Arteriitis temporalis (Riesenzellarteriitis)

[Rheumatological emergency on the edge of intensive care medicine]

In rheumatological practice situations repeatedly occur where critical problems which need to be quickly addressed in order to prevent permanent damage to the patient. The focus of this article is on rapidly progressive inflammatory diseases, severe side effects of many medications and complications of infections during immunosuppressive treatment.

Bilateral Posterior Scleritis Associated with Giant Cell Arteritis: A Case Report

AIM

To report a case of bilateral posterior scleritis associated with giant cell arteritis Case Report: A 62-year-old female patient presented with bilateral progressive vision loss was diagnosed with bilateral posterior scleritis. According to clinical signs and symptoms and laboratory testing, Giant cell arteritis was also diagnosed. Within 8 weeks of the corticosteroid treatment, the serous retinal detachments completely resolved and choroidal thickness decreased in both eyes. Visual acuity increased, and the symtoms related to Giant cell arteritis improved.

CONCLUSION

Posterior scleritis is an inflammatory disease that may be associated with many autoimmune systemic diseases. GCA should be thought of particularly in patients over the age of 50 with bilateral involvement, and a relevant detailed history should be obtained for early and correct diagnosis and treatment.

The diagnosis and treatment of giant cell arteritis

BACKGROUND

Giant cell arteritis (GCA) is the most common systemic vasculitis in persons aged 50 and above (incidence, 3.5 per 100,000 per year). It affects cranial arteries, the aorta, and arteries elsewhere in the body, e.g., in the limbs.

METHODS

We selectively review the pertinent literature, including guidelines and recommendations from Germany and abroad.

RESULTS

The typical symptoms of new-onset GCA are bitemporal headaches, jaw claudiacation, scalp tenderness, visual disturbances, systemic symptoms such as fever and weight loss, and polymyalgia. The diagnostic assessment comprises laboratory testing (erythrocyte sedimentation rate, C-reactive protein), imaging studies (duplex sonography, high-resolution magnetic resonance imaging, positron-emission tomography), and temporal artery biopsy. The standard treatment is with corticosteroids (adverse effects: diabetes mellitus, osteoporosis, cataract, arterial hypertension). A meta-analysis of three randomized controlled trials led to a recommendation for treatment with methotrexate to lower the recurrence rate and spare steroids. Patients for whom methotrexate is contraindicated or who cannot tolerate the drug can be treated with azathioprine instead.

CONCLUSION

Giant cell arteritis, if untreated, progresses to involve the aorta and its collateral branches, leading to various complications. Late diagnosis and treatment can have serious consequences, including irreversible loss of visual function.

[Ocular involvement in connective tissue diseases and vasculitides]

Connective tissue diseases and systemic vasculitides are commonly associated with ocular manifestations, which can lead to severe complications and even blindness. The present review article describes these ocular manifestations, their signs and symptoms and possible treatment options for Sjoegren's syndrome, systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APLS), as well as those of giant cell arteritis/cranial arteritis, ANCA-associated vasculitides and Behçet's disease. Additionally, possible ocular adverse effects of antimalarial agents are described.

[Clinical aspects of temporal arteritis: course variations up to fatal complications]

BACKGROUND

Arteritis temporalis (AT) shows a variable course of the disease and may lead to transient or permanent visual loss.

PATIENTS AND METHODS

In a retrospective consecutive case series 66 patients with suspected AT were followed up of which 65 underwent arterial biopsy. Symptoms, therapy and complications were followed up.

RESULTS

Of the patients 32 (49.2%) revealed a positive histological finding in unilateral (55.4%) or bilateral (44.6%) biopsy. Of these 3 (9.4%) suffered a severe or fatal outcome: two with extensive ischemia of the vertebrobasilar system (one fatal) and one patient died due to acute pancreatitis, a rare side effect of systemic steroid therapy.

CONCLUSION

When systemically apparent, arteritis temporalis can progress to reduction of general health, cerebral ischemia and organ infarction. Therefore, AT is a serious disease requiring interdisciplinary, immediate diagnostics and prompt therapy.

[Acute visual loss with bilateral corneal edema]

An 84-year-old woman presented with bilateral visual loss that had appeared 3 days previously. Split lamp examination showed bilateral corneal edema with normal intraocular pressure. The patient complained of headache and vomiting, and finally collapsed. Elevated levels of inflammation markers led to the suspicion of an inflammatory disease. After investigation for internal or neurological diseases, a biopsy of the temporal artery was performed. Giant cell arteritis (Horton's disease) was found, and steroid therapy was begun. The patient's general condition then improved.

Retinal vascular occlusions: an interdisciplinary challenge

INTRODUCTION

Retinal venous and arterial occlusions are common causes of visual loss. Depending on the location and extent, symptoms may vary from very discrete impairments to complete loss of sight.

METHODS

Selective literature review including the authors' own research data with a particular focus on interdisciplinary aspects.

RESULTS

Retinal vascular occlusions are not a uniform entity. Rather, they reflect the whole breadth of vascular disease. In arterial occlusion, embolic phenomena and Horton's arteritis should be excluded, in addition to local ophthalmological investigations. In retinal venous occlusion, optimal treatment of arterial hypertension is universally useful, while investigations for thrombophilia are useful in patients under 50 years of age. The results of intravitreal injection of corticosteroids and vascular endothelial growth factor inhibitors appear encouraging in treatment of macular edema secondary to retinal vein occlusion.

DISCUSSION

While local diagnostic and therapeutic measures are performed by ophthalmologists, there is an important role for interdisciplinary cooperation in the investigation and systemic treatment of these events.