Temporal arteritis and polymyalgia rheumatica in north-eastern Spain: clinical spectrum and relationship over a 15 year period

OBJECTIVE

To examine the clinical spectrum of polymyalgia rheumatica (PMR) and temporal arteritis (TA) and their relationship over a period of 15 years in an area of north-eastern Spain.

METHODS

We undertook a descriptive study of an unselected population of 163 patients with PMR and/or TA diagnosed from 1985 to 1999.

RESULTS

Of the 163 patients included, 90 had isolated PMR, 41 had PMR associated with TA, and 32 had isolated TA. The clinical spectrum of both conditions in our area was similar to that reported in other populations, including a marked female predominance. However, in our series, no patient developed permanent blindness or other major ischemic complications. PMR was observed in 56% of patients with TA. Conversely, 7% of patients originally suffering from PMR without clinical evidence of arteritis at presentation developed later symptoms of TA, and there were no predictive features for this. Interestingly, none of these patients suffered visual loss or other ischemic complications. The low risk of major complications in these cases does not support the need for systematic arterial biopsy in all patients with symptoms of PMR alone. On comparing patients with isolated TA with patients with PMR associated with TA, no differences were observed, thus discarding the possibility that the second constitutes a distinct and independent subgroup of TA. In contrast, when comparing patients with isolated PMR with patients with PMR associated with TA, we found significant differences between both the groups, with greater abnormality of clinical and laboratory markers of inflammation in patients with PMR associated with TA. These differences seem to reflect a greater degree of systemic inflammation linked to the presence of TA.

CONCLUSION

In our area, TA appears nowadays as a benign disease which infrequently presents blindness or other major complications. Our experience confirms that even after a good clinical response with normalization of a high ESR in PMR, the patient is at risk for clinical development of TA. Finally, our study also shows that isolated TA and PMR associated with TA seem to be the same condition, different from isolated PMR.

[Etiopathogenesis of giant cell arteritis]

Giant cell arteritis is a vasculitis of large and medium size arteries, especially those of the aortic arch with an extracranial distribution, but also the aorta and some of its larger branches. It is characterised by the presence of mononuclear inflammatory infiltrates close to the internal elastic lamina formed by lymphocytes and macrophages, which in slightly more than 50% of the cases contain multinucleate giant cells. The morbidity associated with this disease is related to phenomena of distal ischemia to the luminal stenosis of the inflamed arteries, and to a lesser extent to the formation of aneurisms due to the weakening of the arterial wall. With an unknown aetiology, its pathogenesis is immune through the migration and location of gamma-INF -producing T cells in the adventitia of the inflamed arteries, it being assumed that this is the place of immune stimulation by a still unidentified antigen. The recruitment and activation of macrophages by this cytokine is one of the most important points of its pathogenesis. The destruction by these of the arterial elastic tissue is a relevant phenomenon, as is the production of other factors promoting neoangiogenesis and a proliferation of neointime, responsible through obliterating light for the ischemic manifestations of the disease. The process is accompanied by an important systemic repercussion characterised by a strong reaction of acute phase and general but barely specific symptoms of disease. On the other hand, an important percentage of patients show a clinical picture of polymyalgia rheumatica, an entity that has a historical and controversial relationship to this arteritis. In recent years important contributions have been made to the understanding of the immune mechanisms involved in its pathogenesis.

Giant cell arteritis confined to intramural coronary arteries. Unforeseen hazards myocardial protection

A 74-year-old woman underwent elective double valve replacement (aortic and mitral) for rheumatic valvular disease. She failed to wean from cardiopulmonary bypass due to marked left ventricular dysfunction. At autopsy, severe giant cell arteritis confined to the intramural coronary arteries was seen. Furthermore, there were multiple areas of recent microscopic myocardial infarction around the intramural coronary arteries. This report describes a rare case of giant cell arteritis confined to intramural coronary arteries which lead to inadequate myocardial protection at the time of surgery.

No increased frequency of malignant neoplasms in polymyalgia rheumatica and temporal arteritis. A prospective longitudinal study of 398 cases and matched population controls

OBJECTIVE

To determine the prevalence and incidence of cancer in patients with polymyalgia rheumatica (PMR) and temporal arteritis (TA) compared to matched population controls.

METHODS

In a population based study 1987-97, 398 patients were diagnosed with PMR or TA. Each patient was randomly assigned 4 age and sex matched controls from the same county, totaling 1592 controls. All patients and controls were cross-checked with data files at the Cancer Registry of Norway, for cancers registered up to the end of 1998.

