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Inayat H, Youn S, Bursztyn LLCD. Utility of online GCA risk models in predicting the result of temporal artery biopsy within a clinical setting: study of diagnostic and screening tests. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023:S0008-4182(23)00371-X. [PMID: 38114060 DOI: 10.1016/j.jcjo.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/23/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Temporal artery biopsy (TAB) is the gold standard for the diagnosis of giant cell arteritis (GCA) but has many limitations. The Ing model, González-López model, and Weis model are tools to estimate a patient's likelihood of GCA. This study investigates the utility of these prediction models in triaging patients referred for TAB. METHODS This study is a retrospective examination of patients who underwent TAB by a neuro-ophthalmologist over a 5-year period. Data collected through chart review were inputted into prediction models to evaluate GCA risk and compared with TAB results and clinical diagnosis. Cut-off values for 100% sensitivity and specificity for TAB result were used to determine whether TAB could be avoided where there was preoperative certainty of the result. RESULTS Among 155 eligible patients, mean age was 73 years, and 78.1% were female. TAB was negative in 103 patients (66.5%) and positive in 42 patients (27.1%). Twenty-three patients (22.3%) were diagnosed clinically and treated for biopsy-negative GCA. The Ing model had no positive biopsies below 10.59% and no negative biopsies above 68.44%. The González-López model had no positive biopsies below 0.27% and no negative biopsies above 98.08%. The Weis model had no positive biopsies with a score less than zero. CONCLUSION Forty-one biopsies (28.9%) could have been avoided using the Ing model, 9 (6.34%) using the González-López model, and 28 (19.7%) using the Weis model. The findings suggest that the Ing and Weis models are useful screening tools for GCA with the potential to improve the effective use of health care resources.
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Affiliation(s)
- Hamza Inayat
- Schulich School of Medicine and Dentistry, Western University, London, Ont..
| | - Saerom Youn
- Schulich School of Medicine and Dentistry, Western University, London, Ont
| | - Lulu L C D Bursztyn
- Department of Ophthalmology, Western University, London, Ont.; Clinical Neurological Sciences, Western University, London, Ont
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Papadakos SP, Papazoglou AS, Moysidis DV, Tsagkaris C, Papadakis DL, Koutsogianni A, Fragoulis G, Papadakis M. The Effect of Corticosteroids on Temporal Artery Biopsy Positivity in Giant Cell Arteritis: Timing is Everything. J Clin Rheumatol 2023; 29:173-176. [PMID: 36728371 DOI: 10.1097/rhu.0000000000001938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Temporal artery biopsy (TAB) remains the standard criterion for the diagnosis of giant cell arteritis (GCA). Temporal artery biopsy is suggested to be performed within 2 weeks from the initiation of corticosteroids. However, the effects of TAB timing on the sensitivity of its findings still warrant further investigation. METHODS We reviewed the medical records of patients with GCA from a tertiary medical center in Germany over an 8-year period. RESULTS We analyzed data from 109 patients with a median age of 76 years and a median time from glucocorticoid treatment to TAB of 4 days. Approximately 60% of biopsies were positive. Our analysis yielded a nonsignificant trend toward shorter duration of corticosteroid treatment in the TAB(+) group ( p = 0.06). A more than 7 days' duration of steroid treatment was independently linked with lower rates of positive TAB (adjusted odds ratio, 0.33; 95% confidence interval, 0.11-1.00). CONCLUSION We conclude that the duration of corticosteroid treatment seems to affect the positivity of TAB in patients with suspected GCA. Further larger studies are required to confirm the generalizability of our findings.
