arteritis of the female genital tract

Giant cell arteritis (GCA) of the female genital tract is rare with only 30 cases, including this case, documented in the literature. We present a patient who had total abdominal hysterectomy and bilateral salpingo-oophorectomy for an ovarian cyst and on histologic examination GCA involving the arteries of the myometrium, cervical stroma, ovaries and tubes was unexpectedly discovered. Upon questioning of the patient and further investigations it became clear that the patient did have symptoms and signs suggestive of systemic GCA including fatigue, low-grade fever, weight loss and elevated erythrocyte sedimentation rate (ESR). Treatment with oral corticosteroids resulted in rapid and complete recovery. It is concluded that an incidental finding of GCA in the genitalia should alert the clinician to the possibility of systemic GCA. If upon questioning of the patient and further investigations the existence of systemic GCA is confirmed, treatment with corticosteroids should be considered.

Incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis: A population-based study over 50 years

OBJECTIVE

To determine the incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis (GCA).

METHODS

The cohort of all residents of Olmsted County, Minnesota, in whom GCA was diagnosed between January 1, 1950, and December 31, 1999, was followed up. The incidence of aortic aneurysm, aortic dissection, and large-artery stenosis was determined. Possible predictors and correlates of large-artery complication were assessed.

RESULTS

Forty-six incident cases of large-artery complication (representing 27% of the 168 patients in the cohort) were identified. These included 30 incident cases (18%) of aortic aneurysm and/or aortic dissection. Of these cases, 18 (11%) involved the thoracic aorta, with aortic dissection developing in 9 (5%). There were 21 incident cases (13%) of large-artery stenosis. Fifteen patients (9%) had incident cervical artery stenosis, and 6 (4%) had incident subclavian/axillary/brachial artery stenosis. One patient (0.6%) had incident iliac/femoral artery stenosis attributable to GCA. Hyperlipidemia and coronary artery disease were associated with aortic aneurysm and/or dissection (P < 0.05 for both). Cranial symptoms (headache, scalp tenderness, abnormal temporal arteries) were negatively associated with large-artery stenosis (hazard ratio [HR] 0.10 [95% confidence interval (95% CI) 0.03-0.35, P < 0.0005]), as was a higher erythrocyte sedimentation rate (HR 0.80 [95% CI 0.67-0.95, P < 0.05] per 10 mm/hour).

CONCLUSION

Large-artery complication is common in GCA. Increased awareness of large-artery complication in GCA, particularly early-occurring aortic dissection, may decrease associated mortality.

Glucocorticoid therapy in giant cell arteritis: duration and adverse outcomes

OBJECTIVE

To evaluate the course of glucocorticoid (GC) therapy and associated adverse events in a population-based cohort of patients with giant cell arteritis (GCA).

METHODS

We identified 125 Olmsted County residents with GCA diagnosed between 1950 and 1991 and obtained followup information on the 120 patients who were diagnosed antemortem and agreed to participate in this study. Clinical variables, GC doses, and GC adverse events on each patient were recorded. The relationship between GC therapy and the development of adverse events was studied by the Cox and Anderson-Gill proportional hazards models.

RESULTS

All patients were treated with GCs and responded rapidly (median initial dosage 60 mg prednisone/day). The dosage was later reduced according to the treating physicians' judgment. The median duration required to reach 7.5 mg/day was 6.5 months and the median duration required to reach 5 mg/day was 7.5 months. Relapses or recurrences occurred in 57 patients. For the 87 patients followed to discontinuation of GC therapy and permanent remission of GCA (median of 22 months), the total median dose of prednisone was 6.47 gm. Adverse events associated with GCs were recorded in 103 (86%) patients and 2 or more events occurred in 70 patients (58%). Age and higher cumulative dose of GCs were associated with the development of adverse GC side effects.

CONCLUSION

GCs are therapeutically effective in GCA and the prednisone dosage was reduced to physiologic levels in three-fourths of the patients within 1 year. However, most patients developed serious adverse side effects related to GCs, indicating that less toxic therapeutic measures are needed.

Clinical and epidemiologic analysis of giant cell (temporal) arteritis from a nationwide survey in 1998 in Japan: the first government-supported nationwide survey

OBJECTIVE

To elucidate epidemiologic and clinical manifestations of Japanese patients with giant cell arteritis (GCA), the first nationwide survey for GCA was conducted in 1998 in Japan.

METHODS

The first questionnaire on GCA for patients treated in 1997 was sent to 10,717 medical departments in Japan. A total of 177 patients were reported. Among the 177 patients, 66 GCA patients with detailed clinical and epidemiologic features on second survey were analyzed.

RESULTS

Prevalence in patients 50 years of age and older in 1997 was 1.47 per 100,000 population in Japan. The average age at onset was 71.5 years old. The male:female ratio was 1:1.7. The association with permanent and complete visual loss (6.5%), jaw claudication (15.2%), and polymyalgia rheumatica (PMR) (30.3%) were low in frequency compared with those reported from other countries. All patients were treated with corticosteroids. Only 3 (4.5%) patients were reported as deceased due to other causes.

CONCLUSION

The prevalence of GCA in Japan was revealed to be extremely low compared with other countries. Clinical findings of permanent and complete visual loss, jaw claudication, and PMR were infrequent among Japanese patients with GCA.

Influence of age, sex, and place of residence on clinical expression of giant cell arteritis in northwest Spain

OBJECTIVE

To investigate the epidemiology of giant cell arteritis (GCA), we examined whether differences in clinical and laboratory features exist in patients with biopsy-proven GCA from Northwest Spain according to sex, place of residence, and age at disease onset.