RESULTS

Prior to inclusion, cancer was diagnosed in 32 patients with PMR or TA (8.0%) and 153 controls (9.6%) (OR 0.82, 95% CI 0.55-1.22, p = 0.3). After inclusion, malignant neoplasms were discovered in 34 patients with PMR or TA (9.3%) compared to 143 controls (10.8%) (relative risk 0.86, 95% CI 0.59-1.26, p = 0.4). Thus there was no difference between patients with PMR or TA and their controls regarding prevalence or incidence of cancer. The interval between inclusion and the time of diagnosis of malignant neoplasm did not differ between patients and controls. No significant difference in types or localization of malignant neoplasms was found in patients compared to controls.

CONCLUSION

No differences were found in frequencies or types of malignant neoplasms between patients with PMR or TA and population controls. Neither PMR nor TA as defined by present diagnostic criteria appears associated with cancer.

Temporal arteritis: a cough, toothache, and tongue infarction

Temporal arteritis, the most common form of systemic vasculitis in adults, is a panarteritis that chiefly involves the extracranial branches of the carotid artery. The condition is illustrated in this article by the case of a 79-year-old woman with a dry cough, toothache, tongue infarction, and vision loss. The mean age of onset is 72 years and the disease rarely occurs in persons younger than 50 years. The most common presenting manifestations are headache, jaw claudication, polymyalgia rheumatica, and visual symptoms. Eighty-nine percent of patients have an erythrocyte sedimentation rate greater than 50 mm/h. However, about 40% of patients present with atypical manifestations, including fever of unknown origin, respiratory tract symptoms (especially dry cough), and large artery involvement. Familiarity with such unusual manifestations of temporal arteritis facilitates early diagnosis and treatment, thereby reducing the risk of vision loss.

Sex differences in giant cell arteritis

OBJECTIVE

Although it has been suggested that sex differences underlie the varying presentation of giant cell arteritis (GCA), this has not been proven. We compared medical history, symptoms, and signs in patients with GCA and polymyalgia rheumatica (PMR).

METHODS

We performed a retrospective study in the Hadassah University Hospitals in Jerusalem, Israel. We evaluated medical data of 88 patients (59 women, 29 men) admitted with the diagnosis of GCA or PMR between 1980 and 1998.

RESULTS

Comparison of comorbidities among patients showed that non-insulin dependent diabetes mellitus, cerebrovascular accidents, and chronic renal failure are more prevalent in men, while hypertension has a trend to be more prevalent in women. In the clinical presentation of the disease, eye involvement is more prevalent in men, with a tendency towards blindness. Women tend to have higher prevalence of jaw involvement and complaints of polymyalgia. The sexes also seem to differ with respect to laboratory presentation of the disease.

CONCLUSION

Men and women with GCA and PMR differ in their history, presentation, and laboratory findings. Our results recommend a more aggressive approach to male patients in view of the higher prevalence of severe eye involvement and blindness.

[Giant cell arteritis]

Giant cell arteritis (GCA) or temporal arteritis is the most frequent systemic vasculitis in our area, and its incidence may be on the increase in the last years. GCA involves large and medium-sized vessels, with preference to the extracranial arteries, and it affects persons older than 50 years. The aetiopathogenesis is unknown, although several infectious agents may be implicated. A normal temporal artery biopsy do not exclude a GCA since the lesions may be skip. The most feared complications of GCA are permanent visual loss, ischemic strokes and thoracic and abdominal aortic aneurysms. The treatment consists of high-dose corticoids, and nowadays there is no effective therapeutic alternative without important adverse effects. The mortality of treated patients with GCA does not seem to be increased, probably due to a correct diagnosis and management of this entity.

Some thoughts about the etiopathogenesis of temporal arteritis--a review

The three most striking features of temporal arteritis (TA) are the high incidence in populations of Nordic origins, the remarkable rarity of the disease among persons younger than 50 years, and the predilection for the superficial temporal arteries. At present, neither genetic susceptibility, environmental factors nor occurrence of specitic infections offer complete explanations to why Scandinavians are at increased risk of contracting TA. Similarly, recent developments in immunology and pathology of inflamed arteries cannot explain the preference of TA for this particular medium-size artery or why the disease almost exclusively affects persons older than 50 years. Although significant contributions regarding the pathogenesis of TA during the last decade are encouraging, the etiology of this disease still remains an enigma.

[Clinical features and treatment of giant cell arteritis in Chinese, a prospective study]

OBJECTIVE

To investigate the clinical features of giant cell (temporal) arteritis (GCA) in China.

METHODS

The clinical manifestations, temporal artery biopsy, response to steroid therapy, and follow-up data of sixteen patients with the diagnosis of GCA from July 1999 to March 2001 were analyzed. The American College of Rheumatology (ACR) criteria for classification of GCA were used as reference.

