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Merati M, Radomski S, Below A, Lambert-Cheatham N, Keating R, Chang H, Kaufman D. Multiple Cranial Nerve Palsies as the Presenting Sign of GCA. J Neuroophthalmol 2024; 44:e252-e253. [PMID: 36892944 DOI: 10.1097/wno.0000000000001824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Affiliation(s)
- Melody Merati
- Department of Neurology and Ophthalmology, Michigan State University, East Lansing, Michigan
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Arya Pv A, Madathanapalli KA, Tenezaca FC, Wang A. Temporal arteritis presenting as third nerve palsy - a case report and review of literature. Rheumatol Int 2024:10.1007/s00296-024-05604-6. [PMID: 38739224 DOI: 10.1007/s00296-024-05604-6] [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: 02/06/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024]
Abstract
Giant Cell Arteritis (GCA), also known as Temporal Arteritis, is a type of large vessel vasculitis primarily affecting the elderly population. It typically manifests with headaches, visual impairment, and jaw claudication. Although third nerve palsy as the primary presentation of GCA is rare, it has been reported in previous instances. In this report, we describe the case of a patient presenting with pupil-sparing third nerve palsy, ultimately diagnosed with GCA, and successfully managed with steroids and tocilizumab. A lady in her 80s with past medical history of well-controlled hypertension, bladder cancer in remission, a twenty-pack year smoking history, cervical and lumbar spine stenosis, and recent immunizations presented with acute onset of right-sided pupil-sparing third nerve palsy. Labs were pertinent for an elevated ESR and CRP. Brain imaging was without acute abnormalities. A temporal artery biopsy established evidence of healed arteritis and a diagnosis of GCA was made. The patient was treated with pulse-dose steroids followed by an oral steroid taper and tocilizumab. At one month follow-up, there was partial resolution in her ophthalmoplegia. We underscore the importance of considering temporal arteritis as a potential cause of third nerve palsy in the elderly before attributing it solely to microvascular ischemia, particularly in patients with constitutional features. Additionally, in our comprehensive literature review, we aim to consolidate the existing data from similar presentations, shedding light on the clinical manifestation and disease trajectory.
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Affiliation(s)
- Akhila Arya Pv
- Yale New Haven Health/Bridgeport Hospital, 267 Grant St, Bridgeport, CT, 06610, USA.
| | | | | | - Andrew Wang
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
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Colquhoun M, Alegre Abarrategui J, Shahzad MI, Ellis B. Giant cell arteritis presenting with unilateral sixth nerve palsy. BMJ Case Rep 2023; 16:e253484. [PMID: 37221002 PMCID: PMC10230926 DOI: 10.1136/bcr-2022-253484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Giant cell arteritis (GCA) usually presents with headache, scalp tenderness and raised inflammatory markers. GCA presenting with a clinically evident cranial nerve palsy is rare and may result in a delayed or missed diagnosis if not suspected. We present the rare case of a woman in her 70s with histologically confirmed GCA presenting with a unilateral sixth nerve palsy, which responded to treatment with high-dose oral prednisolone.
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Affiliation(s)
| | | | | | - Benjamin Ellis
- Rheumatology, Imperial College Healthcare NHS Trust, London, UK
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Kruszewski AM, Tamhankar MA. Ophthalmic Manifestations of Giant Cell Arteritis. Int Ophthalmol Clin 2023; 63:13-23. [PMID: 36963824 DOI: 10.1097/iio.0000000000000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
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Ye JJ, Bouffard MA, Brooks E, Hung YP, Kimchi EY. Giant Cell Arteritis Presenting With Multiple Cranial Neuropathies - Case Report. Neurohospitalist 2023; 13:188-191. [PMID: 37064934 PMCID: PMC10091440 DOI: 10.1177/19418744221139893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Vision loss accounts for most ophthalmic presentations of giant cell arteritis (GCA), but an important minority of patients present with diplopia and other cranial neuropathies. Case study: Here we present the case of an 84-year-old woman with a prior history of multiple cancers who was admitted to our hospital after developing double vision. She was found to have mydriasis, ptosis, and ophthalmoplegia in the right eye (OD) consistent with a combined R CNIII/CNVI neuropathy, as well as highly elevated inflammatory markers. Given her cancer history, the patient was initially worked up for various neoplastic, paraneoplastic, inflammatory, and infectious causes of multiple cranial neuropathies; however, as these results were negative, GCA became a more likely contender as a possible rare cause of multiple cranial neuropathies. The patient underwent temporal artery biopsy which showed pathology consistent with giant cell arteritis, and she was treated with steroids with eventual improvement in ophthalmoplegia and ptosis. Conclusions: This case illustrates the importance of recognizing GCA as a rare possible cause of multiple cranial neuropathies, including the indispensable role of temporal artery biopsy.
