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Ninan JV, Lester S, Hill CL. Giant cell arteritis: beyond temporal artery biopsy and steroids. Intern Med J 2018; 47:1228-1240. [PMID: 28485026 DOI: 10.1111/imj.13483] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/25/2017] [Accepted: 04/30/2017] [Indexed: 11/29/2022]
Abstract
Giant cell arteritis is the most common primary vasculitis of the elderly. The acute complications of untreated giant cell arteritis, such as vision loss or occasionally stroke, can be devastating. The diagnosis is, however, not altogether straightforward due to variable sensitivities of the temporal artery biopsy as a reference diagnostic test. In this review, we discuss the increasing role of imaging in the diagnosis of giant cell arteritis. Glucocorticoid treatment is the backbone of therapy, but it is associated with significant adverse effects. A less toxic alternative is required. Conventional and novel immunosuppressive agents have only demonstrated modest effects in a subgroup of steroid refractory Giant cell arteritis due to the different arms of the immune system at play. However, recently a study of interleukin-6 blockade demonstrated benefits of giant cell arteritis. The current status of these immunosuppressive agents and novel therapies are also discussed in this review.
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Affiliation(s)
- Jem V Ninan
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, Modbury Hospital, Adelaide, South Australia, Australia
| | - Susan Lester
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Catherine L Hill
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Abstract
Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are related inflammatory diseases of adults aged 50 years or older. The diagnosis of PMR is based on morning stiffness, proximal shoulder and pelvic girdle pain, and functional impairment. GCA is characterized by headache, jaw claudication, and visual disturbances. Constitutional symptoms and elevated inflammatory markers are common to both conditions. Temporal artery biopsy remains the gold standard for diagnosis of GCA. Glucocorticoids are the cornerstone of therapy, with tapering regimens individualized to the patient. Prompt diagnosis and treatment are essential to avert vision loss in GCA. Tocilizumab increases remission rates in GCA.
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Affiliation(s)
- Mathilde H Pioro
- Department of Rheumatology, Orthopedic and Rheumatologic Institute, Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue A50, Cleveland, OH 44195, USA.
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53
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Ninan JV, Lester S, Hill CL. Diagnosis and management of giant cell arteritis: an Asia-Pacific perspective. Int J Rheum Dis 2018; 22 Suppl 1:28-40. [PMID: 29667308 DOI: 10.1111/1756-185x.13297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Giant cell arteritis is the commonest primary vasculitis of the elderly. However, the prevalence does vary widely between populations with highest incidence amongst Northern Europeans and lowest amongst East Asians. Preliminary studies suggest that clinical manifestations may differ between different populations. Newer diagnostic approaches including ultrasound, MR angiography and PET imaging are under review. While there have been recent advances in the diagnosis of GCA particularly with regard to imaging, there is an urgent need for improvements in methods of diagnosis, treatment and requirement for screening. Glucocorticoid treatment remain the backbone of therapy. However, glucocorticoid therapy is associated with significant adverse effects. Conventional and novel immunosuppressive agents have only demonstrated modest effects in a subgroup of steroid refractory GCA due to the different arms of the immune system at play. However, recently a study of IL-6 blockade demonstrated benefit in GCA. Newer approaches such as fast-track pathways can also result in improvements in consequences of GCA including blindness.
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Affiliation(s)
- Jem V Ninan
- Rheumatology Unit, Modbury Hospital, Modbury, South Australia, Australia.,Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Susan Lester
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Catherine L Hill
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Negative temporal artery biopsy: predictive factors for giant cell arteritis diagnosis and alternate diagnoses of patients without arteritis. Clin Rheumatol 2018; 37:2819-2824. [PMID: 29549493 DOI: 10.1007/s10067-018-4068-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/07/2018] [Accepted: 03/11/2018] [Indexed: 10/17/2022]
Abstract
To investigate whether among patients with a negative temporal artery biopsy (TAB) there are clinical features that may differentiate between patients with an eventual diagnosis of giant cell arteritis (GCA) and those without arteritis, and to assess the eventual diagnoses of patients without arteritis. Retrospective analysis of patients with a negative TAB performed between 1/1/2000 and 31/12/2015. Information collected included baseline clinical and laboratory data. Patients' final diagnoses were obtained from medical records. Patients eventually diagnosed with GCA were compared with those without arteritis, and predictive features for GCA diagnosis were assessed. A total of 154 patients with a negative TAB were included in the study. Among them, 31 (20%) were eventually diagnosed with GCA. The leading alternative diagnoses of patients without arteritis were self-limited disease (23%), isolated polymyalgia rheumatica (PMR) (18%), and neurological conditions (17%). In the multivariate analysis, predictors for diagnosis of GCA among patients with a negative TAB included PMR (OR = 2.86, 95% CI 1.06-7.69), platelet count (OR = 1.28, 95% CI 1.07-1.53), and ACR score > 2 (OR = 13.4, 95% CI 4.27-42.03). Among patients with a negative TAB, the best predictors for diagnosis of GCA are fulfillment of the ACR criteria, a clinical diagnosis of PMR, and high platelet levels. These features may aid in the diagnostic work-up of patients with a negative TAB.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent updates and distill practical points from the literature which can be applied to the care of patients with suspected and confirmed giant cell arteritis (GCA). RECENT FINDINGS Contemporary thinking implicates a fundamental failure of T regulatory cell function in GCA pathophysiology, representing opportunity for novel therapeutic avenues. Tocilizumab has become the first Food and Drug Administration-approved treatment for GCA following demonstration of efficacy and safety in a phase 3 clinical trial. There have been significant parallel advances in both our understanding of GCA pathophysiology and treatment. Tocilizumab, and other agents currently under investigation in phase 2 and 3 clinical trials, presents a new horizon of hope for both disease remission and avoidance of glucocorticoid-related complications.
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Affiliation(s)
- Swati Pradeep
- Department of Neurology, University of Kentucky, 740 S. Limestone, L445, Lexington, KY, 40536, USA
| | - Jonathan H Smith
- Department of Neurology, University of Kentucky, 740 S. Limestone, L445, Lexington, KY, 40536, USA.
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56
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Blockmans D. Fluorodeoxyglucose Positron Emission Tomography for Giant Cell Arteritis. J Rheumatol 2017; 44:1763-1764. [PMID: 29196543 DOI: 10.3899/jrheum.170966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Daniel Blockmans
- Katholieke Universiteit Leuven, General Internal Medicine, Leuven, Belgium.
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Abstract
Giant cell arteritis (GCA) is the most common form of vasculitis in individuals aged 50 years and over. GCA typically affects large and medium-sized arteries, with a predilection for the extracranial branches of the carotid artery. Patients with GCA usually present with symptoms and signs that are directly related to the artery that is affected, with or without constitutional manifestations. The most dreaded complication of GCA is visual loss, which affects about one in six patients and is typically caused by arteritis of the ophthalmic branches of the internal carotid artery. Before the advent of glucocorticoid treatment, the prevalence of visual complications was high. Increasing awareness by physicians of the symptoms of GCA and advances in diagnostic techniques over the past twenty years have also contributed to a substantial decline in the frequency of permanent visual loss. Ischaemic brain lesions are less common than visual lesions, and mostly result from vasculitis of the extradural vertebral or carotid arteries. In the case of both the eye and the brain, ischaemic damage is thought to result from arterial stenosis or occlusion that occurs secondary to the inflammatory process. The inflammatory response at the onset of arteritis, its role as a predictor of complications and the role of traditional cardiovascular risk factors have been extensively investigated in the past decade. In this Review, the epidemiology, risk factors, clinical presentation and current therapeutic approach of GCA-related ischaemic events are discussed, with a particular emphasis on visual loss.