RESULTS

Twenty-one patients who sought medical advice in the Second Hospital Affiliated to Xiangya Medical College were suspected of GCA. A definite diagnosis of GCA was made among sixteen patients. The diagnosis among 13 of them fulfilled the 1990 American College of Rheumatology criteria for the classification of GCA. The mean age at disease onset was 43.13 years (range 28 approximately 60 years) and 81.25% of the patients were under the age of 50 when they came down with the disease. The ratio between male and female cases was 15:1. The commonest initial clinical manifestations included newly occurring headache, temporal artery abnormality, visual symptoms, fever, and raised erythrocyte sedimentation rate. Jaw claudication, fatigue, syncope, and hemiparesis could be found in some patients. All the 16 patients underwent temporal artery biopsy. Light and electron microscopy showed inflammatory cell infiltration in arterial wall in 11 cases, fragmented internal elastica in 16 cases, fibrinoid necrosis in 3 cases, smooth muscle cell changes in 10 cases, and thrombosis in the lumen in 5 cases. The mean time from symptom onset to suspicion of GCA or biopsy was 5.52 months (range 0.25 approximately 24.33 months). The misdiagnosis rate during first visit was 87.50%.

CONCLUSION

GCA may not be a rare disorder in China. In comparison with the cases abroad, the Chinese GCA patients come down with disease at the earlier age, and most Chinese GCA patients are male. This disease is not understood by many clinicians in China. Misdiagnosis is common.

Sex differences in temporal arteritis and polymyalgia rheumatica

OBJECTIVE

Sex-specific differences in treatment outcomes have been observed in polymyalgia rheumatica (PMR) and temporal arteritis (TA), with a significantly longer course of treatment in women than in men. We analyzed whether these sex differences are related to differences in disease presentation and severity of the inflammatory response.

METHODS

The records of 163 cases of PMR and/or TA diagnosed over a 15 year period were reviewed. A comparative study of clinical and laboratory features between men and women was performed.

RESULTS

Of 163 patients, 90 had isolated PMR and 73 had TA. Among patients with TA, 49 women and 24 men were identified, with a ratio of 2. While there were no differences in the frequency of classic disease manifestations, the presence of constitutional syndrome (malaise, anorexia, and weight loss) and fever were significantly more frequent in women than in men. Of note, evaluation of laboratory measures at time of diagnosis also revealed more marked laboratory abnormalities reflecting inflammation in the female group. Among patients with isolated PMR, 58 women and 32 men were identified, a ratio of 1.8. Comparing the clinical features at presentation, significant sex differences were also found, with a higher frequency of constitutional syndrome and lower values of hemoglobin in women. Moreover, women also had higher erythrocyte sedimentation rate values, and higher prevalence of fever and hepatic involvement, although the difference did not reach statistical significance.

CONCLUSION

Modest differences were found in disease expression between women and men with TA and/or PMR. In both conditions, the inflammatory response seemed to be more severe in women. The strong inflammatory response in women could explain the longer duration of treatment reported in this subgroup of patients.

Incidence of temporal arteritis in patients with polymyalgia rheumatica: a prospective study using colour Doppler ultrasonography of the temporal arteries

OBJECTIVE

To determine the incidence of temporal arteritis (TA) in patients with polymyalgia rheumatica (PMR) using colour Doppler ultrasonography of the temporal arteries.

METHODS

Ultrasonography was performed in all 127 consecutive patients with newly diagnosed, active PMR seen between 1994 and 2000 and in 127 age- and sex-matched controls.

RESULTS

Of 102 patients with "pure" PMR, 8% had ultrasonographic findings arousing suspicion of concomitant active TA (specific halo sign and/or positive histology in 7%; histologically proven TA in 4%). Twenty-five patients had clinical signs of both PMR and TA. Histology and sonography were negative in three of these patients. Of the controls, none had a halo sign and four had stenoses.

CONCLUSION

Ultrasonography of the temporal arteries is a new, non-invasive method of diagnosing concomitant TA in patients with PMR.

Visual hallucinations in giant cell arteritis: association with visual loss

OBJECTIVE

To evaluate the frequency and characteristics of visual hallucinations (VH) in patients with giant cell arteritis (GCA) and to determine their relationship to other visual phenomena.

METHODS

This prospective study included 31 consecutive patients with GCA. All were asked whether they had experienced recent visual phenomena. Patients with visual symptoms underwent a comprehensive ophthalmologic examination. When unusual visual phenomena were reported, patients were asked to describe their nature, duration, and frequency of occurrence.