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Affiliation(s)
| | | | - Dimitrios V Moysidis
- Hippokration General Hospital of Thessaloniki, Αristotle University of Thessaloniki, Macedonia, Greece
| | - Christos Tsagkaris
- Novel Global Community Educational Foundation, Hebersham, New South Wales, Australia
| | | | | | - Georgios Fragoulis
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marios Papadakis
- Department of Surgery II, University Witten-Herdecke, Wuppertal, Germany
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Lafreniere AS, Ponich B, Hartley R, Temple-Oberle CF. Questioning the Utility of Temporal Artery Biopsy in Giant Cell Arteritis: A Negative Biopsy May Facilitate Decision-making. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5035. [PMID: 37305198 PMCID: PMC10256361 DOI: 10.1097/gox.0000000000005035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 04/10/2023] [Indexed: 06/13/2023]
Abstract
Plastic surgeons are frequently consulted to perform temporal artery biopsy (TAB), even though patients meet the American College of Rheumatology diagnostic criteria for giant cell arteritis (GCA) and are already treated. This study aimed to analyze the impact of TAB on steroid duration in patients undergoing TAB. Methods We undertook a prospective study of adult patients undergoing TAB for GCA in Calgary. Consecutive, multicenter recruitment was performed over 2 years. Primary outcomes included initiation or discontinuation and duration of corticosteroids. Results Twenty-one TABs were performed in 20 patients. Nineteen percent of TABs were positive, and 71.4%, negative. In 9.5% of patients, accidental sampling of a vessel other than the superficial temporal artery occurred. Fifty-two percent of patients received steroids before TAB, of which the mean duration was 8.0 days for TAB+ (postive temporal artery biopsy result) patients and 8.4 days for TAB- (negative temporal artery biopsy result; P = 0.22) patients. Before TAB, the American College of Rheumatology score was 2.5 for TAB+ patients and 2.4 for TAB- (P = 0.74). Postbiopsy, the American College of Rheumatology score was 3.5 for TAB+ patients (therefore reaching diagnostic threshold of 3) but remained 2.4 for TAB- (P = 0.02). TAB+ patients were treated for 352.3 days, whereas TAB- patients for 16.7 days (P = 0.29). Complications were more likely with long-term (>6 weeks) steroids (P = 0.17). Conclusion In patients with a low suspicion of GCA, a negative TAB helps bolster physician confidence and leads to a shorter steroid duration.
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Affiliation(s)
- Ann-Sophie Lafreniere
- From the Division of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Brett Ponich
- From the Division of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Rebecca Hartley
- From the Division of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Claire F. Temple-Oberle
- From the Division of Plastic and Reconstructive Surgery, University of Calgary, Calgary, Alberta, Canada
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Villeneuve E, Lacroix JM, Brisebois S. Optimizing the use of temporal artery biopsy: a retrospective study. J Otolaryngol Head Neck Surg 2023; 52:4. [PMID: 36703222 PMCID: PMC9878764 DOI: 10.1186/s40463-022-00605-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 10/26/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Giant cell arteritis is an inflammatory disease of the large- and medium-sized vessels. It is the most common primary vasculitis, with lifetime incidences of 0.5% and 1% in men and women, respectively. Its diagnosis is based upon clinical criteria, which may include temporal artery biopsy. Expected positivity rates of temporal artery biopsies and patient selection remain controversial topics in the literature. METHODS A cross-sectional retrospective study of 127 patients referred for temporal artery biopsy with a diagnosis of suspected giant cell arteritis between January 2014 and December 2018 was performed. The primary outcome was the positivity rate. The relationships between positivity rates, symptoms, clinical suspicion, biopsy delay, biopsy length and corticosteroid treatment were also studied. RESULTS A positivity rate of 23.7% (16.6-32.6%) was shown, along with a significant association between jaw claudication and specimen positivity (odds ratio 8.1, p < 0.05). Moreover, there were significant associations between a high initial clinical suspicion of disease and specimen positivity (p < 0.05), as well as a high initial clinical suspicion of disease and pursuit of corticosteroid treatment following biopsy results, regardless of positivity (p < 0.05). The duration of corticosteroid treatment prior to biopsy was not associated with a change in positivity rate. CONCLUSIONS The positivity rate of temporal artery biopsy was 23.7%. Treatment of patients with negative temporal artery biopsy was associated with maintenance of corticosteroid treatment when the initial clinical suspicion of arteritis was high. Therefore, temporal artery biopsy may not be necessary for patients with a high initial clinical suspicion of giant cell arteritis.