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Affiliation(s)
- Jessica J. Ye
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Marc A. Bouffard
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Earllondra Brooks
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Yin P. Hung
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Eyal Y. Kimchi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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Hasegawa E, Kurosawa Y, Wakamatsu A, Sato H, Kobayashi D, Nakatsue T, Kuroda T, Shimizu H, Narita I. A Case of Giant Cell Arteritis that Presented with Buccal Skin Ulceration along the Facial Artery. Intern Med 2022; 62:1541-1545. [PMID: 36198595 DOI: 10.2169/internalmedicine.0395-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
A 68-year-old man presented with right buccal ulceration along the facial artery, temporal pain, lagophthalmos, diplopia, and tongue deviation to the right. Contrast-enhanced computed tomography showed bilateral temporal artery and right maxillary artery wall thickening, and a diagnosis of giant cell arteritis (GCA) was made according to the American College of Rheumatology 1990 criteria. Treatment with corticosteroids ameliorated his symptoms. This is the first report of GCA with buccal skin ulceration along a facial artery. Because a delayed diagnosis can lead to irreversible damage, it is essential to notice rare symptoms, such as skin ulceration and multiple cranial neuropathy-like symptoms.
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Affiliation(s)
- Eriko Hasegawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Yoichi Kurosawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Ayako Wakamatsu
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Hiroe Sato
- Health Administration Center, Niigata University, Japan
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | - Takeshi Nakatsue
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | | | - Hiroshi Shimizu
- Department of Pathology, Brain Research Institute, Niigata University, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Japan
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Willett K, Sreih A, Rhee R, Lee V, Kwong B, Tamhankar MA. Giant Cell Arteritis Associated With Multiple Cranial Neuropathies. J Clin Rheumatol 2021; 27:S769-S770. [PMID: 33759483 DOI: 10.1097/rhu.0000000000001497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Rennie Rhee
- Division of Rheumatology, Department of Medicine
| | | | - Brady Kwong
- From the Scheie Eye Institute, Department of Ophthalmology
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Hiraoka D, Ishizaki J, Horie K, Matsumoto T, Suemori K, Takenaka K, Hasegawa H. Giant Cell Arteritis Presenting with Ptosis and Diplopia. Intern Med 2021; 60:2333-2336. [PMID: 33583895 PMCID: PMC8355394 DOI: 10.2169/internalmedicine.6521-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Giant cell arteritis (GCA) is vasculitis of large-sized vessels that can lead to vision loss. We herein report a rare case of GCA accompanied by ptosis and diplopia as early symptoms, which were caused by third nerve palsy. A 78-year-old man presented with fever, right temporal headache, right eyelid ptosis, and diplopia. GCA was confirmed by a temporal artery biopsy. The symptoms disappeared after a slight delay following the administration of prednisolone. Unlike vision loss, ptosis and diplopia are considered to be reversible and responsive to treatment. GCA should not be ruled out if patients exhibit these ophthalmic symptoms.