RESULTS

Visual symptoms occurred in 6 patients: permanent visual loss in 5 and amaurosis fugax in one. In 4 of the 5 patients with permanent visual loss, it was preceded by intermittent VH over a period of 1-10 days. Patients were aware of the unreal nature of the visions. Hallucinations disappeared within 2 weeks, but in one patient, recurred 6 months later in association with further visual deterioration.

CONCLUSION

The occurrence of visual hallucinations in patients with GCA-associated visual loss is more common than previously appreciated. As hallucinations preceded permanent loss of vision, this phenomenon may serve as a harbinger of imminent visual loss.

Calcification of the internal elastic membrane in temporal arteries: its relation to age and gender

OBJECTIVE

To investigate the age and sex distribution of calcifications of the internal elastic membrane (IEM) in temporal arteries.

METHODS

Calcifications of the IEM were assessed light-microscopically in temporal arteries from 40 women and 21 men, aged 51 or more, who were known not to have giant cell arteritis (GCA). Their relation to age and the difference between women and men were tested statistically.

RESULTS

The IEM calcifications differed morphologically from the calcifications in Mönckeberg's mediosclerosis and atherosclerosis. They increased significantly with age and were 2.62 times more common in women than men.

CONCLUSION

Previous morphological studies indicate that the inflammatory process in GCA is initiated by a foreign-body, giant-cell attack on calcifications of the IEM. The present study showed that IEM calcifications in non-GCA controls show an age and sex distribution similar to that of GCA morbidity. The results may indicate that the presence of IEM calcifications in the general population influences the age and sex distribution of GCA. Furthermore, the findings support the hypothesis that the calcifications, although not disease specific, may play a pathogenetic role in the latter.

[Polymyalgia rheumatica in general practice]

BACKGROUND

Polymyalgia rheumatica is often diagnosed and treated in general practice. Rheumatologists have expressed concern about overdiagnosing and steroid treatment that conceals other diseases and deteriorating osteoporosis.

MATERIAL AND METHODS

A ten-year material (1985-94) of polymyalgia rheumatica from a Norwegian general practice.

RESULTS

Six out of 54 patients with the diagnosis polymyalgia rheumatica had their diagnose changed after one year. Average prednisolone starting dose was 31 mg, median treatment time for women was 20 months and for men 29 months. 10% were treated more than ten years, and 20% relapsed. Patients with fractures in the follow-up period had longer treatment periods; this indicates that a shorter treatment time may be important in preventing osteoporosis.

INTERPRETATION

Diagnosing polymyalgia rheumatica can be done in general practice if there is good communication with second-line medical-services in cases with indistinct or serious symptoms. It is important to have in mind temporal arteritis, rheumatoid arthritis and malignancies. Treatment and follow-up of these patients is a task that needs stable and continuous relations between patient and doctor with special focus on the osteoporosis problem.

[Inaugural symptoms of Horton's disease in a series of 260 patients]

PURPOSE

Horton disease or 'giant cell arteritis' is a known entity in its typical form; the difficulty in diagnosis is due to the atypical signs and symptoms.

METHODS

We review 260 medical files presenting Horton disease between 1979 and 1999 in five different departments: three internal medicine departments, one rheumatology department and one geriatric department.

RESULTS

The study shows a female domination with a mean age of 75 years. Temporal artery biopsy was done on all patients. Ten patients presented a vascular manifestation. The neurological manifestation was the first symptom in four patients. Five patients had cutaneous symptomatology, with positive temporal artery in three cases. Renal manifestation was present in two patients. Two symptoms are important to discuss because of their frequency: the cough and the peripheral arthritis. We found nine observations with arthritis affecting large joints and responding to nonsteroidal antiinflammatories with positive temporal artery biopsy in seven patients, and 21 observations manifesting by cough without radiological signs; in 57% of cases the temporal artery biopsy was positive, and the cough regressed with corticoids.

CONCLUSION

These atypical symptoms have to be known to make a diagnosis and to begin a corticotherapy as soon as possible.

Incidence of nonarteritic anterior ischemic optic neuropathy associated with cataract extraction

OBJECTIVES

To determine the incidence of nonarteritic anterior ischemic optic neuropathy (NAION) after cataract extraction and to use the incidence to evaluate the causal relationship between cataract extraction and NAION.

DESIGN

Cohort study.

PARTICIPANTS

Five thousand seven hundred eighty-seven cataract extraction cases at the Bascom Palmer Eye Institute (BPEI) in a 5-year period between January 1, 1993 and December 31, 1997.