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Affiliation(s)
- Etienne Villeneuve
- Division of Otolaryngology, Head and Neck Surgery, Université de Sherbrooke, Sherbrooke, Canada.
| | | | - Simon Brisebois
- Division of Otolaryngology, Head and Neck Surgery, Université de Sherbrooke, Sherbrooke, Canada
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Dentel A, Clavel G, Savatovsky J, Vignal C, Senè T, Charbonneau F, Zuber K, Lecler A, Hage R. Use of Retinal Angiography and MRI in the Diagnosis of Giant Cell Arteritis With Early Ophthalmic Manifestations. J Neuroophthalmol 2022; 42:218-225. [PMID: 35051984 DOI: 10.1097/wno.0000000000001517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is a vasculitis often revealed by visual signs. Diagnosis is challenging and urgent. Retinal angiography (RA) and MRI allow effective diagnosis. We compared those and proposed an imaging-based approach to diagnose GCA in ophthalmological practice. METHODS We conducted a retrospective study based on the data collected from patients suspected to have GCA on ophthalmological findings. Fluorescein (FA) and indocyanine green (ICG) RAs and MRI were performed and compared with final diagnosis. RESULTS Among the 41 patients included, 25 were diagnosed with GCA. Sensitivities and specificities of FA and ICG were not different. MRI showed a higher sensitivity and specificity. The approach consisting in performing RA followed by MRI provided a better accuracy. CONCLUSION Our study shows that RA can be supplemented by MRI in a specialized center to provide the most accurate diagnosis in GCA revealed by visual signs.
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Affiliation(s)
- Alexandre Dentel
- Department of Ophthalmology (AD, CV, RH), Foundation Adolphe de Rothschild Hospital, Paris, France; Department of Internal Medicine (GC, TS), Foundation Adolphe de Rothschild Hospital, Paris, France; Department of Neuroradiology (JS, FC, AL), Foundation Adolphe de Rothschild Hospital, Paris, France ; and Department of Clinical Research (KZ), Foundation Adolphe de Rothschild Hospital, Paris, France
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Necessity of Temporal Artery Biopsy for Giant Cell Arteritis: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4185. [PMID: 35620490 PMCID: PMC9126522 DOI: 10.1097/gox.0000000000004185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/10/2022] [Indexed: 11/26/2022]
Abstract
Temporal artery biopsy (TAB) is currently the gold standard procedure to diagnose giant cell arteritis. Despite low sensitivity, TAB is routinely performed even if a clinical diagnosis has already been made. The objective of this study was to determine the usefulness of TAB for giant cell arteritis management. Methods We performed a systematic review to identify studies that compared steroid treatment between TAB+ and TAB- patients. EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception until April 4, 2020. Titles, abstracts, and full texts were reviewed by two independent reviewers and conflicts resolved by consensus. Studies reporting TAB result and steroid treatment were included. Information pertaining to steroid treatment was compared between TAB+ and TAB- groups. Steroid duration was compared by grouping patients in a less than 6 month group, a 6-24 month group, and a more than 24 month group. Results An estimated 5288 abstracts were screened and 13 studies involving 1355 patients were included. Rate of prebiopsy steroid treatment was higher in TAB+ patients compared with TAB- patients [93% versus 63% (P < 0.001)]. The TAB+ group was more likely to be started on steroids prebiopsy [28% versus 8% (P < 0.001)]. TAB+ and TAB- patients had similar steroid duration for all groups [<6-month group 17% versus 19% (P-0.596), the 6-24-month group 16% versus 19% (P-0.596), and the >24-month group 66% versus 63% (P-0.642)]. Conclusion TAB results have minimal impact on treatment, and the utility should be reconsidered when a clinical diagnosis of giant cell arteritis is possible.