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Affiliation(s)
- Daisuke Hiraoka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Japan
| | - Jun Ishizaki
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Japan
| | - Kenta Horie
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Japan
| | - Takuya Matsumoto
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Japan
| | - Koichiro Suemori
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Japan
| | - Hitoshi Hasegawa
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Japan
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Kutty RK, Maekawa M, Kawase T, Fujii N, Kato Y. Temporal arteritis with focal pachymeningitis: a deceptive association. NAGOYA JOURNAL OF MEDICAL SCIENCE 2020; 82:143-150. [PMID: 32273643 PMCID: PMC7103863 DOI: 10.18999/nagjms.82.1.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/19/2019] [Indexed: 11/30/2022]
Abstract
Temporal arteritis is an immunological disorder mostly affecting the elderly population. This frequently occurs in association with other rheumatological diseases of the elderly. The symptoms of Temporal arteritis overlap with other symptoms of commonly occurring diseases in that population. Focal pachymeningitis in association with temporal arteritis is a rare finding and a literature review revealed less than ten cases of similar associations being published. In such instances, this finding can be mistaken for aseptic meningitis and treated erroneously. We present our case, discuss the management and summarize a review of literature about focal pachymeningitis along with temporal arteritis which was managed successfully with steroids and Toclizumab.
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Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Trivandrum, India
| | - Michitaka Maekawa
- Department of Nephrology, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Tsukasa Kawase
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Naoko Fujii
- Department of Radiology, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Bantane Hospital, Fujita Health University, Nagoya, Japan
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Saravanan V, Pugmire S, Smith M, Kelly C. Patient-reported involvement of the eighth cranial nerve in giant cell arteritis. Clin Rheumatol 2019; 38:3655-3660. [PMID: 31420810 DOI: 10.1007/s10067-019-04747-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/29/2019] [Accepted: 08/08/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The frequency of eighth nerve lesions in patients with giant cell arteritis (GCA) has rarely been examined. However, sudden onset deafness has been recorded as a presenting feature of GCA on several occasions. This study sought to establish how common this and other symptoms of eighth nerve involvement are in a large retrospective survey. METHODS We contacted 170 patients with GCA and 250 matched PMR patients, inviting them to participate in a questionnaire survey of symptoms of eighth nerve dysfunction. We compared the presence of deafness, tinnitus, loss of balance and vertigo in both groups and examined the relationship between the onset of these symptoms and other features of GCA. RESULTS A total of 317 patients were recruited. The percentage of patients with symptoms of possible vestibulocochlear disease prior to commencement of steroid therapy was significantly greater among GCA patients than PMR patients for all domains. Hearing loss which was twice as common in GCA as in PMR (53% vs 26%) [p = 0.001]. Deafness was concurrent in 35% of GCA patients with other symptoms and 45% reported colocation with headache. Recovery with steroids occurred in 56% of these. CONCLUSION Symptoms of eighth nerve dysfunction are present in over half of patients with GCA. Recovery with steroids was predicted by concurrence with headache in terms of both timing and location. It appears that eighth nerve involvement, especially acute hearing loss, is a not infrequent feature of GCA and often responds well to steroid therapy. Clinicians should enquire about these symptoms when evaluating a patient for possible GCA.Key Points• Deafness is a frequent presenting feature of giant cell arteritis.• Vertigo, tinnitus and loss of balance are also often reported by GCA sufferers.• Steroid therapy is more likely to relieve these symptoms if they are ipsilateral and concurrent with headache.
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Affiliation(s)
- Vadivelu Saravanan
- Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK
| | - Susan Pugmire
- Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK
| | - Mavis Smith
- Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK
| | - Clive Kelly
- Department of Rheumatology, Queen Elizabeth Hospital, Sheriff Hill, Gateshead, UK.
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Lunagariya A, Rupareliya C, Bollu PC, Mahuwala Z. Temporal Arteritis Presenting as an Isolated Bilateral Abducens Nerve Palsy: A Rare Case of a 65-year-old Male. Cureus 2018; 10:e2667. [PMID: 30042918 PMCID: PMC6054368 DOI: 10.7759/cureus.2667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Giant cell arteritis (GCA) or temporal arteritis (TA) is a granulomatous inflammation of medium to large-sized arteries. It may have a diverse presentation. The most common presenting symptoms of GCA are fever, malaise, unilateral headache, jaw claudication, polymyalgia rheumatica (PMR) and ophthalmoplegia. Most severe sequelae of GCA could be blindness. We report a case of a 65-year-old Caucasian male who presented for the third time with recurrent episodes of diplopia. Neurologic exam showed bilateral cranial nerve (CN) VI palsy, slightly worse on the right than the left side. Other focal neurological deficits were absent. GCA was considered and biopsy of the temporal artery was performed which showed necrotizing pan-arteritis, consistent with GCA. The patient was empirically treated with intravenous (IV) methylprednisolone while awaiting the biopsy results which resulted in the resolution of the symptoms. As far as we know, this is the second case in the literature about the bilateral sixth CN involvement in the background of GCA.