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Roberts J, Clifford A. Update on the management of giant cell arteritis. Ther Adv Chronic Dis 2017; 8:69-79. [PMID: 28491267 PMCID: PMC5406009 DOI: 10.1177/2040622317700089] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/23/2017] [Indexed: 12/11/2022] Open
Abstract
Giant cell arteritis (GCA) is a large vessel vasculitis that may be associated with significant complications such as blindness, stroke, or aortic aneurysm and dissection in a subset of patients. Given the serious side effects associated with prolonged courses of glucocorticoids and frequent relapses experienced when doses are tapered, increased efforts are being dedicated to the discovery of safer and more effective therapies to control this disease. The purpose of this review is to critically evaluate the role of glucocorticoid-sparing agents in the medical management of GCA with a special focus on the most recent evidence regarding the role of biologic agents, including tocilizumab (TCZ), abatacept and ustekinumab, and other novel therapies.
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Affiliation(s)
- Janet Roberts
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alison Clifford
- Division of Rheumatology, Department of Medicine, University of Alberta, 8–130K Clinical Sciences Building, Edmonton, AB, T6G 2G3, Canada
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The 2016 revised ACR criteria for diagnosis of giant cell arteritis – Our case series: Can this avoid unnecessary temporal artery biopsies? INTERNATIONAL JOURNAL OF SURGERY OPEN 2017. [DOI: 10.1016/j.ijso.2017.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Richter JG, Sander O, Schneider M. Causes of Cardiovascular Ischemic Events in Giant Cell Arteritis. J Rheumatol 2016; 43:2092-2093. [PMID: 27909138 DOI: 10.3899/jrheum.161237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jutta G Richter
- Policlinic for Rheumatology and Hiller Research Centre for Rheumatology, Medical Faculty, Heinrich Heine University Düsseldorf;
| | - Oliver Sander
- Policlinic for Rheumatology and Hiller Research Centre for Rheumatology, Medical Faculty, Heinrich Heine University Düsseldorf
| | - Matthias Schneider
- Policlinic for Rheumatology and Hiller Research Centre for Rheumatology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are both more common among people of North European decent than among Mediterranean people. Women are 2-3 times more commonly affected. Giant cell arteritis and PMR are extremely rare before age 50 years. Polymyalgia rheumatica may be "isolated" or associated with GCA. There is increased expression of inflammatory cytokines in temporal arteries of PMR patients, without overt histological evidence of arteritis. One-third of "isolated" PMR patients have vascular uptake in positron emission tomography (PET) scans, suggesting clinically unrecognized, "hidden" GCA. Typical manifestations of GCA are headache, tenderness over temporal arteries, jaw claudication, PMR, acute vision loss, and low-grade fever. Bilateral aching of the shoulders with morning stiffness is typical for PMR. In both conditions sedimentation rate and C-reactive protein are elevated, and anemia and thrombocytosis may occur. Color duplex ultrasonography of the temporal arteries may aid in GCA diagnosis. Temporal artery biopsy showing vasculitis, often with giant cells, confirms GCA diagnosis. In cases with negative biopsy one must rely on the clinical presentation and laboratory abnormalities. The diagnosis of PMR is made primarily on clinical grounds. Other conditions that may mimic GCA or PMR must be excluded. Glucocorticoids are the treatment of choice for both conditions. Prompt treatment is crucial in GCA, to prevent irreversible complications of acute vision loss and stroke. Addition of low-dose aspirin may further prevent these complications. The average duration of treatment is 2-3 years, but some patients require a prolonged course of treatment, and some may develop disease-related or treatment-related complications. No steroid-sparing agent has been proven to be widely effective thus far, but some promising therapeutic agents are currently being studied.
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Affiliation(s)
- Gideon Nesher
- Department of Internal Medicine A and the Rheumatology Unit, Shaare-Zedek Medical Center, Jerusalem, Israel
| | - Gabriel S Breuer
- Department of Internal Medicine A and the Rheumatology Unit, Shaare-Zedek Medical Center, Jerusalem, Israel
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Jakobsson K, Jacobsson L, Mohammad AJ, Nilsson JÅ, Warrington K, Matteson EL, Turesson C. The effect of clinical features and glucocorticoids on biopsy findings in giant cell arteritis. BMC Musculoskelet Disord 2016; 17:363. [PMID: 27558589 PMCID: PMC4997683 DOI: 10.1186/s12891-016-1225-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 08/18/2016] [Indexed: 02/05/2023] Open
Abstract
Background To investigate the effect of baseline clinical characteristics and glucocorticoid treatment on temporal artery biopsy (TAB) findings in patients with giant cell arteritis (GCA). Methods Individuals who developed GCA after inclusion in two population-based health surveys were identified through linkage to the local and the national patient registers. In addition, other patients diagnosed with GCA at the Departments of Internal Medicine and Rheumatology at an area hospital were included. A structured review of medical records and TAB pathology reports was performed. The presence or absence of giant cells, granuloma, fragmented internal elastic lamina, fibrosis and grade of inflammatory infiltrates were recorded. Results In 183 cases with a confirmed clinical diagnosis of GCA, 139 were biopsied after start of glucocorticoids (median treatment duration 3 days; interquartile range 2–5). Patients with a positive TAB (77 %) had significantly higher C-reactive protein (CRP; p = 0.007) and erythrocyte sedimentation rate (ESR; p = 0.03) at the time of clinical diagnosis. A positive TAB tended to more common in women, but there was no difference in the proportion of patients with polymyalgia rheumatica or visual symptoms. Patients biopsied before or on the same day as initial treatment where more likely than those biopsied 1–3 days after treatment start to have positive biopsy [odds ratio (OR) 2.86; 95 % CI 1.06–7.70] as well as inflammatory infiltrates (OR 3.30; 95 % CI 1.15–9.49). There was no significant difference in the proportions of a fragmented internal lamina (p = 0.86), giant cells (p = 0.10), granuloma (p = 0.19), minor inflammatory infiltrates (p = 0.47), major inflammatory infiltrates (p = 0.09), or overall positive biopsy (p = 0.17) report by treatment duration comparing: ≤ 0 days, 1–3 days, 4–6 days, 7–28 days. Among those biopsied 7–28 days after start of treatment, 80 % of TABs were positive, and histopathology features were not substantially different from those biopsied after shorter glucocorticoid treatment. Conclusion Biopsies were more likely to be positive and have characteristic histopathologic features in patients with high CRP and ESR, and prior to start of corticosteroid treatment TABs taken 1–4 weeks after initiation of glucocorticoid treatment reveal changes consistent with GCA and therefore still yields clinically useful information for the diagnosis. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1225-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karin Jakobsson
- Department of Clinical Sciences, Rheumatology, Lund University, Malmö, Sweden. .,Department of Rheumatology, Skåne University Hospital, S-205 02, Malmö, Sweden.