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Micieli JA, Grossniklaus HE, Peragallo JH. Masquerades of Giant Cell Arteritis Evident on Temporal Artery Biopsy. J Clin Rheumatol 2021; 27:e568-e574. [PMID: 31124922 DOI: 10.1097/rhu.0000000000001072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van der Geest KSM, Sandovici M, Brouwer E, Mackie SL. Diagnostic Accuracy of Symptoms, Physical Signs, and Laboratory Tests for Giant Cell Arteritis: A Systematic Review and Meta-analysis. JAMA Intern Med 2020; 180:1295-1304. [PMID: 32804186 PMCID: PMC7432275 DOI: 10.1001/jamainternmed.2020.3050] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/25/2020] [Indexed: 01/01/2023]
Abstract
Importance Current clinical guidelines recommend selecting diagnostic tests for giant cell arteritis (GCA) based on pretest probability that the disease is present, but how pretest probability should be estimated remains unclear. Objective To evaluate the diagnostic accuracy of symptoms, physical signs, and laboratory tests for suspected GCA. Data Sources PubMed, EMBASE, and the Cochrane Database of Systematic Reviews were searched from November 1940 through April 5, 2020. Study Selection Trials and observational studies describing patients with suspected GCA, using an appropriate reference standard for GCA (temporal artery biopsy, imaging test, or clinical diagnosis), and with available data for at least 1 symptom, physical sign, or laboratory test. Data Extraction and Synthesis Screening, full text review, quality assessment, and data extraction by 2 investigators. Diagnostic test meta-analysis used a bivariate model. Main Outcome(s) and Measures Diagnostic accuracy parameters, including positive and negative likelihood ratios (LRs). Results In 68 unique studies (14 037 unique patients with suspected GCA; of 7798 patients with sex reported, 5193 were women [66.6%]), findings associated with a diagnosis of GCA included limb claudication (positive LR, 6.01; 95% CI, 1.38-26.16), jaw claudication (positive LR, 4.90; 95% CI, 3.74-6.41), temporal artery thickening (positive LR, 4.70; 95% CI, 2.65-8.33), temporal artery loss of pulse (positive LR, 3.25; 95% CI, 2.49-4.23), platelet count of greater than 400 × 103/μL (positive LR, 3.75; 95% CI, 2.12-6.64), temporal tenderness (positive LR, 3.14; 95% CI, 1.14-8.65), and erythrocyte sedimentation rate greater than 100 mm/h (positive LR, 3.11; 95% CI, 1.43-6.78). Findings that were associated with absence of GCA included the absence of erythrocyte sedimentation rate of greater than 40 mm/h (negative LR, 0.18; 95% CI, 0.08-0.44), absence of C-reactive protein level of 2.5 mg/dL or more (negative LR, 0.38; 95% CI, 0.25-0.59), and absence of age over 70 years (negative LR, 0.48; 95% CI, 0.27-0.86). Conclusions and Relevance This study identifies the clinical and laboratory features that are most informative for a diagnosis of GCA, although no single feature was strong enough to confirm or refute the diagnosis if taken alone. Combinations of these symptoms might help direct further investigation, such as vascular imaging, temporal artery biopsy, or seeking evaluation for alternative diagnoses.
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Affiliation(s)
- Kornelis S. M. van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Sarah L. Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR (National Institute for Health Research) Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS (National Health Service) Trust, University of Leeds, Leeds, United Kingdom
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Nielsen BD, Gormsen LC. 18F-Fluorodeoxyglucose PET/Computed Tomography in the Diagnosis and Monitoring of Giant Cell Arteritis. PET Clin 2020; 15:135-145. [PMID: 32145884 DOI: 10.1016/j.cpet.2019.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
18F-Fluorodeoxyglucose (FDG) PET/computed tomography (CT) is a highly accurate diagnostic tool for large vessel vasculitis (LVV) and is one of the recommended imaging modalities for confirmation of the diagnosis. This article focuses on the role of FDG-PET/CT in LVV diagnosis and disease monitoring, mainly focusing on giant cell arteritis; in particular, the diagnostic accuracy, diagnostic criteria, the potential pitfalls in the interpretation of large vessel FDG uptake, and the clinical indication compared with other imaging modalities are discussed.