METHODS

During the study period, an estimated 5787 cataract extraction cases were identified that met the following criteria: (1) the patient was 50 years of age or older, (2) surgery was performed by phacoemulsification or phacofracture techniques and not planned in combination with another procedure, and (3) follow-up was at BPEI. Charts of patients diagnosed with NAION from January 1, 1993 to December 31, 1998 were reviewed to detect the occurrence of NAION within 1 year of surgery. The diagnosis of NAION was based on the following: (1) an acute decrease in vision, (2) associated nerve fiber layer defect on visual field testing, (3) associated relative afferent pupillary defect, and (4) observed optic nerve edema. The exact binomial test was used to compare the incidence of NAION after cataract extraction against the expected incidence.

MAIN OUTCOME MEASURE

Occurrence of NAION within 1 year after cataract extraction.

RESULTS

Of the 5787 cataract extraction cases, three patients experienced NAION within 1 year of the procedure. Each case occurred after surgery on days 29, 36, and 117, giving an estimated 6-month incidence of 51.8 in 100,000 and a 6-week incidence of 34.6 in 100,000. Both were statistically higher than the previously reported overall incidence of NAION. Two of the three patients had a history of NAION in the contralateral eye.

CONCLUSIONS

Cataract extraction is associated with an increased incidence of NAION, which is higher than the reported overall incidence. However, the risk of NAION after cataract extraction is low, with approximately one occurrence in every 2000 cases. A history of NAION in the fellow eye may be a risk factor.

Lack of association between intercellular adhesion molecule-1 gene polymorphisms and giant cell arteritis

OBJECTIVE

Studies have shown an association between HLA-DRB1*04 and giant cell arteritis (GCA). Intercellular adhesion molecule-1 (ICAM-1) gene polymorphisms were reported to contribute susceptibility to GCA in Italian patients where susceptibility to GCA is not associated with HLA-DRB1*04 alleles. ICAM-1 is also highly expressed within inflammatory infiltrates of the blood vessels of GCA patients. To investigate the clinical implications of ICAM-1 polymorphisms in GCA, we examined their potential association and influence in the development of visual ischemic complications in a series of patients with GCA from Northwest Spain where GCA susceptibility is associated with HLA-DRB1*04.

METHODS

Fifty-eight biopsy proven GCA and 129 ethnically matched controls were studied. Patients and controls were genotyped for ICAM-1 polymorphism at codons 241 and 469 by PCR-RFLP.

RESULTS

The distribution of the alleles and genotypes for each ICAM- polymorphism did not show significant differences between GCA patients and controls. Although visual manifestations were significantly more likely to occur in men than women (OR 5.2, p = 0.018), allele and genotype frequencies of ICAM-1 polymorphisms in patients with GCA were not associated with development of visual complications or anemia. Visual complications in GCA were primarily associated with carriage of an HLA-DRB1*04 allele. No evidence was found for interaction between HLA-DRB1*04 and ICAM-1 polymorphism.

CONCLUSION

ICAM-1 polymorphisms are not genetic risk factors for the susceptibility and severity of GCA in Northwest Spain.

The epidemiology of giant cell arteritis : a 12-year retrospective study

OBJECTIVE

To study the incidence of biopsy-proven giant cell arteritis (GCA) in a Hispanic population with clinical features suggestive of GCA.

DESIGN

Retrospective review.

PARTICIPANTS

Records of 121 consecutive patients who underwent temporal artery biopsy at the Doheny Eye Institute and the Los Angeles County/University of Southern California Hospital from January 1986 through April 1998 were reviewed.

MAIN OUTCOME MEASURES

The incidence of biopsy-proven GCA was determined, and the biopsy-positive group was compared with the biopsy-negative group. Study variables included age at diagnosis, gender, erythrocyte sedimentation rate (ESR), and ethnic background.

RESULTS

Among these 121 patients who underwent temporal artery biopsy, the mean age of those in the biopsy-positive group (75.2 +/- 5.0 years) was higher than that of those in the biopsy-negative group (69.1 +/- 9.2 years; P < 0.0001). There was no statistical correlation between biopsy-positive and biopsy-negative groups for gender or ESR level, but ESR was statistically significant for whites when we controlled for race. Nineteen of 66 white patients (29%) had positive biopsy results, whereas only 1 of the 9 Asian patients (11%) none of the 40 Hispanic patients (0%; P < 0.0001) and none of the 6 African American patients (0%) had positive biopsy results.

CONCLUSIONS

Giant cell arteritis occurs primarily in the white population. None of the Hispanic patients in our study was found to have positive biopsy results. Hispanic persons may have unknown factors that protect them from this disease. Further study is necessary to examine the genetic predisposition.