| | - Lennart Jacobsson
- Department of Clinical Sciences, Rheumatology, Lund University, Malmö, Sweden.,Department of Rheumatology & Inflammation Research, The Sahlgrenska Academy, University of Gothenburg, Institute of Medicine, Gothenburg, Sweden
| | - Aladdin J Mohammad
- Department of Rheumatology, Skåne University Hospital, S-205 02, Malmö, Sweden.,Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, UK
| | - Jan-Åke Nilsson
- Department of Clinical Sciences, Rheumatology, Lund University, Malmö, Sweden.,Department of Rheumatology, Skåne University Hospital, S-205 02, Malmö, Sweden
| | - Kenneth Warrington
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Carl Turesson
- Department of Clinical Sciences, Rheumatology, Lund University, Malmö, Sweden.,Department of Rheumatology, Skåne University Hospital, S-205 02, Malmö, Sweden
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63
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Abstract
Giant cell arteritis (GCA) is the most common vasculitis of the elderly. The diagnosis can be challenging at times because of the limitation of the American Rheumatology Association (ARA) classification criteria and the significant proportion of biopsy-negative patients with GCA. We discuss the role of advanced imaging techniques, including positron emission tomography (PET) scanning, in establishing diagnosis and improved histopathology techniques to improve the sensitivity of temporal artery biopsy. There have been significant advances in the understanding of the pathogenesis of GCA, particularly the role of cytokine pathways such as the interleukins, IL-6-IL-17 axis, and the IL-12-interferon-γ axis and their implication for new therapies. We highlight that glucocorticoids remain the primary treatment for GCA, but recognize the risk of steroid-induced side effects. A number of pharmacotherapies to enable glucocorticoid dose reduction and prevent relapse have been studied. Early diagnosis and fast-track pathways have improved outcomes by encouraging adherence to evidence-based practice.
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Affiliation(s)
- Jem Ninan
- Rheumatology Unit, Modbury Hospital, Modbury, South Australia, Australia
| | - Susan Lester
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia; Department of Medicine, University of Adelaide, Adelaide, Australia
| | - Catherine Hill
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia; Department of Medicine, University of Adelaide, Adelaide, Australia; Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia.
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64
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Abstract
BACKGROUND To identify clinical and laboratory factors contributing to the diagnosis of giant cell arteritis (GCA) and develop a diagnostic algorithm for the evaluation of GCA. METHODS Retrospective review of 213 consecutive cases of temporal artery biopsy (TAB) seen at a single academic center over a 10-year period (2000-2009). Pathologic specimens were re-reviewed and agreement between the original and second readings was assessed. A composite clinical suspicion score was created by adding 1 point for each of the following criteria: anterior extracranial circulation ischemia, new onset headache, abnormal laboratory results (erythrocyte sedimentation rate, C-reactive protein (CRP), or platelet count), jaw claudication, abnormal or tender superficial temporal artery, constitutional symptoms, and polymyalgia rheumatica; one point was subtracted if a comorbid condition could explain a criterion. RESULTS Of the 204 TABs analyzed, pathologic findings were confirmatory in 49 (24.0%) and suggestive in 12 (5.9%). TAB-positive patients were more likely to be older (age 75.2 ± 7.8 vs 69.7 ± 11.0 years, P = 0.0002), complain of jaw claudication (relative-risk = 3.26, P = 0.0014), and have thrombocytosis (relative-risk = 3.3, P = 0.0072) and elevated CRP (relative-risk = 1.8, P = 0.037). None of the patients with a clinical score less than 2 had a positive TAB. Diabetes mellitus and kidney disease were often the explanation for the symptoms and abnormal clinical finding(s) that led to a negative TAB. CONCLUSIONS We propose a clinical algorithm that is highly predictive for a positive TAB and can be valuable in the evaluation process of suspected cases of GCA.
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65
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Muratore F, Cavazza A, Boiardi L, Lo Gullo A, Pipitone N, Germanò G, Bisagni A, Cimino L, Salvarani C. Histopathologic Findings of Patients With Biopsy‐Negative Giant Cell Arteritis Compared to Those Without Arteritis: A Population‐Based Study. Arthritis Care Res (Hoboken) 2016; 68:865-70. [DOI: 10.1002/acr.22736] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/07/2015] [Accepted: 09/15/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Francesco Muratore
- Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere ScientificoReggio Emilia Italy
| | - Alberto Cavazza
- Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere ScientificoReggio Emilia Italy
| | - Luigi Boiardi
- Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere ScientificoReggio Emilia Italy
| | | | - Nicolò Pipitone
- Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere ScientificoReggio Emilia Italy
| | - Giuseppe Germanò
- Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere ScientificoReggio Emilia Italy
| | - Alessandra Bisagni
- Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere ScientificoReggio Emilia Italy
| | - Luca Cimino
- Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere ScientificoReggio Emilia Italy
| | - Carlo Salvarani
- Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere ScientificoReggio Emilia Italy
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Muratore F, Boiardi L, Cavazza A, Aldigeri R, Pipitone N, Restuccia G, Bellafiore S, Cimino L, Salvarani C. Correlations between histopathological findings and clinical manifestations in biopsy-proven giant cell arteritis. J Autoimmun 2016; 69:94-101. [PMID: 27009904 DOI: 10.1016/j.jaut.2016.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To correlate histopathological features of positive temporal artery biopsy (TAB) and clinical manifestations of the disease in a large single-center population-based cohort of patients with biopsy-proven giant cell arteritis (GCA). METHODS A pathologist with expertise in vasculitis and blinded to clinical data and final diagnosis reviewed all TABs performed for suspected GCA at our hospital between January 1986 and December 2013. Histopathologic features evaluated were: the severity of inflammation and intimal hyperplasia, both graded on a semiquantitative scale (mild = 1, moderate = 2, severe = 3), the presence of intraluminal acute thrombosis, calcifications, giant cells, fibrinoid necrosis and laminar necrosis. RESULTS 274 patients had a final diagnosis of biopsy-proven GCA and were included in the study. Cranial ischemic events (CIEs) were observed in 161 (58.8%), visual manifestations in 79 (28.8%) and permanent (partial or complete) visual loss in 51 (18.6%) patients. Predictors for the development of CIEs were older age (OR = 1.057, 95% CI 1.019-1.097, p = 0.003), lower ESR values (OR = 0.990, 95% CI 0.981-0.999, p = 0.026) as well as the presence of giant cells (OR = 1.848, 95% CI 1.045-3.269, p = 0.035) and laminar necrosis at TAB (OR = 2.334, 95% CI 1.187-4.587, p = 0.014). Predictors for the development of permanent visual loss were lower CRP values (OR = 0.906, 95% CI 0.827-0.992, p = 0.033) and the presence of calcifications at TAB (OR = 3.672, 95% CI 1.479-9.121, p = 0.005). Fibrinoid necrosis was not observed in any of the TABs evaluated. CONCLUSION Pathological features of TAB may predict some manifestations of GCA. These findings may have implications for patients' management.
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Affiliation(s)
- Francesco Muratore
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Luigi Boiardi
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Alberto Cavazza
- Pathology Unit, Department of Oncology, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Raffaella Aldigeri
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Giovanna Restuccia
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Salvatore Bellafiore
- Pathology Unit, Department of Oncology, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Luca Cimino
- Ophthalmology Unit, Department of Surgery, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy.
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Management of giant cell arteritis: Recommendations of the French Study Group for Large Vessel Vasculitis (GEFA). Rev Med Interne 2016; 37:154-65. [DOI: 10.1016/j.revmed.2015.12.015] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 11/17/2022]
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68
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Correlation of clinical profile and specific histopathological features of temporal artery biopsies. J Neuroophthalmol 2016; 35:127-33. [PMID: 25742197 DOI: 10.1097/wno.0000000000000213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study sought to correlate the clinical features of patients with giant cell arteritis (GCA) who present with ophthalmic symptoms and signs, with 2 specific histopathological findings-the presence of giant cells and arterial wall neoangiogenesis. The goal was to assess if these pathological features might be useful in guiding the approach to patient management. METHODS Medical charts were retrospectively reviewed from 58 patients who underwent a temporal artery biopsy at a single institution. Detailed information was collected about the clinical presentation and course, with an emphasis on visual function. Histopathological and immunohistochemical techniques were used to examine temporal artery biopsies for evidence of inflammation. Correlations were made between the clinical data and the presence of giant cells and neoangiogenesis. RESULTS Twenty-one (34%) biopsies were positive for inflammation consistent with GCA. Although the percentage of positive biopsies with giant cells was high, neither the presence of giant cells nor neoangiogenesis was predictive of a patient's presenting visual symptoms, severity and bilaterality of vision loss, other ophthalmic manifestations of GCA, presence of headache or jaw claudication, or erythrocyte sedimentation rate. Giant cells were more common in patients with recent weight loss. Immunohistochemistry confirmed diagnoses but did not alter the clinical course or treatment plan. CONCLUSIONS There was no correlation between the clinical, specifically visual, features of GCA and the presence or absence of giant cells or neoangiogenesis in temporal artery biopsy specimens. Although the presence of neoangiogenesis may be important in the pathogenesis of GCA, our study showed no correlation between this finding and the clinical course.
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Labarca C, Koster MJ, Crowson CS, Makol A, Ytterberg SR, Matteson EL, Warrington KJ. Predictors of relapse and treatment outcomes in biopsy-proven giant cell arteritis: a retrospective cohort study. Rheumatology (Oxford) 2016; 55:347-56. [PMID: 26385368 PMCID: PMC4939727 DOI: 10.1093/rheumatology/kev348] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 08/13/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To evaluate characteristics of relapse, relapse rates, treatment and outcomes among patients with biopsy-proven GCA in a large, single-institution cohort. METHODS We conducted a retrospective review of all patients with biopsy-proven GCA from 1998 to 2013. Demographic, clinical, laboratory and treatment data at presentation and during follow-up were collected. Comparisons by relapse rate were performed using chi-square tests. Prednisone discontinuation by initial oral dose ≤40 and >40 mg/day was compared using Cox models. RESULTS The cohort included 286 patients [74% female, mean age at diagnosis 75.0 years (s.d. 7.6), median follow-up 5.1 years). During follow-up, 73 patients did not relapse, 80 patients had one relapse and 133 had two or more relapses. The first relapse occurred during the first year in 50% of patients, by 2 years in 68% and by 5 years in 79%. More patients with established hypertension (P = 0.007) and diabetes (P = 0.039) at GCA diagnosis were in the high relapse rate group ( ≥ 0.5 relapses/year) and more females were in the low or high relapse groups than in the no relapse group (P = 0.034). Patients receiving an initial oral prednisone dose >40 mg/day were able to reach a dose of <5 mg/day [hazard ratio (HR) 1.46 (95% CI 1.09, 1.96)] and discontinue prednisone [HR 1.56 (95% CI 1.09, 2.23)] sooner than patients receiving ≤40 mg/day without an increase in observed glucocorticoid-associated adverse events. CONCLUSION Females and patients with hypertension or diabetes at GCA diagnosis have more relapses during follow-up. Patients treated with an initial oral prednisone dose >40 mg/day achieved earlier prednisone discontinuation.
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Affiliation(s)
- Cristian Labarca
- Department of Internal Medicine, Universidad del Desarrollo, Clinica Alemana de Santiago, Santiago, Chile
| | | | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Division of Biostatistics and
| | - Ashima Makol
- Division of Rheumatology, Department of Medicine
| | | | - Eric L Matteson
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Hernández-Rodríguez J, Murgia G, Villar I, Campo E, Mackie SL, Chakrabarty A, Hensor EMA, Morgan AW, Font C, Prieto-González S, Espígol-Frigolé G, Grau JM, Cid MC. Description and Validation of Histological Patterns and Proposal of a Dynamic Model of Inflammatory Infiltration in Giant-cell Arteritis. Medicine (Baltimore) 2016; 95:e2368. [PMID: 26937893 PMCID: PMC4778989 DOI: 10.1097/md.0000000000002368] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 11/25/2015] [Accepted: 11/28/2015] [Indexed: 11/26/2022] Open
Abstract
The extent of inflammatory infiltrates in arteries from patients with giant-cell arteritis (GCA) have been described using different terms and definitions. Studies investigating the relationship between GCA histological features and clinical manifestations have produced controversial results. The aims of this study were to characterize and validate histological patterns in temporal artery biopsies (TABs) from GCA patients, to explore additional histological features, including the coexistence of different patterns, and also to investigate the relationship of the inflammatory patterns with clinical and laboratory features.We performed histological examination of TAB from patients with GCA consecutively diagnosed between 1992 and 2012. Patterns of inflammation were defined according to the extent and distribution of inflammatory infiltrates within the artery. Clinical and laboratory variables were recorded. Two external investigators underwent a focused, one-day training session and then independently scored 77 cases. Quadratic-weighted kappa was calculated.TAB from 285 patients (200 female/85 male) were evaluated. Four histological inflammatory patterns were distinguished: 1 - adventitial (n = 16); 2 - adventitial invasive: adventitial involvement with some extension to the muscular layer (n = 21); 3 - concentric bilayer: adventitial and intimal involvement with media layer preservation (n = 52); and 4 - panarteritic (n = 196). Skip lesions were observed in 10% and coexistence of various patterns in 43%. Raw agreement of each external scorer with the gold-standard was 82% and 77% (55% and 46% agreement expected from chance); kappa = 0.82 (95% confidence interval [CI] 0.70-0.95) and 0.79 (95% CI 0.68-0.91). Although abnormalities on temporal artery palpation and the presence of jaw claudication and scalp tenderness tended to occur more frequently in patients with arteries depicting more extensive inflammation, no statistically significant correlations were found between histological patterns and clinical features or laboratory findings.In conclusion, we have described and validated 4 histological patterns. The presence of different coexisting patterns likely reflects sequential steps in the progression of inflammation and injury. No clear relationship was found between these patterns and clinical or laboratory findings. However, several cranial manifestations tended to occur more often in patients with temporal arteries exhibiting panarteritic inflammation. This validated score system may be useful to standardize stratification of histological severity for immunopathology biomarker studies or correlation with imaging.
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Affiliation(s)
- José Hernández-Rodríguez
- From the Vasculitis Research Unit, Department of Autoimmune Diseases (JHR, GM, IV, CF, SPG, GEF, MCC); Department of Anatomic Pathology, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (EC); Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust (SLM, EMAH, AWM); Leeds Teaching Hospitals NHS Trust, Leeds, UK (AC); Department of Internal Medicine, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (JMG)
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Frohman L, Wong ABC, Matheos K, Leon-Alvarado LG, Danesh-Meyer HV. New developments in giant cell arteritis. Surv Ophthalmol 2016; 61:400-21. [PMID: 26774550 DOI: 10.1016/j.survophthal.2016.01.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 01/05/2016] [Accepted: 01/08/2016] [Indexed: 12/01/2022]
Abstract
Giant cell arteritis (GCA) is a medium-to-large vessel vasculitis with potentially sight- and life- threatening complications. Our understanding of the pathogenesis, diagnosis, and treatment of GCA has advanced rapidly in recent times. The validity of using the American College of Rheumatology guidelines for diagnosis of GCA in a clinical setting has been robustly challenged. Erythrocyte sedimentation rate, an important marker of inflammation, is lowered by the use of statins and nonsteroidal anti-inflammatory drugs. Conversely, it may be falsely elevated with a low hematocrit. Despite the emergence of new diagnostic modalities, temporal artery biopsy remains the gold standard. Evidence suggests that shorter biopsy lengths and biopsies done weeks to months after initiation of steroid therapy are still useful. New imaging techniques such as positron emission tomography have shown that vascular inflammation in GCA is more widespread than originally thought. GCA, Takayasu arteritis, and polymyalgia rheumatica are no longer thought to exist as distinct entities and are more likely parts of a spectrum of disease. A range of immunosuppressive drugs have been used in conjunction with corticosteroids to treat GCA. In particular, interleukin-6 inhibitors are showing promise as a therapy.
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Affiliation(s)
- Larry Frohman
- Department of Ophthalmology, Rutgers-New Jersey Medical School, New Jersey, USA; Department of Neurosciences, Rutgers-New Jersey Medical School, New Jersey, USA
| | - Aaron B C Wong
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | - Kaliopy Matheos
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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72
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Gutierrez J, Katan M, Elkind MS. Collagen Vascular and Infectious Diseases. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00036-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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73
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Calvo Romero J. Giant cell arteritis: Diagnosis and treatment. Rev Clin Esp 2015. [DOI: 10.1016/j.rceng.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Espígol-Frigolé G, Prieto-González S, Alba MA, Tavera-Bahillo I, García-Martínez A, Gilabert R, Hernández-Rodríguez J, Cid MC. Advances in the diagnosis of large vessel vasculitis. Rheum Dis Clin North Am 2015; 41:125-40, ix. [PMID: 25399944 DOI: 10.1016/j.rdc.2014.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The diagnosis of large-vessel vasculitis has experienced substantial improvement in recent years. While Takayasu arteritis diagnosis relies on imaging, the involvement of epicranial arteries by giant-cell arteritis facilitates histopathological confirmation. When appropriately performed temporal artery biopsy has high sensitivity and specificity. However, an optimal biopsy is not always achievable and, occasionally, the superficial temporal artery may not be involved. Imaging in its various modalities including colour-duplex ultrasonography, computed tomography angiography, magnetic resonance angiography and positron emission tomography, are emerging as important procedures for the diagnosis and assessment of disease extent in large-vessel vasculitis. Recent contributions to the better performance and interpretation of temporal artery biopsies as well as advances in imaging are the focus of the present review.
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Affiliation(s)
- Georgina Espígol-Frigolé
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Marco A Alba
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Itziar Tavera-Bahillo
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Ana García-Martínez
- Vasculitis Research Unit, Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Villarroel 170, Barcelona 08036, Spain
| | - Rosa Gilabert
- Center for Diagnostic Imaging, Hospital Clínic, Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Maria C Cid
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain.
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75
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Calvo Romero JM. Giant cell arteritis: diagnosis and treatment. Rev Clin Esp 2015; 215:331-7. [PMID: 25957859 DOI: 10.1016/j.rce.2015.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/27/2015] [Accepted: 03/09/2015] [Indexed: 11/16/2022]
Abstract
Giant cell arteritis is the most common primary systemic vasculitis in adults. The condition is granulomatous arteritis of large and medium vessels, which occurs almost exclusively in patients aged 50 years or more. This article reviews the diagnosis and treatment of the disease.
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Affiliation(s)
- J M Calvo Romero
- Servicio de Medicina Interna, Hospital Ciudad de Coria, Coria, Cáceres, España.
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76
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Berti A, Campochiaro C, Cavalli G, Pepe G, Praderio L, Sabbadini MG, Dagna L. Giant cell arteritis restricted to the limb arteries: An overlooked clinical entity. Autoimmun Rev 2015; 14:352-7. [DOI: 10.1016/j.autrev.2014.12.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 12/10/2014] [Indexed: 12/19/2022]
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Abstract
Large vessel vasculitis (LVV) covers a spectrum of primary vasculitides predominantly affecting the aorta and its major branches. The two main subtypes are giant cell arteritis (GCA) and Takayasu arteritis (TA). Less commonly LVV occurs in various other diseases. Clinical manifestations result from vascular stenosis, occlusion, and dilation, sometimes complicated by aneurysm rupture or dissection. Occasionally LVV is discovered unexpectedly on pathological examination of a resected aortic aneurysm. Clinical evaluation is often unreliable in determining disease activity. Moreover, the diagnostic tools are imperfect. Acute phase reactants can be normal at presentation and available imaging modalities are more reliable in delineating vascular anatomy than in providing reliable information on degree of vascular inflammation. Glucocorticoids are the mainstay of therapy of LVV. Patients may develop predictable adverse effects from long-term glucocorticoid use. Several steroid-sparing agents have also shown some promise and are currently in use. Endovascular revascularization procedures and open surgical treatment for aneurysms and dissections are sometimes necessary, but results are not always favorable and relapses are common. This article, the first in a series of two, will be devoted to GCA and isolated (idiopathic) aortitis, while TA will be covered in detail in the next article.
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78
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Le K, Bools LM, Lynn AB, Clancy TV, Hooks WB, Hope WW. The effect of temporal artery biopsy on the treatment of temporal arteritis. Am J Surg 2015; 209:338-41. [DOI: 10.1016/j.amjsurg.2014.07.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 07/18/2014] [Accepted: 07/24/2014] [Indexed: 11/24/2022]
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Klink T, Geiger J, Both M, Ness T, Heinzelmann S, Reinhard M, Holl-Ulrich K, Duwendag D, Vaith P, Bley TA. Giant Cell Arteritis: Diagnostic Accuracy of MR Imaging of Superficial Cranial Arteries in Initial Diagnosis—Results from a Multicenter Trial. Radiology 2014; 273:844-52. [DOI: 10.1148/radiol.14140056] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- Jonathan H. Smith
- Kentucky Neuroscience Institute; University of Kentucky; Lexington KY USA
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81
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Abstract
Temporal artery biopsy is considered the gold standard investigation of giant cell arteritis and is recommended in suspected cases despite a sensitivity of 81-91%. This review highlights the potential risk of facial nerve injury during temporal artery biopsy and introduces recent advances in the emerging role of imaging modalities. When these non-invasive techniques are used in conjunction with American College of Rheumatology scoring, which includes clinical features and biochemical test results, temporal artery biopsy may be avoided in selected cases.
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82
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The diagnosis and classification of giant cell arteritis. J Autoimmun 2014; 48-49:73-5. [PMID: 24461386 DOI: 10.1016/j.jaut.2014.01.017] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/13/2013] [Indexed: 11/22/2022]
Abstract
Giant-cell arteritis (GCA) involves the major branches of the aorta with predilection for the extracranial branches of the carotid artery. It occurs in individuals older than 50 years and the incidence increases with age. The signs and symptoms of giant cell arteritis can be classified into four subsets: cranial arteritis, extracranial arteritis, systemic symptoms and polymyalgia rheumatica. Patients may develop any combination of these manifestations, associated with laboratory evidence of an acute-phase reaction. The only test that confirms GCA diagnosis is a temporal artery biopsy, showing vasculitis with mononuclear cell inflammatory infiltrates, often with giant cells. Due to the focal and segmental nature of the infiltrates, areas of inflammation may be missed by the biopsy and the histological examination is normal in about 15% of the cases. Some imaging modalities may aid in the diagnosis of GCA. Among those, color duplex ultrasonography of the temporal arteries is more commonly used. There are no independent validating criteria to determine whether giant cell arteritis is present when a temporal artery biopsy is negative. The American College of Rheumatology criteria for the classification of giant cell arteritis may assist in the diagnosis. However, meeting classification criteria is not equivalent to making the diagnosis in individual patients, and the final diagnosis should be based on all clinical, laboratory, imaging and histological findings. Glucocorticoids are the treatment of choice for GCA. The initial dose is 40-60 mg/day for most uncomplicated cases. Addition of low-dose aspirin (100 mg/d) has been shown to significantly decrease the rate of vision loss and stroke during the course of the disease.
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83
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Schallhorn J, Haug SJ, Yoon MK, Porco T, Seiff SR, McCulley TJ. A National Survey of Practice Patterns. Ophthalmology 2013; 120:1930-4. [DOI: 10.1016/j.ophtha.2013.01.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 12/19/2012] [Accepted: 01/24/2013] [Indexed: 10/26/2022] Open
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Design of the tocilizumab in giant cell arteritis trial. Int J Rheumatol 2013; 2013:912562. [PMID: 23653652 PMCID: PMC3638687 DOI: 10.1155/2013/912562] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/12/2013] [Indexed: 01/05/2023] Open
Abstract
Overview. The GiACTA trial is a multicenter, randomized, double-blind, and placebo-controlled study designed to test the ability of tocilizumab (TCZ), an interleukin (IL)-6 receptor antagonist, to maintain disease remission in patients with giant cell arteritis (GCA). Design. Approximately 100 centers will enroll 250 patients with active disease. The trial consists of a 52-week blinded treatment phase followed by 104 weeks of open-label extension. Patients will be randomized into one of four groups. Group A (TCZ 162 mg weekly plus a 6-month prednisone-taper); group B (TCZ 162 mg every other week plus a 6-month prednisone-taper); group C (placebo plus a 6-month prednisone-taper); and group D (placebo plus a 12-month prednisone taper). We hypothesize that patients assigned to TCZ in addition to a 6-month prednisone course are more likely to achieve the primary efficacy endpoint of sustained remission (SR) at 52 weeks compared with those assigned to a 6-month prednisone course alone, thus potentially minimizing the long-term adverse effects of corticosteroids. Conclusion. GiACTA will test the hypothesis that interference with IL-6 signaling exerts a beneficial effect on patients with GCA. The objective of this paper is to describe the design of the trial and address major issues related to its development.
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Abstract
Although it varies from center to center, the frequency of temporal artery biopsy in patients suspected of having temporal arteritis (TA) is relatively small. Most commonly, patients suspected of having TA are placed on prednisone for varying periods of time, and if symptoms disappear or lessen the diagnosis is made. During a recent 13-year period at Baylor University Medical Center at Dallas, 15 patients with TA had the diagnosis of TA confirmed by histological examination of a biopsy of one temporal artery. The length of the biopsied artery varied from 0.7 to 5.5 cm (mean 2.7). The 15 patients ranged in age from 68 to 94 years (mean 82, median 85), and 11 (73%) were women. In 13 of the 15 patients (87%), the lumen of the temporal artery was narrowed >95% in cross-sectional area by the panarteritis, and the temporal artery was associated with giant cells in 11 patients (73%). Large collections of erythrocytes were present in the inflamed arterial walls in 5 patients (33%). All 15 patients were treated with varying doses of prednisone with favorable response in each. Eight patients (53%) died from 1 to 105 months (mean 52, median 57) after biopsy of the temporal artery. We have neither positive nor negative evidence that the TA played a role in the patients' death. Despite the present study and numerous others in the last 70 years, the cause of TA remains a mystery.
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Affiliation(s)
- William C Roberts
- Baylor Heart and Vascular Institute (Roberts, Zafar, Ko) and the Departments of Pathology and Internal Medicine (Division of Cardiology) (Roberts), Baylor University Medical Center at Dallas
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Jakobsson K, Jacobsson L, Warrington K, Matteson EL, Turesson C. Biopsy findings in giant cell arteritis: relationship to baseline factors and corticosteroid treatment. Scand J Rheumatol 2013; 42:331-2. [DOI: 10.3109/03009742.2013.775330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Joshua F. Ultrasound applications for the practicing rheumatologist. Best Pract Res Clin Rheumatol 2013; 26:853-67. [PMID: 23273796 DOI: 10.1016/j.berh.2012.10.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 10/12/2012] [Indexed: 02/07/2023]
Abstract
Musculoskeletal ultrasound is an increasingly used tool for the evaluation and management of rheumatologic diseases. Its utilisation by rheumatologists is varied around the world and is dependent upon training and local expertise. Its applications can be broadly categorised into three main areas; for the education of patients, to aid the rheumatologist in the diagnosis and monitoring of disease, and therapeutically for joint aspiration and injection. Ultrasound is a safe, portable, easily repeatable, dynamic images in multiple planes and cheap form of imaging. Ultrasound however, is operator dependent and has a number of artefacts that can result in misinterpretation. Musculoskeletal Ultrasound uses a number of modes to characterise joint pathology, including grey scale, colour and power Doppler, spectral Doppler, 3D imaging, elastography. Musculoskeletal ultrasound can detect and monitor multiple joint pathologies including synovitis, tenosynovitis, and tendon pathologies, entheseal processes, bone erosions and osteophytes, cartilage changes and bursal pathologies.
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Unizony S, Arias-Urdaneta L, Miloslavsky E, Arvikar S, Khosroshahi A, Keroack B, Stone JR, Stone JH. Tocilizumab for the treatment of large-vessel vasculitis (giant cell arteritis, Takayasu arteritis) and polymyalgia rheumatica. Arthritis Care Res (Hoboken) 2013; 64:1720-9. [PMID: 22674883 DOI: 10.1002/acr.21750] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The interleukin-6 pathway is up-regulated in giant cell arteritis (GCA), Takayasu arteritis (TA), and polymyalgia rheumatica (PMR). We retrospectively assessed the outcomes of 10 patients with relapsing/refractory GCA, TA, or PMR treated with tocilizumab (TCZ). METHODS Patients with GCA (n = 7), TA (n = 2), and PMR (n = 1) received TCZ. Seven subjects had failed at least 1 second-line agent. The outcomes evaluated were symptoms of disease activity, inflammatory markers, ability to taper glucocorticoids, and cross-sectional imaging when indicated clinically. RESULTS The mean followup time of this cohort since diagnosis was 27 months (range 16-60 months). The patients were treated with TCZ for a mean period of 7.8 months (range 4-12 months). Before TCZ therapy, the patients experienced an average of 2.4 flares/year. All patients entered and maintained clinical remission during TCZ therapy. The mean daily prednisone dosages before and after TCZ initiation were 20.8 mg/day (range 7-34.3 mg/day) and 4.1 mg/day (range 0-10.7 mg/day), respectively (P = 0.0001). The mean erythrocyte sedimentation rate declined from 41.5 mm/hour (range 11-68 mm/hour) to 7 mm/hour (range 2.2-11.3 mm/hour; P = 0.0001). The adverse effects of TCZ included mild neutropenia (n = 4) and transaminitis (n = 4). One patient flared 2 months after TCZ discontinuation. An autopsy on 1 patient who died from a postoperative myocardial infarction following elective surgery revealed persistent vasculitis of large and medium-sized arteries. CONCLUSION TCZ therapy led to clinical and serologic improvement in patients with refractory/relapsing GCA, TA, or PMR. The demonstration of persistent large-vessel vasculitis at autopsy of 1 patient who had shown a substantial response requires close scrutiny in larger studies.
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Affiliation(s)
- S Unizony
- Massachusetts General Hospital, Boston, USA
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89
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Abstract
Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are inflammatory diseases that typically affect white individuals >50 years. Women are affected ∼2-3 times more often than men. PMR and GCA occur together more frequently than expected by chance. The main symptoms of PMR are pain and stiffness in the shoulders, and often in the neck and pelvic girdle. Imaging studies reveal inflammation of joints and bursae of the affected areas. GCA is a large-vessel and medium-vessel arteritis predominantly involving the branches of the aortic arch. The typical clinical manifestations of GCA are new headache, jaw claudication and visual loss. PMR and GCA usually remit within 6 months to 2 years from disease onset. Some patients, however, have a relapsing course and might require long-standing treatment. Diagnosis of PMR and GCA is based on clinical features and elevated levels of inflammatory markers. Temporal artery biopsy remains the gold standard to support the diagnosis of GCA; imaging studies are useful to delineate large-vessel involvement in GCA. Glucocorticoids remain the cornerstone of treatment of both PMR and GCA, but patients with GCA require higher doses. Synthetic immunosuppressive drugs also have a role in disease management, whereas the role of biologic agents is currently unclear.
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90
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Borchers AT, Gershwin ME. Giant cell arteritis: A review of classification, pathophysiology, geoepidemiology and treatment. Autoimmun Rev 2012; 11:A544-54. [DOI: 10.1016/j.autrev.2012.01.003] [Citation(s) in RCA: 177] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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91
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Schmidt J, Warrington KJ. Polymyalgia rheumatica and giant cell arteritis in older patients: diagnosis and pharmacological management. Drugs Aging 2012; 28:651-66. [PMID: 21812500 DOI: 10.2165/11592500-000000000-00000] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Giant cell arteritis (GCA) is an inflammatory vasculopathy that involves large- and medium-sized arteries and can cause vision loss, stroke and aneurysms. GCA occurs in people aged >50 years and is more common in women. A higher incidence of the disease is observed in populations from Northern European countries. Polymyalgia rheumatica (PMR) is a periarticular inflammatory process manifesting as pain and stiffness in the neck, shoulders and pelvic girdle. PMR shares the same pattern of age and sex distribution as GCA. The pathophysiology of PMR and GCA is not completely understood, but the two conditions may be related and often occur concurrently. A delay in the diagnosis should be avoided because of the risk of vascular ischaemic complications due to GCA. The diagnosis should be considered in patients aged >50 years presenting with symptoms such as new headache, visual disturbances, jaw claudication or symptoms of PMR. GCA can also present as a systemic inflammatory syndrome with fever of unknown origin. Marked elevation of acute-phase reactants, recognizable in higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, is often seen in both PMR and GCA. However, some patients can present with a normal ESR. Confirmation of the diagnosis of GCA by temporal artery biopsy is important because clinical findings and laboratory tests are not specific, and because a diagnosis of GCA commits patients to long-term treatment with corticosteroids. The role of imaging techniques for the diagnosis of GCA remains unclear, but these modalities can be helpful in assessing the extent of vascular involvement, especially when extra-cranial disease is present. In PMR, subdeltoid and subacromial bursitis can be identified by imaging techniques, especially ultrasound or MRI. The clinical manifestations of GCA and PMR respond dramatically within 12-48 hours of starting corticosteroid treatment. The initial corticosteroid dosage commonly used in GCA is oral prednisone 40-60 mg/day, and for patients with PMR a dosage of 15-20 mg/day is often sufficient. A prolonged course of treatment is necessary, and corticosteroids are gradually tapered, guided by regular clinical evaluation and ESR (and/or CRP) measurement. Methotrexate is the best studied corticosteroid-sparing agent in GCA, and may be useful for patients with frequent disease relapses and/or corticosteroid-related toxicity. Retrospective studies favour aspirin (acetylsalicylic acid) as an effective adjuvant treatment for reducing the ischaemic complications of GCA. The long-term course of corticosteroid therapy frequently exposes elderly patients with PMR/GCA to various adverse effects, which can be attenuated with appropriate prophylactic measures. Co-morbid diseases and polypharmacy can pose particular challenges in the geriatric population. In general, the life expectancy of patients with GCA does not appear to be shortened, whereas the morbidity associated with the disease and its treatment is well recognized.
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Affiliation(s)
- Jean Schmidt
- Department of Internal Medicine and RECIF, Amiens University Hospital, France
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Goslin BJ, Chung MH. Temporal Artery Biopsy as a Means of Diagnosing Giant Cell Arteritis: Is There Over-Utilization? Am Surg 2011. [DOI: 10.1177/000313481107700927] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Temporal artery biopsy (TAB) is often recommended for patients suspected of having temporal arteritis. The sensitivity of TAB varies widely and is dependent upon a number of factors (e.g., number of biopsy specimens, corticosteroid pretreatment, specimen length). The purpose of this study was to determine the clinical utility of TAB in patients who are suspected of having giant cell arteritis (GCA). A retrospective review of patients who underwent TAB at Spectrum Health from January 1, 1998 to December 31, 2007 was performed. Forty-seven patients, ranging in age from 25 to 87 years (mean: 70.7 years), underwent 53 TABs. Females accounted for 72.3 per cent of the subjects. Positive biopsy results showing signs of GCA were obtained in 38.3 per cent of patients. Of patients who underwent biopsy, 78 per cent could have been excluded from the procedure based upon individual diagnostic criteria. Positive and negative biopsies had average lengths of 1.84 cm and 1.29 cm, respectively ( P < 0.05). In the community hospital setting, patients suspected of having GCA are frequently recommended to undergo unnecessary TAB. We advocate for more careful selection of patients to undergo this diagnostic surgical procedure. In cases where TAB is needed, we recommend a biopsy length of > 2 cm to increase the accuracy of diagnosis.
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Affiliation(s)
- Brent J. Goslin
- Michigan State University-College of Human Medicine, East Lansing, Michigan
- Grand Rapids Medical Education and Research Center/Michigan State University, General Surgery Residency, Grand Rapids, Michigan
| | - Mathew H. Chung
- Michigan State University-College of Human Medicine, East Lansing, Michigan
- Grand Rapids Medical Education and Research Center/Michigan State University, General Surgery Residency, Grand Rapids, Michigan
- Spectrum Health, Grand Rapids, Michigan
- Michigan Medical, P.C., Grand Rapids, Michigan
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94
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[Therapy of vasculitides: according to recommendations of the European League Against Rheumatism (EULAR) and European Vasculitis Study Group (EUVAS)]. Internist (Berl) 2011; 52:671-81. [PMID: 21512793 DOI: 10.1007/s00108-010-2772-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The stringent definition of disease and activity stage as well as the performance of several controlled trials in the field of vasculitis in the past years now enables an evidence-based stage and activity adapted treatment, especially for ANCA-associated vasculitides. On the basis of available controlled trials, the European League Against Rheumatism (EULAR) and European Vasculitis Study Group (EUVAS) established and published recommendations for the management of vasculitides. This manuscript summarizes the treatment recommendations published in 2009 and highlights new studies which have been published since then.
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95
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Abstract
This article reviews the ophthalmic manifestations of giant cell arteritis. An overview of giant cell arteritis as a disease spectrum is presented with special emphasis on the ophthalmic involvement.
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Affiliation(s)
- Salman Waqar
- Department of Ophthalmology, Torbay General Hospital, Torbay
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96
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BELILOS ELISE, MADDOX JUDY, KOWALEWSKI ROBERTM, KOWALEWSKA JOLANTA, TURI GEORGEK, NOCHOMOVITZ LUCIENE, KHAN YAQOOT, CARSONS STEVENE. Temporal Small-Vessel Inflammation in Patients with Giant Cell Arteritis: Clinical Course and Preliminary Immunohistopathologic Characterization. J Rheumatol 2010; 38:331-8. [DOI: 10.3899/jrheum.100455] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To investigate the occurrence, clinical correlates, and immunohistochemical phenotype of temporal small-vessel inflammation (TSVI) in temporal artery biopsies from patients presenting with clinical features of giant cell arteritis (GCA).Methods.We retrospectively reviewed 41 temporal artery biopsy specimens for the presence of inflammatory infiltrates in small vessels external to the temporal artery adventitia (TSVI); 33 had sufficient clinical and pathological data for detailed analysis. Clinical and laboratory features at presentation and corticosteroid treatment patterns of patients with isolated TSVI were compared to those of patients with positive and negative biopsies. The cellular composition of the infiltrates was further characterized by immunohistochemistry.Results.Twenty-three (70%) specimens had evidence of TSVI including 10 with concurrent GCA and 13 (39%) with isolated TSVI. TSVI was found in all positive temporal artery biopsies. The proportion of macrophages and of lymphocyte subpopulations differed between infiltrates observed in TSVI and those of the main temporal artery wall. Initial erythrocyte sedimentation rate (ESR) was similar in the TSVI and positive biopsy groups and was significantly higher than in the negative biopsy group. Patients with isolated TSVI more often had symptoms of polymyalgia rheumatica compared to the positive biopsy group. Patients with TSVI received corticosteroid doses that were intermediate between patients with positive and those with negative biopsies.Conclusion.A significant number of patients with clinical features of GCA demonstrated isolated TSVI. Differences in the clinical presentation and cellular composition suggest that TSVI may represent a subset of GCA and should be considered in the interpretation of temporal artery biopsies and treatment decisions.
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97
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Holle JU, Bley T, Gross WL. [Classification and therapy of vasculitis according to recommendations of the European League Against Rheumatism (EULAR)]. Radiologe 2010; 50:846-54. [PMID: 20717646 DOI: 10.1007/s00117-010-2000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Vasculitis is still being classified according the criteria of the American College of Rheumatology and the Chapel Hill Consensus Conference Definitions. Diagnostic criteria are currently being established. The classification criteria are based on the size of the inflamed blood vessel (e.g. large vessel vasculitis with inflammation of the aorta and its branches), clinical symptoms and findings (such as cephalalgia in giant cell arteritis) and histological findings. In recent years a definition of disease stages and activity has been established and a number of controlled trials have been carried out in order to provide evidence-based stage and activity adapted therapy regimens. Recommendations for the management of vasculitis have been published in 2009 by EULAR (European League Against Rheumatism). This article gives a review of the classification of vasculitis and summarizes the current European guidelines on management.
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Affiliation(s)
- J U Holle
- Klinik für Rheumatologie und Klinische Immunologie, Klinikum Bad Bramstedt, Oskar-Alexander-Str. 26, 24576, Bad Bramstedt, Deutschland.
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98
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Rieck KL, Kermani TA, Thomsen KM, Harmsen WS, Karban MJ, Warrington KJ. Evaluation for clinical predictors of positive temporal artery biopsy in giant cell arteritis. J Oral Maxillofac Surg 2010; 69:36-40. [PMID: 20674120 DOI: 10.1016/j.joms.2010.02.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 10/04/2009] [Accepted: 02/12/2010] [Indexed: 11/15/2022]
Abstract
PURPOSE To examine the clinical predictors of a positive temporal artery biopsy (TAB) among patients suspected of having giant cell arteritis. PATIENTS AND METHODS We conducted a retrospective study of all consecutive patients who underwent TAB by a single surgeon (K.L.R.) at the Department of Oral Maxillofacial Surgery from April 30, 2002, to June 29, 2006. The medical records were reviewed for the clinical symptoms, laboratory findings, biopsy results, and final diagnosis. The variables of interest as predictors of positive biopsy findings were analyzed using logistic regression analysis. RESULTS During the study period, 82 patients underwent TAB. Histologic evidence of arteritis was present in 22 patients (26.8%). Two (2.4%) were diagnosed with giant cell arteritis clinically but had negative TAB findings. The patients presenting with weight loss or jaw claudication were more likely to have a positive TAB finding (odds ratio 4.50, 95% confidence interval 1.45 to 13.93; and odds ratio 3.71, 95% confidence interval 1.28 to 10.76, respectively). No laboratory findings were predictive of a positive TAB finding. Prednisone use before TAB also was not associated with a decreased likelihood of a positive finding. CONCLUSIONS Patients suspected of having giant cell arteritis were more likely to have a positive TAB finding if they presented with weight loss or jaw claudication. In the present series, corticosteroid therapy before biopsy did not affect the rate of positive TAB findings.
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Affiliation(s)
- Kevin L Rieck
- Division Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
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99
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Abstract
Inflammatory diseases of blood vessels can occur in any part of the vascular system with a variety of clinical and histopathological manifestations. Possible etiologies include primary systemic vasculitis, secondary vasculitis or isolated single organ vasculitis. Key criteria of morphological vasculitis work-up are vessel size, type of inflammation (granulomatous, necrotizing and/or leukocytoclastic) as well as presence or absence of immune complexes and extravascular inflammatory changes. Together with the typical organ involvement and serological data, these criteria constitute the basis of vasculitis classification. A histopathologically confirmed biopsy is the gold standard for a diagnosis of vasculitis, although a definite diagnosis can frequently not be made solely on histopathological grounds. Differential diagnostic overlaps and possible ways of discrimination are presented. In many cases, however, histopathology can only provide a definite diagnosis in combination with clinical and serological data. A conclusive morphological diagnosis depends on the right time of biopsy and selection of appropriate biopsy material.
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Affiliation(s)
- K Holl-Ulrich
- Institut für Pathologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany.
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100
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Holl-Ulrich K, Noack F, Feller AC. [Vasculitis: histopathology and differential diagnosis]. Z Rheumatol 2009; 68:320-8. [PMID: 19337743 DOI: 10.1007/s00393-008-0402-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A histopathologically confirmed biopsy is the gold standard for the diagnosis of vasculitis. Possible etiologies include primary systemic vasculitis, secondary vasculitis or isolated single organ vasculitis, although on histopathological grounds alone a clear differentiation is frequently not possible. The key criteria of morphological vasculitis work-up include vessel size, type of inflammation (granulomatous, necrotizing and/or leukocytoclastic) as well as the presence or absence of immune complexes and extravascular inflammatory changes. Together with the typical organ involvement and serological data, these criteria constitute the basis of vasculitis classification. Differential diagnostic overlaps and possible discrimination methods are presented. In the same way that the clinical approach of vasculitis patients is an interdisciplinary one, histopathology can only provide a definite diagnosis in combination with clinical and serological data. A conclusive morphological diagnosis depends on the right time of biopsy and the selection of appropriate biopsy material.
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Affiliation(s)
- K Holl-Ulrich
- Referenzzentrum für Vaskulitis-Diagnostik, Institut für Pathologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany.
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