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Affiliation(s)
- Berit Dalsgaard Nielsen
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 59, Entrance E, Aarhus, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, Entrance J, Aarhus 8200, Denmark; Diagnostic Centre, Silkeborg Regional Hospital, Falkevej 1A, 8600 Silkeborg, Denmark.
| | - Lars Christian Gormsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, Entrance J, Aarhus 8200, Denmark
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Membrey B, Miranda S, Lévesque H, Cailleux N, Benhamou Y, Armengol G. Artérite gigantocellulaire : apport de l’écho-doppler. Rev Med Interne 2020; 41:106-110. [DOI: 10.1016/j.revmed.2019.10.337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/04/2019] [Accepted: 10/21/2019] [Indexed: 01/22/2023]
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Increased diagnostic accuracy of giant cell arteritis using three-dimensional fat-saturated contrast-enhanced vessel-wall magnetic resonance imaging at 3 T. Eur Radiol 2019; 30:1866-1875. [PMID: 31811430 DOI: 10.1007/s00330-019-06536-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/08/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To compare the diagnostic accuracy of 3D versus 2D contrast-enhanced vessel-wall (CE-VW) MRI of extracranial and intracranial arteries in the diagnosis of GCA. METHODS This prospective two-center study was approved by a national research ethics board and enrolled participants from December 2014 to October 2017. A protocol including both a 2D and a 3D CE-VW MRI at 3 T was performed in all patients. Two neuroradiologists, blinded to clinical data, individually analyzed separately and in random order 2D and 3D sequences in the axial plane only or with reformatting. The primary judgment criterion was the presence of GCA-related inflammatory changes of extracranial arteries. Secondary judgment criteria included inflammatory changes of intracranial arteries and the presence of artifacts. A McNemar's test was used to compare 2D to 3D CE-VW MRIs. RESULTS Seventy-nine participants were included in the study (42 men and 37 women, mean age 75 (± 9.5 years)). Fifty-one had a final diagnosis of GCA. Reformatted 3D CE-VW was significantly more sensitive than axial-only 3D CE-VW or 2D CE-VW when showing inflammatory change of extracranial arteries: 41/51(80%) versus 37/51 (73%) (p = 0.046) and 35/50 (70%) (p = 0.03). Reformatted 3D CE-VW was significantly more specific than 2D CE-VW: 27/27 (100%) versus 22/26 (85%) (p = 0.04). 3D CE-VW showed higher sensitivity than 2D CE-VW when detecting inflammatory changes of intracranial arteries: 10/51(20%) versus 4/50(8%), p = 0.01. Interobserver agreement was excellent for both 2D and 3D CE-VW MRI: κ = 0.84 and 0.82 respectively. CONCLUSIONS 3D CE-VW MRI supported more accurate diagnoses of GCA than 2D CE-VW. KEY POINTS • 3D contrast-enhanced vessel-wall magnetic resonance imaging is a high accuracy, non-invasive diagnostic tool used to diagnose giant cell arteritis. • 3D contrast-enhanced vessel-wall imaging is feasible for clinicians to complete within a relatively short time, allowing immediate assessment of extra and intracranial arteries. • 3D contrast-enhanced vessel-wall magnetic resonance imaging might be considered a diagnostic tool when intracranial manifestation of GCA is suspected.
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Monti S, Águeda AF, Luqmani RA, Buttgereit F, Cid M, Dejaco C, Mahr A, Ponte C, Salvarani C, Schmidt W, Hellmich B. Systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis: focus on giant cell arteritis. RMD Open 2019; 5:e001003. [PMID: 31673411 PMCID: PMC6803016 DOI: 10.1136/rmdopen-2019-001003] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/10/2019] [Accepted: 08/17/2019] [Indexed: 12/13/2022] Open
Abstract
Objectives To analyse the current evidence for the management of large vessel vasculitis (LVV) to inform the 2018 update of the EULAR recommendations. Methods Two systematic literature reviews (SLRs) dealing with diagnosis/monitoring and treatment strategies for LVV, respectively, were performed. Medline, Embase and Cochrane databases were searched from inception to 31 December 2017. Evidence on imaging was excluded as recently published in dedicated EULAR recommendations. This paper focuses on the data relevant to giant cell arteritis (GCA). Results We identified 287 eligible articles (122 studies focused on diagnosis/monitoring, 165 on treatment). The implementation of a fast-track approach to diagnosis significantly lowers the risk of permanent visual loss compared with historical cohorts (level of evidence, LoE 2b). Reliable diagnostic or prognostic biomarkers for GCA are still not available (LoE 3b).The SLR confirms the efficacy of prompt initiation of glucocorticoids (GC). There is no high-quality evidence on the most appropriate starting dose, route of administration, tapering and duration of GC (LoE 4). Patients with GCA are at increased risk of dose-dependent GC-related adverse events (LoE 3b). The addition of methotrexate or tocilizumab reduces relapse rates and GC requirements (LoE 1b). There is no consistent evidence that initiating antiplatelet agents at diagnosis would prevent future ischaemic events (LoE 2a). There is little evidence to guide monitoring of patients with GCA. Conclusions Results from two SLRs identified novel evidence on the management of GCA to guide the 2018 update of the EULAR recommendations on the management of LVV.