METHODS

Retrospective study of biopsy-proven GCA diagnosed from January 1, 1981, to December 31, 2001, at the single hospital for a well defined population of 250,000. A comparative analysis was conducted of clinical and laboratory features according to sex, place of residence (rural or urban), and age at the onset of symptoms (< 70 yrs; >or= 70 yrs).

RESULTS

Between 1981 and 2001, 210 patients from the Lugo region were diagnosed with biopsy-proven GCA. In urban areas GCA was significantly more common in women (rate ratio 1.58, 95% CI 1.00-2.53, p = 0.05). Women presented manifestations of polymyalgia rheumatica (PMR) more commonly than men. However, no statistically significant difference in the frequency of visual manifestations or permanent visual loss were observed between the sexes. GCA was slightly more common in rural than in urban areas (annual adjusted incidence rate in rural areas 10.4/100,000 in people age >or= 50 years vs 9.1/100,000 in urban areas; p = 0.34). GCA was more common among men in rural areas (rate ratio 1.73, 95% CI 1.10-2.70, p = 0.02). Patients younger than 70 years at the time of diagnosis (20%) had a trend to a longer delay to diagnosis and a marginal increase in the frequency of PMR compared with those with disease onset at age >or= 70 years. A higher inflammatory response was observed in the patients younger than 70 years.

CONCLUSION

In patients with biopsy-proven GCA from Northwest Spain PMR manifestations are more commonly observed in women. The higher inflammatory response and the longer delay to diagnosis in younger patients call for a higher physician awareness of this vasculitis among individuals younger than 70 years.

Silent, or masked, giant cell arteritis is associated with a strong inflammatory response and a benign short term course

OBJECTIVE

To determine the frequency, characteristics, and short term outcome of patients who have biopsy-proven giant cell arteritis (GCA) but no local symptoms that can be attributed to vasculitis inflammation [silent temporal arteritis (TA)] throughout the pretreatment course of the disease or an observational period lasting at least 2 months.

METHODS

Of 175 consecutive patients with biopsy-proven GCA, 130 had typical cranial arteritis, 21 had silent vasculitis, and the remaining 24 had either discrete cranial symptoms (19 cases) or isolated extracranial vasculitis (5 cases). We sought to determine which of 15 pretreatment characteristics were associated with silent TA, as compared with typical cranial arteritis, and assessed the short term outcome in these patients.

RESULTS

Of 21 patients with silent GCA, 14 met criteria for fever of unknown origin. Aside from their different clinical presentation, this population was characterized by a longer delay in diagnosis (p = 0.003), a higher mean erythrocyte sedimentation rate (p = 0.002), higher C-reactive protein (p = 0.002), and lower levels of albumin (p = 0.01) and hemoglobin (p < 0.0001). Permanent visual loss, which occurred in 24 patients (13.7%), exclusively involved those presenting with symptoms and/or signs suggesting cranial arteritis, especially those with frank cranial arteritis. This complication was associated negatively with the delay in diagnosis (p = 0.01), and marginally with the number of symptoms and/or signs suggesting cranial arteritis recorded in each patient (p = 0.07). Oral prednisone at a mean daily dose of 0.7 mg/kg resulted in satisfactory control of silent TA within 4 weeks in all patients but one, and could subsequently be safely tapered by half in a mean delay of 38 +/- 23 days. No differences were observed between patients with silent TA and other forms of the disease regarding the mean prednisone dose at 3 month followup (18.2 +/- 4.5 vs 20.9 +/- 5.9 mg/day) and 6 month followup (14 +/- 4.4 vs 15.6 +/- 6 mg/day ).

CONCLUSION

Silent TA may represent a distinct subset of giant cell arteritis, marked by a protracted inflammatory response and a relatively benign short term outcome, excellent response to corticosteroids, and no visual ischemic events, despite the long period of exposure to this complication before appropriate treatment.

The epidemiology of biopsy-positive giant cell arteritis: special reference to changes in the age of the population

OBJECTIVE

The incidence of giant cell arteritis (GCA) increases with age. The aim of the present study was to investigate whether the increasing incidence of biopsy-proven GCA in Göteborg, Sweden, could be explained in terms of a change in the age composition of the general population.

METHODS

All cases of biopsy-verified GCA between 1976 and 1995 were recorded. The annual incidence was calculated for women and men aged 50 yr or older and its relationship with the age composition of the general population was tested statistically.

RESULTS

There was a significant positive correlation between age and the risk of developing GCA. In the general population, there was a shift towards higher age; in 1976, the mean age of people 50 yr or older was 63.2 (men) and 65.0 (women), whereas in 1995 it was 65.0 (men) and 68.1 (women). After compensating for this, the incidence of biopsy-proven GCA still increased significantly. Moreover, for women aged 50 yr or older, the risk of developing the disease increased more among younger subjects than older ones.

CONCLUSIONS

The increase in the incidence of biopsy-proven GCA between 1976 and 1995 could not be explained merely in terms of the increasing age of the general population. It is most probably related to an increase in the influence of other factors.

Giant cell arteritis: epidemiological clues to its pathogenesis and an update on its treatment

Giant cell arteritis (GCA) is a chronic systemic vasculitis with a marked female predominance and restriction to old age. The disease process distinctly targets large and medium sized arteries, preferentially the aorta and its extracranial branches. Morphological observations indicate that the age and sex distribution of GCA is related to the occurrence of degenerative changes in the arterial wall. GCA is not a truly infectious vasculitis. However, an infection might be a triggering factor. Different centres report an increase in GCA incidence, but annual fluctuations have not been shown to be statistically significant. However, significant seasonal variations have been observed by several groups. The mortality is not increased in adequately treated patients. Although, alternative steroid-sparing agents have been proposed, corticosteroids are still the first treatment choice.