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Affiliation(s)
| | | | - Pradeep C Bollu
- Department of Neurology, University of Missouri, Columbia, USA
| | - Zabeen Mahuwala
- Department of Neurology, University Of Kentucky College of Medicine
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Abstract
PURPOSE OF REVIEW The primary systemic vasculitides represent a spectrum of rare but life-threatening conditions that may also affect the eye in various forms. This article reviews recently published data on ocular manifestations of systemic vasculitis. RECENT FINDINGS Early diagnosis and timely treatment has led to better visual outcomes in giant cell arteritis (GCA). Gene expression from orbital tissues could distinguish granulomatosis with polyangiitis (GPA) from sarcoidosis and Graves disease, but not from idiopathic orbital inflammation. Rituximab was an effective therapeutic option in ocular GPA. An ocular attack severity scoring system, flare levels, fluorescein angiography and optical coherence tomography parameters have been suggested as predictors of visual prognosis in Behçet disease. Efficacy of tumor necrosis factor-alpha inhibitors, interferon α and anti-interleukin-1 agents was shown in noncontrolled studies of ocular Behçet disease. SUMMARY Widely used fast-track pathway care as well as ocular imaging to detect subclinical involvement may enable earlier diagnosis of GCA and prevention of permanent visual loss. Orbital inflammation may not remain idiopathic with advances in gene expression profiling of orbital tissues. With an increased availability and the use of biologic agents, visual prognosis will improve in patients with severe ocular complications of systemic vasculitides.
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Abstract
PURPOSE OF REVIEW Giant cell arteritis (GCA) remains a potentially blinding inflammatory vasculitis of the elderly. Because prolonged doses of corticosteroids remain the best established treatment, side-effects during treatment are common and potentially serious. This review addresses the challenges clinicians face in managing this disease. RECENT FINDINGS High-dose corticosteroids with slow tapering and close monitoring are the mainstay of treatment. Investigations into adjunctive treatment have yet to establish other agents as beneficial, but further research is ongoing with some promising results. SUMMARY GCA represents a challenging illness to clinicians because of its potential for causing blindness and the need for prolonged high doses of corticosteroids with their many complications.
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Ponte C, Rodrigues AF, O’Neill L, Luqmani RA. Giant cell arteritis: Current treatment and management. World J Clin Cases 2015; 3:484-94. [PMID: 26090367 PMCID: PMC4468893 DOI: 10.12998/wjcc.v3.i6.484] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/28/2015] [Accepted: 03/30/2015] [Indexed: 02/05/2023] Open
Abstract
Glucocorticoids remain the cornerstone of medical therapy in giant cell arteritis (GCA) and should be started immediately to prevent severe consequences of the disease, such as blindness. However, glucocorticoid therapy leads to significant toxicity in over 80% of the patients. Various steroid-sparing agents have been tried, but robust scientific evidence of their efficacy and safety is still lacking. Tocilizumab, a monoclonal IL-6 receptor blocker, has shown promising results in a number of case series and is now being tested in a multi-centre randomized controlled trial. Other targeted treatments, such as the use of abatacept, are also now under investigation in GCA. The need for surgical treatment is rare and should ideally be performed in a quiescent phase of the disease. Not all patients follow the same course, but there are no valid biomarkers to assess therapy response. Monitoring of disease progress still relies on assessing clinical features and measuring inflammatory markers (C-reactive protein and erythrocyte sedimentation rate). Imaging techniques (e.g., ultrasound) are clearly important screening tools for aortic aneurysms and assessing patients with large-vessel involvement, but may also have an important role as biomarkers of disease activity over time or in response to therapy. Although GCA is the most common form of primary vasculitis, the optimal strategies for treatment and monitoring remain uncertain.
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