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Affiliation(s)
- Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Ana F Águeda
- Rheumatology, Baixo Vouga Hospital Centre Agueda Unit, Agueda, Portugal
| | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Frank Buttgereit
- Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Maria Cid
- Vasculitis Research Unit, Hospital Clinic; Institute d'Investiacions Biomèdiques August pi I Sunyer, University of Barcelona, Barcelona, Spain
| | - Christian Dejaco
- Rheumatology; South Tyrol Health Trust, Gesundheitsbezirk Bruneck, Brunico, Italy.,Rheumatology, University of Graz, Graz, Austria
| | - Alfred Mahr
- Internal Medicine, Université Paris Diderot Institut Saint Louis, Paris, France
| | - Cristina Ponte
- Rheumatology, Hospital de Santa Marta, Lisboa, Portugal.,Rheumatology Research Unit, University of Lisbon Institute of Molecular Medicine, Lisboa, Portugal
| | - Carlo Salvarani
- Rheumatology, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Modena, Italy
| | - Wolfgang Schmidt
- Klinik für Innere Medizin, Rheumatologie und Klinische Immunologie Berlin-Buch, Immanuel Krankenhaus Berlin Standort Berlin-Wannsee, Berlin, Germany
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitis-Zentrum Süd, Medius Kliniken, Universitatsklinikum Tubingen, Tubingen, Germany
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Hellmich B, Agueda A, Monti S, Buttgereit F, de Boysson H, Brouwer E, Cassie R, Cid MC, Dasgupta B, Dejaco C, Hatemi G, Hollinger N, Mahr A, Mollan SP, Mukhtyar C, Ponte C, Salvarani C, Sivakumar R, Tian X, Tomasson G, Turesson C, Schmidt W, Villiger PM, Watts R, Young C, Luqmani RA. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis 2019; 79:19-30. [PMID: 31270110 DOI: 10.1136/annrheumdis-2019-215672] [Citation(s) in RCA: 572] [Impact Index Per Article: 114.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Since the publication of the European League Against Rheumatism (EULAR) recommendations for the management of large vessel vasculitis (LVV) in 2009, several relevant randomised clinical trials and cohort analyses have been published, which have the potential to change clinical care and therefore supporting the need to update the original recommendations. METHODS Using EULAR standardised operating procedures for EULAR-endorsed recommendations, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 13 countries. We modified existing recommendations and created new recommendations. RESULTS Three overarching principles and 10 recommendations were formulated. We recommend that a suspected diagnosis of LVV should be confirmed by imaging or histology. High dose glucocorticoid therapy (40-60 mg/day prednisone-equivalent) should be initiated immediately for induction of remission in active giant cell arteritis (GCA) or Takayasu arteritis (TAK). We recommend adjunctive therapy in selected patients with GCA (refractory or relapsing disease, presence of an increased risk for glucocorticoid-related adverse events or complications) using tocilizumab. Methotrexate may be used as an alternative. Non-biological glucocorticoid-sparing agents should be given in combination with glucocorticoids in all patients with TAK and biological agents may be used in refractory or relapsing patients. We no longer recommend the routine use of antiplatelet or anticoagulant therapy for treatment of LVV unless it is indicated for other reasons. CONCLUSIONS We have updated the recommendations for the management of LVV to facilitate the translation of current scientific evidence and expert opinion into better management and improved outcome of patients in clinical practice.
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Affiliation(s)
- Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken, University of Tübingen, Kirchheim-Teck, Germany
| | - Ana Agueda
- Rheumatology Department, Centro Hospitalar do Baixo Vouga E.P.E, Aveiro, Portugal
| | - