The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis

Population-Based Performance of Inflammatory Markers in Giant Cell Arteritis

OBJECTIVE

To determine the population-based sensitivities and specificities of various inflammatory markers for the diagnosis of GCA.

DESIGN

Retrospective population-based cross-sectional study.

PARTICIPANTS

Patients who underwent temporal artery biopsy (TAB) from 01/01/1995 through 12/31/2019 in Olmsted County, Minnesota were identified using the Rochester Epidemiology Project (REP). Subjects were categorized as GCA or non-GCA using the 1990 American College of Rheumatology classification criteria for GCA.

TESTING

Sensitivity and specificity of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and platelets for a positive GCA diagnosis were calculated.

MAIN OUTCOME MEASURES

GCA diagnosis.

RESULTS

There were 553 patients who underwent TAB, 143 with GCA and 410 without GCA. Median age at time of TAB was 75 years (IQR 69-81) and 372 (67%) were female. Patients with GCA had higher CRP (91.1 vs 49.1 mg/L, P < .001), ESR (66.4 vs 52.0 mm/hr, P < .001), and platelets (370.5 vs 283.1 × 109/L, P < .001) than patients in the non-GCA cohort. Sensitivity was 96% for CRP, 80% for ESR, and 49% for platelets. Specificity was 21% for CRP, 43% for ESR, and 79% for platelets. Combined ESR and CRP had a sensitivity of 77% and specificity of 54% while combined ESR, CRP, and platelets had a sensitivity of 41% and specificity of 84%. Normal inflammatory markers, including ESR, CRP, and platelets, were observed in 2 (3%) GCA patients.

CONCLUSIONS

This population-based study evaluated the performance of various inflammatory markers in the diagnosis of GCA. Inflammatory markers are helpful in the diagnosis of GCA, but normal values do not exclude the diagnosis.

Cerebrovascular accidents in giant cell arteritis: prevalence and predictive factors from the ARTESER registry

OBJECTIVE

To determine the prevalence and predictive factors of cerebrovascular accidents (CVA) in GCA.

METHODS

ARTESER is a large Spanish multicentre registry including patients with GCA from across the entire country diagnosed between June 2013 and March 2019 and sponsored by the Spanish Society of Rheumatology. The variables collected at diagnosis were demographics, clinical manifestations (including the occurrence and location of CVA), laboratory, histology and imaging findings. Patients with and without CVA were compared in a bivariate analysis. Multivariate logistic regression was performed to determine potential predictive factors of CVA.

RESULTS

A total of 1540 patients with GCA were included for analysis (mean age 77.1 years, 70% females). CVA occurred in 61 (3.96%), of whom 38 (62.3%) involved the vertebrobasilar territory and 21 (34.4%) the carotid territory. The factors associated with CVA were the occurrence of transient ischaemic attack (TIA) [odds ratio (OR) 8.63; 95% CI 2.877-25.86], large vessel (LV) involvement (OR 2.79; 95% CI 1.421-5.465) and the presence of concomitant visual manifestations (OR 2.73; 95% CI 1.427-5.235). The risk of death during follow-up was significantly higher in patients with CVA (18% vs 8.8%; P = 0.014). Patients with CVA received significantly higher mean prednisone (mg) dose at diagnosis (433.9 vs 216; P < 0.001) and cumulative prednisone dose during follow-up (11 203.9 vs 8,194.1; P < 0.001).

CONCLUSION

The prevalence of CVA in patients with GCA is low, but increases the risk of mortality. The presence of TIA, LV involvement and visual manifestations are factors associated with increased risk of CVA.

The clinical characteristics and significance of novel inflammatory biomarkers in patients with polymyalgia rheumatica: A single-center study from China

OBJECTIVE

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disorder predominantly affecting older adults, characterized by proximal muscle pain and stiffness. The prevalence of PMR in Chinese population is relatively low comparing to European population, resulting in limited research regarding its clinical manifestations and serological characteristics among Chinese patients. We aimed to analyse the features of Chinese patients with PMR and explore the significance of novel inflammatory biomarkers.

METHODS

We retrospectively collected the medical data of hospitalized patients diagnosed with PMR at Peking University People's Hospital between 1992 and 2022. Electronic medical records were reviewed. We analyzed the clinical and laboratory characteristics of patients with PMR, and explored new inflammatory markers.

RESULTS

A total of 87 patients were included in the study, with a male-to-female ratio of 1:2.6. The most common clinical manifestation was shoulder girdle pain (96.6 %), followed by pelvic girdle pain (89.7 %), cervical spine pain (63.2 %), morning stiffness (48.3 %), and lumbar spine pain (40.2 %). Cervical spine pain was more common in female patients than in male patients. 12 out of 87 (13.8 %) patients with PMR were complicated with giant cell arteritis (GCA). Anorexia was more commonly seen in patients with GCA (P = 0.024). IL-6 was the most frequently elevated cytokine and was significantly associated with fever. The systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) were correlated with C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

CONCLUSION

Shoulder girdle and pelvic girdle pain were the most common manifestations of PMR. 13.8 % of the patients had concurrent GCA. Elevated levels of IL-6 were significantly correlated with fever, indicating that IL-6 may contribute to the systemic inflammation of PMR. SII, NLR and PLR were positively associated with the levels of ESR and CRP, suggesting that these novel markers are promising inflammatory markers in patients with PMR.

Arterial and venous thrombosis in systemic and monogenic vasculitis

Systemic vasculitis, common forms of which include anti-neutrophil cytoplasmic antibody-associated small-vessel vasculitis, large-vessel vasculitis and Behçet syndrome, are frequently complicated by arterial or venous thrombotic events (AVTEs). Newly identified entities such as DADA2 (deficiency of adenosine deaminase 2) and VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, which are driven by genetic mutations, also exhibit vasculitic features and are associated with a high risk of AVTEs. AVTEs in systemic vasculitis, including monogenic forms of vasculitis, are due to the complex interaction of inflammation and coagulation. New insights into the pathogenetic mechanisms implicate endothelial dysfunction, immune complex deposition and the interplay of pro-inflammatory cytokines with prothrombotic factors, which collectively promote thrombus formation. AVTEs impose a substantial disease burden, complicate diagnosis and negatively affect prognosis by increasing the risk of morbidity and mortality. Early diagnosis and treatment are crucial to prevent lasting damage. Management strategies should target both thrombosis and underlying inflammation. Antithrombotic therapies, including low-dose aspirin, or oral anticoagulants should be used on the basis of individual thrombotic risk assessment. Immunosuppressive therapy is the cornerstone of treatment for arterial and venous thrombosis, particularly in Behçet syndrome, in which vascular inflammation has a crucial role in thrombotic complications.

Tissue degrading and remodelling molecules in giant cell arteritis

OBJECTIVES

GCA is a granulomatous vasculitis affecting large vessels, leading to intimal occlusion accompanied by the accumulation of myofibroblasts. Histopathologically, GCA is characterized by destruction of the tunica media and hypertrophy of the intima with invasion of activated CD4+ T cells, macrophages and multinucleated giant cells (MNGCs). Despite these well-defined histopathological features, the molecular pathology of GCA has largely remained elusive. We aimed to characterize the pathologic features of GCA at the molecular level.

METHODS

To identify key molecules involved in GCA pathogenesis, we conducted genome-wide gene expression profiling on arterial lesions obtained through temporal artery biopsy of 16 patients who had not received any prior treatment. The resulting data were examined to reveal specific pathways and genes, and some of the molecules were followed up by immunohistochemistry.

RESULTS

Our analysis revealed a unique gene expression pattern in GCA lesions, including enrichment of immune cells and phagocytic pathways related to microglia and osteoclasts. Subsequent immunohistochemistry analysis identified the presence of MMP12 (macrophage elastase), HLA-DRA, and phagocytosis- and osteoclast-associated molecules in infiltrating macrophages and MNGCs. Additionally, we discovered LRRC15-expressing cells in the tunica intima, suggesting a myofibroblast subpopulation that suppresses cytotoxic CD8+ T cells. These molecules were upregulated in other granulomatous diseases affecting not only arteries but also lymph nodes.

CONCLUSION

Our study revealed novel molecules associated with the pathological features of GCA, providing a foundation for better understanding of GCA pathogenesis and development of targeted therapeutic strategies.

Tocilizumab in cranial and extracranial giant cell arteritis: a national multicentre study of 471 cases

OBJECTIVE

The spectrum of GCA includes various vascular phenotypes. Tocilizumab (TCZ) is the only biologic therapy currently approved, regardless of phenotype. We aimed to assess the effectiveness of TCZ in various phenotypes.

METHODS

This is a multicentre observational study of GCA patients treated with TCZ. They were divided into three phenotypes: (i) cranial (cGCA), (ii) extracranial GCA (ecGCA) and (iii) mixed GCA (mixGCA). Outcomes included clinical remission, EULAR complete remission, relapses, absence of inflammation as shown using imaging techniques, and safety.

RESULTS

We studied 471 patients (342 women; mean age 74.0 ± 9.0 years). The phenotypic distribution was: cGCA (n = 217; 46%), mixGCA (174; 37%) and ecGCA (80; 17%). Patients with ecGCA were younger (66.5 ± 10.1 years) than those with cGCA (74.8 ± 8.1) and those with mixGCA (71.4 ± 8.5), and had a longer delayed GCA diagnosis {median [interquartile range (IQR) [6 (1-14)] vs 1 (1-3) vs 2 (1-6) months, respectively}. Systemic manifestations were similar in the three groups, while ischaemic manifestations were more frequent in cGCA. Combined TCZ, in addition to glucocorticoids, was used more frequently in ecGCA (36%). Clinical remission was observed in 51%/43%/47% in cGCA/ecGCA/mixGCA, respectively, after the first month, and in 79%/81%/89% after 24 months. Complete EULAR remission in 35%/27%/28% (after 1 month) and 72%/73%/67% (after 24 months). Absence of inflammation being shown in the imaging techniques was 15%/26% after 12 months, and 22%/7% (ecGCA/mixGCA) (after 24 months). Relevant adverse events were observed in 109 (23.1%) patients.

CONCLUSION

TCZ shows rapid and maintained effectiveness in all GCA phenotypes in clinical remission and EULAR complete remission. By contrast, absence of inflammation as shown using imaging techniques was much lower in ecGCA and mixGCA.

Soluble Co-Inhibitory Immune Checkpoint Molecules Are Increased in Patients With Polymyalgia Rheumatica Without Significant Correlations With Clinical Status: A Case-Control Study

OBJECTIVE

A dysregulated immune response is involved in the pathogenesis of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). These diseases have been reported as immune-related adverse events in patients with cancer treated with immune checkpoints inhibitors. In this cross-sectional study, the relationship between soluble immune checkpoint molecules (sICMs) and clinical/imaging features of PMR and GCA was investigated.

METHODS

Consecutive patients with PMR diagnosed according to the criteria by Bird et al were compared with age- and sex-matched healthy controls. Patients with PMR and overlapping GCA had to also satisfy the 1990 ACR classification criteria for GCA. All patients underwent standardized clinical, laboratory examination, and 18F-fluorodeoxyglucose positron emission tomography/computed tomography scans. The sICM anticytotoxic T Ly-4, the programmed cell death protein 1 (PD-1), and PD-1 ligands PD-L1 and PD-L2 were measured by enzyme-linked immunosorbent assay.

RESULTS

Forty patients (80% women, mean age 76 years, and mean disease duration 88 days) were assessed. Of these, 30 had isolated PMR and 10 had PMR with GCA. Patients showed significantly higher concentrations of all sICMs compared with controls (P < 0.001). Conditional logistic regression revealed the strong discriminative capacity of these molecules between patients and healthy controls, with PD-1 showing complete separation among groups (effect size = 0.78) and PD-L1 (odds ratio [OR] 134.33, P < 0.001) and PD-L2 (OR 63.00, P < 0.001) demonstrating the strongest ability to distinguish patients from controls. Correlations between sICM levels and clinical features were generally weak or absent, with no significant differences based on disease phenotype or glucocorticoid exposure. Results were similar in glucocorticoid-naive patients.

CONCLUSION

sICMs are significantly elevated in PMR and GCA and strongly differentiate patients from healthy controls. Although they do not correlate with clinical or imaging features, their consistent elevation in active disease might suggest a complex interplay between innate and adaptive immunity.

Sustained drug-free remission in giant cell arteritis

OBJECTIVES

The objectives of this study were to evaluate the frequency and timing of sustained drug-free remission (SDFR) in patients with GCA and to identify potential predictive factors of this outcome.

METHODS

A retrospective review of all patients included in the large Spanish multicentre registry for GCA (ARTESER) with at least 2 years of follow-up was undertaken. SDFR was defined as the absence of typical signs, symptoms, or other features of active GCA for ≥12 months after discontinuation of treatment.

RESULTS

We included 872 patients. Forty-seven percent had received concomitant treatment with tocilizumab and/or immunosuppressants, mainly MTX. SDFR was achieved in 21.2% (185/872) of the patients. The cumulative rates of patients achieving SDFR at 2, 3 and 4 years were 6.3%, 20.5% and 25.3%, respectively. Patients who achieved SDFR could reduce their prednisone dosage to 10 mg/day (P = 0.090) and 5 mg/day (P = 0.002) more quickly than those who did not. Relapses were less frequent in patients with SDFR (P = 0.006). The presence of relapses [incident rate ratio (IRR): 0.492, P < 0.001] and the need for i.v. methylprednisolone boluses at diagnosis (IRR: 0.575, P = 0.003) were significantly associated with a decreased likelihood of achieving SDFR. Only 5 patients (2.7%) experienced a recurrence, with a median onset of 19 months after achieving SDFR (interquartile range 25th-75th: 14-35 months).

CONCLUSION

Within 3-4 years of diagnosis, only one-quarter of patients with GCA successfully reached the SDFR. Once the SDFR was achieved, the likelihood of experiencing recurrence was low. Relapses and the need for glucocorticoid boluses appear to have been predictors of the need for long-term glucocorticoids.

Integration of transcriptome and immunophenotyping data highlights differences in the pathogenetic kinetics of B cells across immune-mediated disease

OBJECTIVE

To elucidate crucial immune cell subsets and associated immunological pathways by stratifying patients with immune-mediated diseases (IMDs) using immunophenotyping and transcriptomic approaches.

METHODS

We conducted flow cytometric and transcriptomic analyses in 23 immune cell subsets derived from 235 patients with six IMDs, using our database, utilizing our database, ImmuNexUT. Patients were stratified based on immunophenotyping data. Subsequently, we examined clinical and transcriptomic differences among these stratified clusters.

RESULTS

Patients with IMDs were stratified into two clusters based on their immunophenotypes. Cluster 1 was enriched with differentiated B cells, including unswitched memory B cells (USM B), switched memory B cells, double-negative B cells and plasmablasts, while cluster 2 was enriched with naïve B cells. Higher disease activity in rheumatoid arthritis and decreased respiratory functions in systemic sclerosis were observed in cluster 1, whereas the disease activity of systemic lupus erythematosus was higher in cluster 2. Numerous differentially expressed genes were detected in USM B. Cluster 1 was associated with glycosylation processes in USM B and elevated B cell-activating factor signalling from myeloid cells in B cells, while cluster 2 exhibited higher B-cell receptor signalling in USM B. Patients in cluster 2, which had an elevated age-associated B-cell signature, exhibited more frequent flares, suggesting that an increased proportion of naïve B cells with this signature is associated with poor prognosis.

CONCLUSION

Immunophenotyping-based clusters and transcriptome-based states revealed quantitative and qualitative differences in B cells. To predict IMD prognosis, assessing both the quantity and quality of naïve B cells may be crucial.

Validation of the 2022 ACR/EULAR classification criteria for giant cell arteritis in Korean patients with giant cell arteritis

OBJECTIVES

We applied the 2022 American College of Rheumatology (ACR)/European Alliance of Association for Rheumatology (EULAR) criteria to Korean patients previously diagnosed with giant cell arteritis (GCA) according to the 1990 ACR criteria and validated its clinical efficiency.

METHODS

Nine patients with GCA were included. The proportion of patients meeting each item of the 1990 ACR criteria and the 2022 ACR/EULAR criteria were assessed.

RESULTS

The median age was 65.0 years, and 77.8% of the patients were women. Seven (77.8%) patients had polymyalgia rheumatica. All nine patients were reclassified as having GCA according to the 2022 ACR/EULAR criteria. Among the 10 items of the 2022 ACR/EULAR criteria, the item contributing the most to the reclassification was elevated acute-phase reactant levels (100%), followed by new temporal headache (77.8%) and fluorodeoxyglucose positron emission tomography activity throughout the aorta (77.5%).

CONCLUSIONS

In this study, for the first time, we demonstrated a concordance rate of 100% between the two criteria in Korean patients previously diagnosed with GCA. Moreover, we also clarified the major contributors to the reclassification according to the 2022 ACR/EULAR criteria.

Ultrasonography-led multimodal diagnostic pathway for giant cell arteritis

OBJECTIVES

This study aims to establish the sensitivity and negative predictive value of a multimodal pathway incorporating ultrasonography, 18-fluorodeoxyglucose labelled PET-CT and temporal artery biopsy for the diagnosis of giant cell arteritis.

METHODS

In total, 1000 consecutive referrals for a new diagnosis of giant cell arteritis were analysed. All patients had a protocolized examination. Patients with a negative ultrasonography and a CRP of ≥20 mg/L received an extended ultrasound examination. If that was negative, and there was no other explanation for their presentation, a second test in the form of either a temporal artery biopsy or an 18-fluorodeoxyglucose labelled PET-CT was offered. We calculated the sensitivity and negative predictive value of the interventions for diagnosing giant cell arteritis.

RESULTS

279/1000 patients had positive ultrasonography for giant cell arteritis. 202 had bilateral superficial temporal arterial involvement. Ultrasonography of the axillary artery and other head/neck arteries increased the yield by 53 and 24 patients, respectively. 181 patients were referred for a second test. 24/139 temporal artery biopsies and 7/42 18-fluorodeoxyglucose labelled PET-CT scans were positive. The sensitivity and negative predictive value rise from 62.3% and 84.7%, respectively, for imaging superficial temporal arteries alone, to 95.7% and 98.0%, respectively, for extended ultrasonography plus a second test.

CONCLUSION

This is the first real-world evidence of the utility of ultrasonography for the diagnosis of giant cell arteritis as part of a multimodal diagnostic pathway.

Performance of EMA algorithm, 2022 ACR/EULAR criteria, and EMA-ACR/EULAR algorithm in classifying pediatric ANCA-associated vasculitis: a national cohort study in China

BACKGROUND

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a type of necrotizing vasculitis with poor prognosis, which is more severe in children. Classifying AAV patients may be helpful for diagnosis and management. However, present classification criteria for pediatric AAV are developed mainly based on adults, which have limitations in clinical practice. In this study, we introduced an updated algorithm based on the European Medicines Agency (EMA) algorithm in conjunction with the American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) criteria. This new approach aims to resolve the issue of duplicate classification present in the 2022 ACR/EULAR criteria and to refine the existing EMA algorithm.

METHODS

This study included 179 pediatric patients diagnosed with AAV across 17 centers in China. Patients were classified using the EMA algorithm, the ACR/EULAR criteria, and the EMA-ACR/EULAR algorithm. The Kappa value and Net Reclassification Index (NRI) were used to evaluate the classification performance of these criteria.

RESULTS

According to the EMA algorithm, 136 (76.0%) patients were classified with microscopic polyangiitis (MPA) and 14 (7.8%) with granulomatosis with polyangiitis (GPA), while 29 (16.2%) remained unclassifiable. According to the ACR/EULAR criteria, 145 (81.0%) patients were classified with MPA, 14 (7.8%) with GPA, 2 (1.1%) with eosinophilic granulomatosis with polyangiitis (EGPA), and 4 (2.2%) with both MPA and GPA, while 14 (7.8%) remained unclassifiable. The EMA-ACR/EULAR algorithm classified 124 patients (69.3%) as MPA, 26 (14.5%) as GPA, and 2 (1.1%) as EGPA, while 27 (15.1%) were unclassified. The Kappa values between the EMA algorithm and ACR/EULAR criteria for GPA and MPA were 0.225 [95% confidence interval (CI) 0.000-0.456, P = 0.003] and 0.357 (95% CI 0.196-0.518, P < 0.001). Compared to these two criteria, the EMA-ACR/EULAR algorithm demonstrated positive NRIs in the classification of both GPA (0.702, 95% CI 0.258-1.146, P = 0.002; 0.547 95% CI 0.150-0.944, P = 0.007) and MPA (0.425, 95% CI 0.209-0.642, P < 0.001; 0.519, 95% CI 0.305-0.733, P < 0.001).

CONCLUSIONS

The EMA-ACR/EULAR algorithm addresses the limitations of the 1990 ACR criteria within the EMA framework and resolves the issue of duplicate classification in the 2022 ACR/EULAR criteria. However, further research is necessary to validate the superiority of the EMA-ACR/EULAR algorithm in the clinical classification of pediatric AAV patients.

Severe Lower Gastrointestinal Bleeding Leading to Bilateral Non-arteritic Anterior Ischemic Optic Neuropathy: A Rare Systemic Complication

Lower gastrointestinal bleeding (LGIB) is a common clinical emergency; however, systemic complications such as bilateral non-arteritic anterior ischemic optic neuropathy (NAION) are exceedingly rare. We report the case of a 78-year-old male with a history of hypertension and hyperlipidemia who developed progressive bilateral vision loss following hospitalization for severe LGIB. His hemoglobin nadir dropped to 6.9 g/dL from a baseline of 11 g/dL, prompting transfusion with one unit of packed red blood cells. Arteritic causes were ruled out through appropriate workup. Imaging demonstrated significant carotid and vertebrobasilar atherosclerotic disease, and ophthalmologic evaluation confirmed bilateral NAION. This case highlights the potential for ischemic optic neuropathy in the setting of acute anemia and underlying vascular insufficiency. Clinicians should maintain a high index of suspicion for ischemic complications following severe gastrointestinal bleeding, particularly in high-risk patients.

The use of intravenous methylprednisolone in giant cell arteritis: a population-based study

OBJECTIVES

To determine clinical characteristics, outcome and occurrence of comorbidities in patients with biopsy-confirmed giant cell arteritis (GCA) treated with intravenous methylprednisolone (IVMP) vs those receiving oral glucocorticoids (OGC) only.

METHODS

A retrospective study included patients with GCA diagnosed from 2004 through 2019. Clinical and laboratory characteristics, and cumulative GC dose were compared in patients receiving IVMP vs OGCs. Changes in visual acuity (VA), occurrence of comorbidities after GCA diagnosis, and mortality were analysed.

RESULTS

A total of 419 patients (69% female) were included. In total, 111 patients were initially treated with IVMP, 104 (94%) of whom showed visual manifestations at onset and 308 received OGCs only. Ninety patients (21.5%) exhibited visual involvement at onset, verified by an ophthalmologist. Compared with OGC, patients receiving IVMP exhibited lower inflammatory response at presentation. There was a tendency for improvement in VA with the use of IVMP, but the results were not statistically significant (OR 1.19, 95% CI 0.35-4.01). Patients treated with IVMP had a higher risk of newly diagnosed diabetes mellitus within a year of GCA diagnosis (OR 2.59, 95% CI 1.19-5.63). This risk remained elevated after adjusting for cumulative OGC dose at three months (adjusted OR 3.30, 95% CI 1.29-8.43). There was no difference in survival between treatment groups.

CONCLUSIONS

Our study found no evidence supporting any benefit of using IVMP in improving VA or survival. IVMP may increase diabetes risk within a year of GCA diagnosis. Further studies are needed to evaluate the value of IVMP in GCA.

Diagnostic approach in giant cell arteritis

Giant cell arteritis (GCA), also known as temporal arteritis, is the most common form of vasculitis in the elderly. While initially described as involving the temporal arteries, GCA can also affect the aorta and its major branches. Despite the increased use of imaging modalities and the availability of temporal artery biopsy, diagnosing GCA remains challenging. GCA should be considered a spectrum, with diagnostic methodologies tailored to the prevalent symptoms. The sensitivity and specificity of different diagnostic approaches can vary depending on the clinical setting. Timing in diagnosing GCA is crucial to prevent serious complications, such as blindness and cerebrovascular ischemic events. While the prompt initiation of glucocorticoids (GCs) has reduced the incidence of major ischemic events, an uncertain diagnosis may expose the patient to unnecessary harm, such as complications from overtreatment or organ damage due to inadequate control of vasculitis. This narrative review will summarize the most widely available diagnostic techniques for GCA and outline our approach for cases where the diagnosis may be uncertain.

A Clinical Probability-Based, Stepwise Algorithm for the Diagnosis of Giant Cell Arteritis: Study Protocol and Baseline Characteristics of the First 50 Patients Included in the Prospective Validation Study with Focus on Cranial Symptoms

Background: Early diagnosis of giant cell arteritis (GCA) is crucial to avoid loss of vision, but detailed headache characteristics of GCA have been poorly studied. Clinical prediction rules have shown promise in guiding management decisions in suspected GCA. Methods: This is a prospective, monocentric cohort study on patients ≥50 years of age with suspected GCA. The diagnostic efficacy and safety of a previously published prediction rule embedded in a stepwise diagnostic algorithm is compared to the final clinical diagnosis incorporating the results of temporal artery biopsy (TAB). The protocol of the ongoing study is presented in detail. Based on an interim analysis of the first 50 included patients, characteristics of cranial symptoms of patients with positive and negative TAB are compared, and a modification of the original prediction rule is presented. Results: TAB was positive in 23 and negative in 26 cases. In one patient, the TAB specimen contained no arterial segment, so this patient was excluded from the interim analysis. Headache was more commonly located temporally and bilaterally. Cranial ischemic symptoms and superficial temporal artery-related symptoms were more common in patients with positive TAB. The quality and intensity of headaches did not differ significantly between groups. As the original prediction rule misclassified a single patient who eventually had a positive TAB, the clinical prediction rule was modified. Conclusions: Given the limited sensitivity and specificity of cranial symptoms, a stepwise diagnostic algorithm based on the modified prediction rule may facilitate clinical decision-making in suspected GCA.

Clinical characterization of aortitis and periaortitis: study of 134 patients from a single university hospital

Aortitis and periaortitis refer to the inflammation of the aortic wall and the surrounding tissues. Both conditions are associated with various diseases and express nonspecific manifestations. Early diagnosis and treatment are crucial to improve the prognosis of the disease. This study aimed to assess the causes and main clinical features of aortitis and periaortitis in patients from a single centre in Spain. Observational, retrospective study of patients diagnosed with aortitis or periaortitis at a Spanish referral center over the last decade. 134 patients (87 female; mean age of 55.1 ± 9.1 years) were recruited, 132 of which had aortitis and two periaortitis. Aortitis was associated with giant cell arteritis (n = 102), Takayasu's arteritis (n = 6), IgG4-related disease (n = 6), infectious diseases (n = 3), malignancy (n = 1), drugs (n = 1), isolated aortitis (n = 1), and other immune-mediated inflammatory diseases (IMIDs) (n = 12). IMIDs included were Sjögren's syndrome (n = 2), sarcoidosis (n = 2), rheumatoid arthritis (n = 2), axial spondyloarthritis (n = 2), inflammatory bowel disease (n = 1), primary biliary cirrhosis (n = 1), idiopathic pulmonary fibrosis (n = 1), and polyarteritis nodosa (n = 1). Periaortitis was due to idiopathic retroperitoneal fibrosis in both cases. Imaging techniques used for diagnosis included 18F-FDG PET/CT scan (n = 133), CT-angiography (n = 44), and/or MRI-angiography (n = 33). Polymyalgia rheumatica (52.2%) and asthenia (53.7%) were the most common manifestations, followed by limb claudication (23.9%) and inflammatory back pain (26.9%). Acute-phase reactants were typically increased. Aortitis is a common condition and may be associated with multiple non-infectious diseases. Its clinical presentation is often unspecific, requiring a high level of suspicion to get an early diagnosis and treatment.

Epidemiology of systemic vasculitis

PURPOSE OF REVIEW

Ongoing research contributes to our understanding of the epidemiology of vasculitis and its outcomes across the globe. This review aims to summarize important research studies published on this topic in the last 18 months.

RECENT FINDINGS

The implementation of rapid referral systems and use of large vessel imaging have improved the diagnosis of giant cell arteritis. A population-based study in immunoglobulin G4-related disease provides incidence and prevalence estimates for the United States for the first time. Recently published data supported viral infectious triggers for Kawasaki disease and immunoglobulin A vasculitis. Population studies in antineutrophil cytoplasmic antibody associated vasculitis report an increase in the incidence of eosinophilic granulomatosis with polyangiitis and have provided further insights into the burden of cardiovascular disease in these patients. Data on Behçet's disease continues to show increased all-cause mortality and need for better treatment strategies.

SUMMARY

Recent literature highlights the heterogeneity of the epidemiology of vasculitis in different parts of the world as well as associated outcomes, comorbidities, and potential triggers. Thought new classification criteria are being employed in some forms of vasculitis, standardization of case identification remains an unmet need in multiple other forms of vasculitis.

Machine learning-driven immunophenotypic stratification of mixed connective tissue disease, corroborating the clinical heterogeneity

OBJECTIVE

The objective of this study was to stratify patients with MCTD, based on their immunophenotype.

METHODS

We analysed the immunophenotype and transcriptome of 24 immune cell subsets [from patients with MCTD, SLE, idiopathic inflammatory myopathy (IIM) and SSc] from our functional genome database, ImmuNexUT (https://www.immunexut.org/). MCTD patients were stratified by employing machine-learning models, including Random Forest, trained by immunophenotyping data from SLE, IIM and SSc patients. The transcriptomes were analysed with gene set variation analysis (GSVA), and the clinical features of the MCTD subgroups were compared.

RESULTS

This study included 215 patients, including 22 patients with MCTD. Machine-learning models, constructed to classify SLE, IIM and SSc patients, based on immunophenotyping, were applied to MCTD patients, resulting in 16 patients being classified as having an SLEimmunophenotype and 6 as having a non-SLE immunophenotype. Among the MCTD patients, patients with the SLE immunophenotype had higher proportions of Th1 cells {2.85% [interquartile range (IQR) 1.54-3.91] vs 1.33% (IQR 0.99-1.74) P = 0.027} and plasmablasts [6.35% (IQR 4.17-17.49) vs 2.00% (IQR 1.20-2.80) P = 0.010]. Notably, the number of SLE-related symptoms was higher in patients with the SLE immunophenotype [2.0 (IQR 1.0-2.0) vs 1.0 (IQR 1.0-1.0) P = 0.038]. Moreover, the GSVA scores of interferon-α and -γ responses were significantly higher in patients with the SLE immunophenotype in central memory CD8+ T cells, while hedgehog signalling was higher in patients with the non-SLE immunophenotype, in five-cell subsets.

CONCLUSION

This study describes the stratification of MCTD patients, based on immunophenotyping, suggesting the presence of distinct immunological processes behind the clinical subtypes of MCTD.

The mirrored arterial dilemma

An 89-year-old man presented with acute and painless loss of vision in his left eye. He denied constitutional symptoms. Visual acuity was light perception with pallid optic disc edema. Neurological work-up and serological inflammatory markers were normal. Due to the clinical suspicion for giant cell arteritis (GCA), he was started on corticosteroid therapy and bilateral temporal artery biopsies (TABs) were performed. Histopathology of the left temporal artery ipsilateral to the visual loss was negative for arteritis, while the contralateral temporal artery was positive for arteritis. The diagnostic evaluation of GCA and value of unilateral versus bilateral TABs is discussed.

Headache as the most common manifestation of giant cell arteritis?: a systematic review with meta-analysis

OBJECTIVE

This study aimed to assess the relative frequency of clinical features of giant cell arteritis (GCA) and to investigate the predictors of temporal artery biopsy (TAB) outcomes.

METHODS

A literature search of Pubmed/Medline, Embase, ScienceDirect, Scopus, Web of Science (WoS), and Directory of Open Access journals (DOAJ) was conducted from January 1, 1990 to February 2025. Observational studies that reported original data on clinical features in patients diagnosed with GCA in accordance with 1990 ACR and/or 2022 ACR/EULAR classification criteria were deemed for inclusion. A random-effects meta-analysis was performed to determine the pooled prevalence estimates. The study's design adhered closely to the MOOSE standards. The JBI appraisal tool was used to evaluate the risk of bias. The study's protocol was pre-registered on PROSPERO (ID: CRD42024584763).

RESULTS

Out of initial 12,628 records, 62 articles (9971 patients) met all of the eligibility criteria. Mean patients' age upon diagnosis was 74.33 years (95%CI: 74.12-74.54 years). The most prevalent clinical feature of GCA was new-onset headache (75.7%; 95CI%: 72.2-79.0; 95%PI: 0.47-0.92). Other common symptoms of GCA were temporal artery abnormalities (51.5%; 95%CI: 45.2-57.7; 95%PI: 0.25-0.77), weakness/malaise (46.7%; 95%CI: 35.4-58.4; 95%PI: 0.09-0.88), and scalp tenderness (39.1; 95%CI: 35.3-43.1; 95%PI: 0.22-0.59). Positive TAB results were present in 73.8% of patients (95%CI: 68.1-78.8%; 95%PI: 0.35-0.94). The presence of headache (LogOR = -1.11; 95%CI: -1.92 to -0.29) or PMR (-0.71; 95%CI: -1.09 to -0.32) significantly decreases the chance of receiving positive TAB results.

CONCLUSIONS

Since there is a greater likelihood of obtaining negative biopsy results, the TAB may not be required when a patient exhibits a headache along with other clinical symptoms that enable them to be diagnosed with GCA.

A feasible treatment strategy for tapering subcutaneous tocilizumab in giant cell arteritis: a 24-month multi-center retrospective study

To examine whether extending tocilizumab (TCZ) intervals is a feasible treatment strategy in giant cell arteritis (GCA). This multicenter retrospective study included patients with GCA who started subcutaneous TCZ at five Japanese hospitals between January 2008 and July 2021. We collected clinical data and monitored relapses for up to 24 months following the initiation of TCZ. The treatment regimen, including TCZ intervals and glucocorticoid (GC) dosage, was evaluated every 6 months. Of 56 eligible patients, 44 (79%) initiated TCZ weekly, and 12 (21%) every two weeks. The GC dosage consistently decreased after initiating TCZ; GC discontinuation was achieved in 87.5% at month 24. The number of patients extending TCZ intervals increased over time. Among the 32 patients who were followed at month 24, 5 (15.6%) continued weekly TCZ; the TCZ interval was every two weeks in 13 (40.6%), every three weeks in 7 (21.9%), and every four weeks or longer in 5 (15.6%), and 2 (6.3%) discontinued TCZ due to well-controlled disease. During 24-month follow-up, 10 (31.3%) extended TCZ intervals by two weeks or more from the starting dose. Three patients experienced relapses after extending TCZ intervals for well-controlled GCA, and all improved by shortening TCZ intervals. Gradually extending TCZ intervals by one week each is a feasible treatment strategy for well-controlled GCA patients after achieving GC-free status. While some patients may experience relapses following the extension of TCZ intervals, these relapses might be potentially managed by adjusting only the TCZ intervals.

Association Between Phase Angle and Tongue Pressure in Older Inpatients with Connective Tissue Diseases

To investigate the association between tongue pressure (TP) and phase angle (PhA) in patients with connective tissue diseases (CTDs) aged 65 years or older. This retrospective cross-sectional study was conducted on 189 patients with CTDs who underwent hospital rehabilitation. TP was measured using a tongue pressure measuring device, and PhA was calculated from the bioimpedance analysis readings. Statistical analyses included multivariate linear regression with TP and receiver operating characteristic curves to determine PhA cutoff values indicative of low TP, defined as < 24.3 kPa for men and < 23.7 kPa for women. A total of 189 patients with CTDs (mean age 75 years; 49 men and 140 women; mean PhA 4.0°; mean TP 27.7 kPa) were included in the analysis. Fifty-five patients had low TP. Patients with low TP had lower PhA values than those with normal TP (mean PhA values 3.5° versus 4.3°). After adjusting for confounding factors, PhA (β = 0.387, p < 0.001) was significantly associated with TP. Cutoff values for PhA predicting low TP were identified as 3.9° for men and 3.5° for women. PhA is associated with TP, independent of other factors, in older inpatients with CTDs. The identified PhA cutoff values could enable the early detection of declining TP.

Visual manifestations in giant cell arteritis: identification of risk factors from the ARTESER Registry

OBJECTIVE

To determine the prevalence and predictive factors of visual manifestations in a large registry of patients with GCA.

METHODS

ARTESER is a large Spanish multicentre registry supported by the Spanish Society of Rheumatology. It includes patients with GCA from across the entire country diagnosed between June 2013 and March 2019. The variables collected at diagnosis were demographics, clinical manifestations (including all visual manifestations), laboratory, temporal artery biopsy, and imaging findings (ultrasound, FDG-PET/CT, MRI angiography, CT angiography). Patients with and without visual involvement were compared in a bivariate analysis. Multivariate logistic regression was performed to determine potential predictive factors of visual manifestations.

RESULTS

The study population comprised 1636 GCA patients, of whom 599 (36.6%) presented visual manifestations. Anterior ischemic optic neuropathy was the most frequent (n = 274 of 599; 45.7%) ocular complication. The independent predictors that increased the risk (OR; 95% confidence interval) of visual involvement were older age (1.027; 1.009-1.045) and jaw claudication (1.724; 1.325-2.243). The variables associated with a reduced risk were polymyalgia rheumatica (0.541; 0.414-0.708), fever (0.373; 0.264-0.527), longer symptom duration (0.946; 0.909-0.985) and higher erythrocyte sedimentation rate (ESR) (0.992; 0.988-0.997), common features of patients with large vessel GCA.

CONCLUSION

One-third of GCA patients present visual manifestations at diagnosis. Older age and jaw claudication are independent predictors of visual manifestations, whereas polymyalgia rheumatica, fever, longer symptom duration and high ESR reduce the risk of visual involvement.

Unilateral Arteritic Anterior Ischaemic Optic Neuropathy (AAION) as a Presenting Manifestation of Fatal Giant Cell Arteritis (GCA): A Case Report

Giant cell arteritis (GCA), also known as temporal arteritis, is a form of vasculitis that primarily affects the large and medium-sized arteries, which can lead to narrowing or blockage of the arteries. When GCA involves vital vessels such as the coronary arteries, aorta, or cerebral arteries, it can pose a serious risk to life. We present a case of a 61-year-old Malay woman with hypertension and chronic kidney disease who presented with a two-day history of sudden-onset visual loss in the right eye preceded by an inferior visual field defect for four days associated with both lower limb pain. Otherwise, there was no fever, headache, scalp pain, or jaw claudication. Her vision was hand movement and 6/6 in the right eye and left eye, respectively, with a positive relative afferent pupillary defect. Fundus examination showed a swollen 'chalky white' pallid appearance of the optic disc with splinter haemorrhage. The examination of the left eye was normal. Both temporal arteries were dilated, tortuous, and non-pulsatile. There were multiple painful necrotic skin lesions over both lower limbs. Blood tests showed a markedly high erythrocyte sedimentation rate (120 mm/hour) and C-reactive protein (144.2 mg/L). The temporal artery biopsy was suggestive of GCA, and the findings were supported by a biopsy from the necrotic skin lesions. She was treated with intravenous methylprednisolone for three days, and her vision maintained hand movement with no involvement of the left eye. She was discharged with oral prednisolone 1 mg/kg; however, one month later, she succumbed to death from cardiac complications.

High-resolution magnetic resonance imaging visualizes intracranial large artery involvement in giant cell arteritis

OBJECTIVE

Giant cell arteritis (GCA) is a large vessel vasculitis, typically involving the aorta and its branches with predilection for the scalp arteries. Intracranial involvement is still part of ongoing research. We assessed inflammation of the intracranial arteries on 3D compressed sensing black-blood MRI (3D-CS-BB-MRI) in patients with GCA and age-matched controls.

METHODS

One hundred and five patients with 3D-CS-BB-MRI of the brain were included in this retrospective dual-centre case-control study, 55 with diagnosed GCA and 50 age-matched controls. High-resolution 3D-CS-BB-MRI was performed on a 3 T MR scanner with a post-contrast 3D-compressed-sensing MR pulse sequence, specifically a T1-weighted sampling perfection, application-optimized contrasts using different flip angle evolution (SPACE) pulse sequence with whole-brain coverage and isotropic resolution of 0.55 mm3. Two neuroradiologists blinded to clinical data independently scored the cerebral arteries qualitatively for inflammation; circumferential vessel wall thickening and contrast enhancement were scored positive for vasculitis.

RESULTS

Eight of 55 GCA patients (14.5%) showed inflammation of at least one intracranial artery. The internal carotid artery (ICA) was affected in 6/55 (10.9%), the vertebral artery in 4/55 (7.3%) and the basilar artery and posterior cerebral artery in 1/55 (1.8%). All patients with inflammatory changes reported headaches and none showed any focal neurological deficit. Besides headache and general weakness, there was no significant correlation between inflammation of the intracranial arteries and clinical symptoms. No age-matched control patient showed inflammatory changes of the intracranial arteries.

CONCLUSION

High-resolution 3D-CS-BB-MRI revealed inflammatory changes of intracranial arteries in 14.5% of GCA patients, with the intradural ICA as the most frequently affected vessel.

An innovative hybrid training method for ultrasound in giant cell arteritis, polymyalgia rheumatica and large vessel vasculitis

We propose a novel hybrid physical and virtual training method, complemented by online learning, as an effective method to teach and acquire ultrasound skills. We aim to illustrate this through our experience with a remote ultrasound training module for giant cell arteritis scanning. The significance of this innovation is the ability to mitigate the challenges faced by ultrasound training during pandemic-times, including the need for physical distancing, group size limitation and overseas travel restrictions. Furthermore, the hybrid training provides an invaluable access to distant specialist cognitive and procedural expertise when conventional means may not be feasible. Although this form of ultrasound training has limitations, such as diminished face-to-face contact, we were able to resume training despite the unfavourable circumstances. By harnessing virtual technology for hands-on training, we can strive to reduce worldwide training inequalities, particularly in areas requiring highly specialised skills where expertise may not be available locally. Even as the world has moved out of 'lockdown', the pandemic has serendipitously provided novel ways of doing things; the lessons learnt here can be utilised for future hybrid training models, especially where hands-on experience is crucial.

Associations between plasma metabolism-associated proteins and future development of giant cell arteritis: results from a prospective study

OBJECTIVE

The aim of this study was to investigate the relationship between biomarkers associated with metabolism and subsequent development of GCA.

METHOD

Participants in the population-based Malmö Diet Cancer Study (MDCS; N = 30 447) who were subsequently diagnosed with GCA were identified in a structured process. Matched GCA-free controls were selected from the study cohort. Baseline plasma samples were analysed using the antibody-based OLINK proteomics metabolism panel (92 metabolic proteins). Analyses were pre-designated as hypothesis-driven or hypothesis-generating. In the latter, principal component analysis was used to identify groups of proteins that explained the variance in the proteome.

RESULTS

There were 95 cases with a confirmed incident diagnosis of GCA (median 12.0 years after inclusion). Among biomarkers with a priori hypotheses, adhesion G protein-coupled receptor E2 (ADGRE2) was positively associated [odds ratio (OR) per S.D. 1.67; 95% CI 1.08-2.57], and fructose-1,6-bisphosphatase 1 (FBP1) was negatively associated (OR per S.D. 0.59; 95% CI 0.35-0.99) with GCA. In particular, ADGRE2 levels were associated with subsequent GCA in the subset sampled <8.5 years before diagnosis. For meteorin-like protein (Metrnl), the highest impact on the risk of GCA was observed in those patients sampled closest to diagnosis, with a decreasing trend with longer time to GCA (P = 0.03). In the hypothesis-generating analyses, elevated levels of receptor tyrosine-like orphan receptor 1 (ROR1) were associated with subsequent GCA.

CONCLUSION

Biomarkers identified years before clinical diagnosis indicated a protective role of gluconeogenesis (FBP1) and an association with macrophage activation (ADGRE2 and Metrnl) and proinflammatory signals (ROR1) for development of GCA.

Predominance of T-bet-positive Th1 cells in infiltrating T-lymphocytes in most of active arteritis lesions of giant cell arteritis

Immunological mechanisms through the activation of CD4-positive T-cells have been assumed to be involved in the pathogenesis of giant cell arteritis (GCA). Many studies employing frozen tissues of temporal artery biopsy, peripheral blood lymphocytes, and plasma of GCA patients have revealed the contribution of interferon-γ and interleukin-17 in both protein and mRNA levels. However, the analyses using formalin-fixed and paraffin-embedded (FFPE) tissue specimens, in which the correlation between histopathologic pictures and immunological circumstances would be elucidated, have been limited. Here, we performed the immunohistochemical analyses of infiltrating small lymphocytes in GCA lesions using FFPE specimens, especially of the subsets of CD4-positive T-cells by immunohistochemistry with antibodies against T-bet, GATA-3, RORγT, and Foxp3, which is the differentiation-specific transcription factor for Th1, Th2, Th17, and Treg cells, respectively. In these slides, the nuclear-positive staining is much more clearly and easily identifiable than the cytoplasmic staining for cytokines. The results indicate the predominance of T-bet-positive Th1 cells in infiltrating T-cells in most of active arteritis lesions of GCA. Furthermore, our data suggest the possible immunosuppressive microenvironment induced by T-reg cells and M2-type macrophages in the arteritis lesions throughout the course of GCA inflammation.

A Novel Ultrasound Finding for the Diagnosis of Giant Cell Arteritis: Comparison With Temporal Artery Biopsy Findings

Hypoechoic halo is a typical ultrasound finding in giant cell arteritis (GCA), but it may be a false positive due to arteriosclerosis. Therefore, we focused on the segmental distribution of GCA lesions, defined the luminal irregularity in long-axis images as the string of beads sign, and examined its diagnostic ability. As a result, the C-statistic of hypoechoic halo and string of beads sign was better than that of hypoechoic halo alone (1.00 vs. 0.89). Based on the above, the diagnostic ability of GCA can be improved by adding the string of beads sign to the conventional hypoechoic halo.

Performance of the modified 2022 ACR/EULAR giant cell arteritis classification criteria without age restriction for discriminating from Takayasu arteritis

OBJECTIVE

To evaluate the ability to discriminate giant cell arteritis (GCA) from Takayasu arteritis (TAK) according to the modified 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology (ACR/EULAR) GCA classification criteria.

METHODS

Patients enrolled in the Japanese nationwide retrospective registry were evaluated using the criteria with partial modification; wall thickening of descending thoracic-abdominal aorta were mainly diagnosed by contrast-enhanced computed tomography (CT) or magnetic resonance imaging instead of evaluating with positron emission tomography (PET)-CT. The discriminability of the criteria was evaluated using C-statistic (> 0.7: good ability).

RESULTS

Newly diagnosed patients with GCA (n = 139) and TAK (n = 129) were assessed, and 23.3% of TAK were aged 50 years or older at onset. The sensitivity of the modified 2022 ACR/EULAR GCA classification criteria with a score ≥ 6 was 82.0%, 68.5%, and 32.1% in all GCA, GCA with large-vessel involvement, and GCA without cranial arteritis, respectively. The specificity of the modified criteria was 96.1% for the 129 TAK as controls. Five patients with late-onset TAK met the modified criteria, and four had cranial signs and symptoms, two had bilateral axillary artery involvement, and four had descending thoracic-abdominal aorta involvement. The discriminability of the criteria was good (C-statistic: 0.986, 95% confidence interval [CI]: 0.976-0.996) and remained good after excluding age (C-statistic: 0.927, 95% CI: 0.894-0.961). The discriminability of a set of large-vessel lesions (bilateral axillary artery and descending thoracic-abdominal aorta) and inflammatory markers was markedly decreased with poor C-statistic value (C-statistic: 0.598, 95% CI: 0.530-0.667). Discriminability was improved after adding polymyalgia rheumatica (PMR) (C-statistic: 0.757, 95% CI: 0.700-0.813) or age (C-statistic: 0.913, 95%CI: 0.874-0.951) to the set of large-vessel lesions. In GCA patients with a score ≤ 5, 52% had bilateral subclavian and/or axillary artery involvement.

CONCLUSION

The modified 2022 ACR/EULAR GCA classification criteria well performed in classifying GCA and TAK without PET-CT in routine clinical practice. A set of items included in the modified GCA classification criteria had good discriminative ability for GCA and TAK, even when age was excluded. However, age restriction or PMR was required to distinguish GCA without cranial lesions from TAK.

Mortality in patients with giant cell arteritis in Spain: results from the ARTESER registry

OBJECTIVES

To compare mortality rates between GCA patients and the general population in Spain, and to identify associated factors influencing mortality.

METHODS

ARTESER, a multicenter registry by the Spanish Society of Rheumatology, includes GCA patients from June 2013 to March 2019. Demographic, clinical, imaging, histological and mortality data were collected retrospectively. Only patients with at least one year of follow-up were included for analysis. The mortality rates were expressed as the number of deaths per 1000 person-years, with 95% confidence interval (CI) by sex and age group. Kaplan-Meier method was performed for survival analysis. The factors influencing mortality were analyzed using Cox regression model.

RESULTS

A total of 1200 patients with GCA were analyzed, with a mean (SD) follow-up of 2.18 (1.53) years. The overall five-year cumulative mortality rate (95%CI) was 37.86 (31.75-43.96) per 1000 patients/year. The cumulative mortality rate was significantly higher in males than females (59.04vs29.06; p<0.001). The age- and sex-adjusted cumulative mortality rate was similar to the Spanish general population (19.75vs20.72;p=0.559). In the multivariate analysis, older age (HR 1.11, 95%CI 1.073-1.142) and male sex (HR 1.775, 95%CI 1.214-2.594) were associated with increased mortality. Headache (HR 0.55, 95%CI 0.362-0.843) and high hemoglobin levels (HR 0.85, 95%CI 0.744-0.970) were protective factors against death.

CONCLUSIONS

The overall five-year age- and sex-adjusted cumulative mortality rate in GCA is similar compared to the general population. Older age and male sex appear to be associated with an increased risk of mortality, whereas headache and high hemoglobin levels might serve as protective factors against death.

NMR-based metabolomics in giant cell arteritis and polymyalgia rheumatica sequential sera differentiates active and inactive disease

OBJECTIVES

GCA is an inflammatory disease following a chronic, relapsing course. The metabolic alterations related to the intense inflammatory process during the active phase and the rapid impact of steroid treatment remain unknown. This study aims to investigate the serum metabolome in active and inactive disease states.

METHODS

A total of 110 serum samples from 50 patients (33 GCA and 17 PMR) at three time points-0 (V1: active disease), 1 and 6 months (V2 and V3: remission)-of treatment with glucocorticoids (GCs) were subjected to NMR-based metabolomic analysis. Multi- and univariate statistical analyses were utilized to unveil metabolome alterations following treatment.

RESULTS

Distinct metabolic profiles were identified between activity and remission, independent of disease type. N-acetylglycoproteins and cholines of bound phospholipids emerged as predictive markers of disease activity. Altered levels of 4 of the 21 small molecules were also observed, including increased levels of phenylalanine and decreased glutamine, alanine and creatinine in active disease. Metabolic fingerprinting discriminated GCA from PMR in remission. GCA and PMR patients exhibited characteristic lipid alterations as a response and/or adverse effect of GC treatment. Correlation analysis showed that several identified biomarkers were further associated with acute phase reactants, CRP and ESR.

CONCLUSION

The NMR profile of serum metabolome could identify and propose sensitive biomarkers of inflammation. Metabolome alterations, following GC treatment, could provide predictors for future steroid-induced side effects.

Diagnostic performance of a newly launched Canadian fast-track ultrasound clinic by rheumatologists for the diagnosis of giant cell arteritis

BACKGROUND

Giant cell arteritis (GCA) can present diagnostic challenges and early diagnosis is crucial due to potential ischemic complications. Recent guidelines suggest that a suspected diagnosis should be confirmed with temporal artery biopsy or imaging, including ultrasound (US). In our Canadian setting, point-of-care temporal artery US was near unavailable, and biopsy remains the standard of care. We hypothesize that launching a fast-track US clinic by rheumatologists may spare the need for a temporal artery biopsy. Therefore, this study aimed to assess the diagnostic performance of US in this newly launched fast-track clinic.

METHODS

In this single-center retrospective cross-sectional analysis, 99 visits were identified from the fast-track clinic between January 2020 and July 2022. Each subject had an US according to a standard protocol for suspicion of either new-onset or relapse of GCA. Ultrasonographers were rheumatologists who acquired training on vascular US techniques before launching the clinic. For each patient presenting with suspected new-onset GCA, the pretest probability was calculated using the Southend GCA probability score. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using the rheumatologist clinical diagnosis as the gold standard for GCA diagnosis.

RESULTS

A total of 22 subjects had a diagnostic of GCA and 77 had another diagnostic. Patients with and without GCA were, respectively, 81.8% versus 72.7% females, had a mean age of 76.6 ± 7.7 versus. 74.8 ± 9.8 years, and a mean CRP of 73.4 ± 57.8 versus 38.3 ± 59.9 mg/l. Temporal artery US demonstrated a sensitivity of 86.3% [95% confidence interval (CI), 65.1-97.1%], a specificity of 90.9% (95% CI, 82.2-6.3%), a PPV of 73.1% (95% CI, 56.8-84.9%), and a NPV of 95.9% (95% CI, 89.0-.5%). 14 patients had a suspicion of relapse and were all correctly identified by the US. Among those with suspicion of new-onset 27, 34 and 24 US were performed for high, intermediate, and low pretest probability of GCA, respectively. The high-risk subgroup demonstrated higher PPV while similar sensitivity/specificity was observed between all three subgroups.

CONCLUSION

Our results highlight the benefits of US as a key diagnostic tool for GCA, particularly when combined with clinical evaluations. An excellent discriminative ability for diagnosis of GCA was shown in this newly launched clinic suggesting that the role of TAB may need to be redefined. These findings will guide on broader implementation of US programs for GCA.

Plasma proteome profiling in giant cell arteritis

OBJECTIVES

This study aimed to identify plasma proteomic signatures that differentiate active and inactive giant cell arteritis (GCA) from non-disease controls. By comprehensively profiling the plasma proteome of both patients with GCA and controls, we aimed to identify plasma proteins that (1) distinguish patients from controls and (2) associate with disease activity in GCA.

METHODS

Plasma samples were obtained from 30 patients with GCA in a multi-institutional, prospective longitudinal study: one captured during active disease and another while in clinical remission. Samples from 30 age-matched/sex-matched/race-matched non-disease controls were also collected. A high-throughput, aptamer-based proteomics assay, which examines over 7000 protein features, was used to generate plasma proteome profiles from study participants.

RESULTS

After adjusting for potential confounders, we identified 537 proteins differentially abundant between active GCA and controls, and 781 between inactive GCA and controls. These proteins suggest distinct immune responses, metabolic pathways and potentially novel physiological processes involved in each disease state. Additionally, we found 16 proteins associated with disease activity in patients with active GCA. Random forest models trained on the plasma proteome profiles accurately differentiated active and inactive GCA groups from controls (95.0% and 98.3% in 10-fold cross-validation, respectively). However, plasma proteins alone provided limited ability to distinguish between active and inactive disease states within the same patients.

CONCLUSIONS

This comprehensive analysis of the plasma proteome in GCA suggests that blood protein signatures integrated with machine learning hold promise for discovering multiplex biomarkers for GCA.

18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Large-Vessel Vasculitis During Active and Inactive Disease Stages Is Associated with the Metabolic Profile, but Not the Macrophage-Related Cytokines: A Proof-of-Concept Study

Giant cell arteritis (GCA) is an autoimmune/autoinflammatory disease affecting large vessels in patients over 50 years old. The disease presents as an acute inflammatory response with two phenotypes, cranial GCA and large-vessel vasculitis (LV)-GCA, involving the thoracic aorta and its branches. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET-CT) is among the imaging techniques contributing to diagnosing patients with systemic disease. However, its association with soluble inflammatory markers is still elusive. This proof-of-concept study aims to identify novel soluble serum biomarkers in PET/CT-positive patients with LV-GCA and associate them with active (0 months) and inactive disease (6 months following treatment), in sequential samples. The most-diseased-segment target-to-background ratio (TBRMDS) was calculated for 13 LV-GCA patients, while 14 cranial GCA and 14 Polymyalgia Rheumatica patients with negative initial PET/CT scans served as disease controls. Serum macrophage-related cytokines were evaluated by cytometric bead array (CBA). Finally, previously published NMR/metabolomics data acquired from the same blood sampling were analyzed along with PET/CT findings. TBRMDS was significantly increased in active versus inactive disease (3.32 vs. 2.65, p = 0.006). The analysis identified nine serum metabolites as more sensitive to change from the active to inactive state. Among them, choline levels were exclusively altered in the LV-GCA group but not in the disease controls. Cytokine levels were not associated with PET/CT activity. Combining CRP, ESR, and TBRMDS with choline levels, a composite index was generated to distinguish active and inactive LV-GCA (20.4 vs. 11.62, p = 0.001). These preliminary results could pave the way for more extensive studies integrating serum metabolomic parameters with PET/CT imaging data to extract sensitive composite disease indexes useful for everyday clinical practice.

The impact of histopathological criteria for definite vasculitis in giant cell arteritis: retrospective analysis of temporal artery biopsies

Histopathological findings associated with definite vasculitis in temporal artery biopsy (TAB) defined in 2022 ACR/EULAR classification criteria for Giant Cell Arteritis (GCA) was published in 2022. We aimed to evaluate the TAB of our GCA patients for histopathological findings associated with definite vasculitis. Patients who were diagnosed with GCA by clinicians and underwent TAB between January 2012 and May 2022 were included. Hospital electronic records and patients' files were reviewed retrospectively. A total of 90 patients' pathology reports were evaluated by a pathologist and a rheumatologist. In cases where microscopic findings were not specified in the pathology reports, histopathologic specimens were re-evaluated (n = 36). A standard checklist was used for histopathological findings of definite vasculitis. Patients were divided into two groups; (i) definite vasculitis-GCA and (ii) non-definite-GCA group, and the clinical and demographic characteristics for all patients were compared. The mean age of patients was 69.8 (± 8.5) years and 52.2% were female. In the first evaluation, 66 (73.3%) patients had a diagnosis of vasculitis according to pathology reports. In the re-evaluation of biopsy specimens, at least one definite finding of vasculitis was observed in TAB of 10/24 (41.6%) patients whose microscopic findings were not specified in the pathology reports. The ROC analysis showed that biopsy length had diagnostic value in predicting the diagnosis of definite vasculitis (AUC: 0.778, 95% CI: 0.65-0.89, p < 0.001). In those with a biopsy length of ≥ 1 cm, sensitivity was 76.5%, specificity was 64.3%, and PPV value was 92. In multivariate analysis, the most significant factor associated with definite vasculitis was biopsy length (OR: 1.18 (1.06-1.31), p = 0.002). Microscopic findings were reported in over 70% of patients. Reinterpretation of results according to a standard check-list improved the impact of TAB in the diagnosis of GCA. A biopsy length ≥ 1 cm was found to contribute towards a definitive histopathological vasculitis diagnosis.

Association between phase angle and sarcopenia in patients with connective tissue diseases

BACKGROUND AND AIMS

Early detection and management of sarcopenia in patients with connective tissue diseases (CTDs) are essential. However, the relationship between the phase angle and sarcopenia in patients with CTDs is unknown. This study investigated the association between the phase angle and sarcopenia in patients with (CTDs) and determined the optimal phase angle cutoff values for the early detection of sarcopenia.

METHODS

A retrospective cross-sectional study was conducted in 279 hospitalized patients with CTDs undergoing rehabilitation (median age 73.3 years; 80 men and 199 women). Bioimpedance analysis was used to measure the phase angle, and sarcopenia was assessed according to the Asian Working Group for Sarcopenia criteria.

RESULTS

Sarcopenia was identified in 134 patients (36 men and 98 women). Patients with sarcopenia had a significantly smaller phase angle than those without sarcopenia. Multivariate analysis revealed that phase angle was significantly associated with sarcopenia after adjusting for confounding factors in each sex. The optimal phase angle cutoff value for identifying sarcopenia was 4.6° for men and 4.3° for women, with area under the curve values of 0.795 and 0.754, respectively.

CONCLUSION

Phase angle is a valuable marker for identifying sarcopenia in patients with CTDs. The established phase angle cutoff values of 4.6° in men and 4.3° in women can facilitate the early detection and management of sarcopenia.

An overview of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in giant cell arteritis

PET/CT is an imaging modality that is increasingly being used to diagnose large-vessel vasculitis. In the case of giant cell arteritis, it was first used to demonstrate inflammation of the walls of large arterial trunks such as the aorta and its main branches, showing that aortic involvement is common in this vasculitis and associated with the occurrence of aortic complications such as aneurysms. More recently, with the advent of digital PET/CT, study of the cranial arteries (i.e., temporal, occipital, maxillary and vertebral arteries) has become possible, further increasing the diagnostic interest of this examination for the diagnosis of GCA. Despite these advantages, there are still limitations and questions regarding the use of PET/CT for the diagnosis and especially the follow-up of GCA. The aim of this review is to take stock of currently available data on the use of PET/CT for GCA diagnosis and follow-up.

Epidemiology of large vasculitis in Shanghai, China: A 10-year multicenter hospital-based study and systematic review

BACKGROUND

Takayasu arteritis (TAK) and giant cell arteritis (GCA) are two major large vessel vasculitis, with varied epidemiology by geographical location, age, and race. However, the epidemiological data in Chinese population is rarely reported. This study estimated the epidemiology of TAK and GCA in Shanghainese individuals residing in China over a 10-year period.

METHODS

TAK data for individuals over 16 years and GCA data for individuals over 50 years were retrieved from 38 comprehensive hospitals in Shanghai, China through the electronic medical record systems between January 1, 2011, and December 31, 2020. A systematic literature review was performed to determine the global distribution of TAK and GCA by searching PubMed, Ovid-Medline, Excerpta Medica Database (EMBASE), and Web of Science.

RESULTS

In 173 identified TAK cases (67% females; mean age, 46 ± 15 years), the period prevalence was 11.72 cases per million, and the mean annual incidence was 1.33 cases per million. The highest prevalence (17.74 cases per million) and incidence (1.71 cases per million) were observed in the 16- to 34-year-old age group. In 92 identified GCA cases (56% females; age, >50 years), the period prevalence was 2.73 cases per 100 000 persons, and the mean annual incidence was 1.91 cases per 100 000 persons. Meta-analysis of the incidence study of TAK and GCA showed that the pooled incidence rate of TAK and GCA was 1.29 per million and 15.48 per 100 000 person-years, respectively. Subgroup analysis showed that the incidence of TAK was significantly higher in Asia than in other regions, while the incidence of GCA was higher in Europe, especially North Europe.

CONCLUSION

The epidemiological patterns of TAK and GCA were comprehensively mapped globally and locally, in Shanghai, China.

Uveitis in Giant Cell Arteritis: A Retrospective Study of Seven Observational Cases and Literature Review

PURPOSE

To describe the demographic and clinical characteristics of uveitis in patients with giant cell arteritis (GCA), their treatments, and evolution.

METHODS

A national retrospective cohort study was performed. The inclusion criteria were as follows: patients with GCA fulfilling the 2022 ACR/EULAR criteria and a diagnostic of uveitis attested by an ophthalmologist.

RESULTS

Seven women were included. The median age at diagnosis of uveitis was 71 years (64-84). All uveitis were diagnosed during active GCA (five at initial diagnosis, two at relapse). All uveitis were acute (100%), mostly anterior (86%) and bilateral (71%). Granulomatous features were less common (29%). All uveitis were treated with local and systemic corticosteroids. After a median follow-up of 30 (21-55) months, all patients achieved complete ophthalmic remission, with only one relapse at 2 years. GCA was also in complete remission.

CONCLUSIONS

Uveitis could reveal GCA, and its presence correlated with disease activity of GCA. The most frequent clinical presentation of uveitis was acute and anterior; using local and systemic corticosteroids, the prognosis was favorable.

Predictive biomarkers of response to tocilizumab in giant cell arteritis (GCA): correlations with imaging activity

In the recent EULAR recommendations, ultrasound examination is now recommended as a first-line imaging test in all patients with suspected giant cell arteritis (GCA) and the axillary arteries should be included in the standard exam. As an alternative to ultrasound evaluation, cranial and extracranial arteries can be examined using FDG-PET or MRI. The aim of our study was to observe in a retrospective case series whether there is a correlation between biomarkers and imaging activity in a population of patients followed in real life with GCA treated with prednisone (PDN) and tocilizumab (TCZ). We retrospectively enrolled 68 patients with newly diagnosed GCA between January 2020 and September 2021, followed in real life, who were examined at the Rheumatology Unit of the San Giovanni di Dio Hospital, Florence, Italy. Patients were evaluated at T0-T3-T6-T12-T18-T24 for the following blood tests: ESR, CRP, fibrinogen, platelet count, serum amyloid A (SAA), IL-6, and circulating calprotectin (MRP). Ultrasound examination of the temporal arteries and axillary arteries was assessed at T0 within 7 days of starting treatment with high-dose glucocorticoids and subsequently at T3-T6-T12-T18-T24. A scale from 0 to 3 with semi-quantitative tools (SUV max) was assessed at T0-T12-T24. The evaluation of the correlation coefficient between laboratory and imaging variables has shown that SAA and MRP have the most powerful correlation with the PET score (0.523 and 0.64), and MRP also has an excellent correlation coefficient with the Halo score (0.658). The evaluation of the ROC curves shows for a PET score 3 and SAA values higher than 26 mg/L, sensitivity of 81.5% and specificity of 84.1%, and for a PET score 3 and MRP values higher than 2.3 mcg/mL, sensitivity of 100% and specificity of 76.8%. In this study, we demonstrated that SAA and MRP can be useful as promising tools to detect GCA activity. The study demonstrates a good correlation between the two biomarkers and the imaging activity evaluated by the Halo and PET scores.

Visualization of cranial giant cell arteritis with [18F]FDG PET/CT: A case report

Giant cell arteritis is a form of large vessel vasculitis which can present with nonspecific symptoms, and if left untreated can cause significant morbidity and/or death. Early diagnosis and management are therefore paramount. The use of [18F]FDG PET/CT in the evaluation of giant cell arteritis has increased in recent years, with newer generation PET scanners capturing the historically elusive cranial vessel inflammation in active vasculitis. We present a case of giant cell arteritis which was suspected on conventional imaging modalities, and subsequently evaluated with [18F]FDG PET/CT which revealed marked vascular inflammation involving both cranial and other large vessels.

Temporal artery biopsy in giant cell arteritis: clinical perspectives and histological patterns

Although its role has been debated, temporal artery biopsy (TAB) remains the gold standard for the diagnosis of cranial giant cell arteritis (GCA). The specificity of TAB is excellent and the sensitivity, albeit lower, is comparable with other diagnostic modalities used for the diagnosis of GCA. This outpatient procedure has a low rate of complications and is well integrated in the majority of healthcare systems. The length of the specimen, the number of the examined sections and the prolonged use of glucocorticoids before the biopsy may affect the outcome of the TAB as diagnostic tool. The typical histological findings in GCA are often characterized by granulomatous inflammation with infiltration of mononuclear cells with or without the presence of giant cell, varying degrees of external and internal elastic lamina damage and intimal thickening. Overlooking signs of inflammation in the adventitia and in connective tissue surrounding the temporal artery may lead to false negative results. The distinction between healed arteritis and age-related atherosclerosis may be challenging.

Application of the 2022 ACR/EULAR criteria for Takayasu arteritis to previously diagnosed patients based on the 1990 ACR criteria

OBJECTIVES

Recently, a joint group of the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) proposed new criteria for Takayasu arteritis (TAK) (the 2022 ACR/EULAR criteria). This study applied the 2022 ACR/EULAR criteria to patients with previously diagnosed TAK based on the 1990 ACR criteria and investigated the concordance rate between the two criteria according to the four imaging modalities.

METHODS

This study reviewed the medical records of 179 patients who met the 1990 ACR criteria for TAK. The imaging modalities included conventional angiography, computed tomography angiography, fluorodeoxyglucose-positron emission tomography, and magnetic resonance angiography.

RESULTS

Regardless of the imaging modalities, the concordance rate between the two criteria was 85.5% when including all patients, whereas it increased to 98.1% when only patients aged ≤60 years were included. Among the four imaging modalities, computed tomography angiography exhibited the highest concordance rate between the two criteria (85.6%). The concordance rate among patients aged >60 years was 95.7%. Only one patient aged 50-60 years was reclassified as having both TAK and giant cell arteritis.

CONCLUSIONS

The concordance rate was 85.5% regardless of the imaging modalities and increased to 86.9% on simultaneous computed tomography angiography and fluorodeoxyglucose-positron emission tomography imaging.

The utility of 18F-FDG-PET/CT in detecting extracranial large vessel vasculitis in rheumatic polymyalgia or giant cell arteritis. A systematic review and meta-analysis

OBJECTIVE

Systematic review of current evidence to analyze the prevalence of extracranial large vessel vasculitis (LVV) using 18F-FDG PET/CT in patients with polymyalgia rheumatica (PMR) or giant cell arteritis (GCA).

MATERIALS AND METHODS

PubMed and EMBASE were searched and the results were screened by two reviewers. Study quality was assessed using a modified version of the Newcastle-Ottawa scale. Heterogeneity between studies was assessed using the I2 statistic and the Q test. Further subgroup analyses were performed by disease type, study quality, and 18F-FDG PET/CT uptake criteria. Publication bias was assessed by funnel plot and Egger's test.

RESULTS

268 publications were identified, of which 17 met the selection criteria and were included in the meta-analysis. The overall pooled prevalence of extracranial LVV by 18F-FDG PET/CT was 54.5% [95% CI: 42.6%-66.1%]. In patients with GCA the prevalence was significantly higher than in patients with PMR (60.1% vs. 41.8%, P = 0.006). Likewise, studies with a lower risk of bias reported a higher prevalence of extracranial LVV (61.1% vs. 46.9%; P = 0.010). No publication bias was observed.

CONCLUSIONS

The 18F-FDG PET/CT test may be useful in the detection of extracranial LVV, both in patients with PMR or GCA. Such involvement is more frequent in patients with GCA, and may vary depending on the quality of the studies.

Clinical Manifestations and Prognosis of Giant Cell Arteritis: A Retrospective Cohort Study

The aim of the study was to evaluate the clinical manifestations and survival of patients with giant cell arteritis (GCA).

MATERIALS AND METHODS

. A retrospective study included 166 patients with newly diagnosed GCA. Clinical, laboratory, and instrumental data and three sets of classification criteria were used to confirm the diagnosis: the American College of Rheumatology (ACR) 1990, the revised ACR criteria of 2016 and/or the new ACR and European Alliance of Rheumatologic Associations (EULAR) 2022 criteria. Some of the patients underwent instrumental investigations: temporal artery ultrasound Doppler (n = 61), contrast-enhanced computed tomography (n = 5), CT angiography (n = 6), magnetic resonance imaging (n = 4), MR angiography (n = 3), and 18F-FDG PET/CT (n = 47). Overall and recurrence-free survival rates were analyzed using survival tables and Kaplan-Meier method.

RESULTS

. The most frequent first manifestations of GCA were headache (81.8%), weakness (64%), fever (63.8%), and symptoms of rheumatic polymyalgia (56.6%). Changes in temporal arteries in color duplex scanning were detected in 44 out of 61 patients. GCs therapy was performed in all patients who agreed to be treated (n = 158), methotrexate was used in 49 out of 158 patients, leflunomide in 9 patients. In 45 (28.5%) out of 158 patients, a stable remission was achieved as a result of GC monotherapy; in 120 (75.9%) patients, long-term maintenance therapy with GCs was required to prevent exacerbations, including 71 (44.9%) patients in combination with methotrexate or other immunosuppressive drugs. The follow-up period of patients with a history of relapses was 21.0 (8.0-54.0) months. Relapses developed in 73 (46.2%) patients. The overall one-year survival rate was 97.1% [95% CI 94.3; 99.9], and the five-year survival rate of patients was 94.6% [95% CI 90.2; 99.0]. The one-year relapse-free survival rate was 86.4% [95% CI 80.5; 92.3], and the five-year relapse-free survival rate was 52.4% [95% CI 42.0; 62.8]. Twelve (7.2%) of 166 patients died. The cause of death was myocardial infarction in two patients, stroke in two patients, and breast cancer in one patient; in the remaining seven cases, the cause of death was not determined.

CONCLUSIONS

: Given the high frequency of disease exacerbation, patients with GCA require long-term follow-up, especially during the first year after diagnosis.

Cranial and extracranial manifestations of giant cell arteritis: a single-center observational study

INTRODUCTION

Giant cell arteritis (GCA) presents two major phenotypes - cranial (cGCA) and extracranial (exGCA). exGCA may be overlooked. The study aimed to compare the clinical characteristics between cGCA and exGCA.

METHODS

Electronic medical records of patients treated between January 2015 and July 2023 at the Department of Rheumatology were searched for the diagnosis of GCA. The clinical characteristics of patients with cGCA, exGCA, and overlapping GCA manifestations were compared.

RESULTS

Out of 32 patients with GCA, 20 had cGCA, 7 had exGCA, and 5 had overlap manifestations. The groups did not differ significantly in demographics, clinical signs/symptoms, or laboratory test results. Importantly, the combined group of patients with exGCA and overlap GCA had a statistically significant delay in initiating treatment (median 12 weeks) compared to patients with cGCA (median 4 weeks; p = 0.008).

CONCLUSION

Our study confirmed the insidious nature of exGCA, which lacks distinctive clinical symptoms and consequently leads to delayed treatment.

AMALRIC TRIANGULAR SIGN AND CAROTID DOPPLER ULTRASONOGRAPHIC FINDINGS IN CENTRAL RETINAL ARTERY OCCLUSION

PURPOSE

The aim of this study was to determine the incidence of the Amalric triangular sign (ATS) in patients with central retinal artery occlusion and investigate its association with visual function and carotid Doppler ultrasonography findings.

METHODS

A retrospective chart review was conducted on 21 eyes from 21 patients with complete central retinal artery occlusion. Best-corrected visual acuity and carotid Doppler ultrasonography findings [peak systolic velocity, end-diastolic velocity, and resistance index (RI) = (PSV - EDV)/PSV] were investigated.

RESULTS

Three patients (14%) exhibited the ATS. Best-corrected visual acuity at first visit was significantly worse in ATS-positive patients than in ATS-negative patients (P = 0.024). Doppler waveform analysis of the common carotid artery showed that ATS-positive patients had a significantly lower end-diastolic velocity [P = 0.009, median 10 (range 9-10) vs. 17 (13-24) m/second] and significantly higher resistance index [P = 0.021, median 0.80 (range 0.79-0.83) vs. 0.72 (0.66-0.82)] than did ATS-negative.

CONCLUSION

The Amalric triangular sign was observed in three patients with central retinal artery occlusion, who showed worse best-corrected visual acuity at the first visit than did those without the ATS. Carotid Doppler ultrasonography revealed that ATS-positive patients had a significantly higher resistance index and lower end-diastolic velocity at the common carotid artery than did ATS-negative, indicating steno-occlusive changes in the internal carotid artery.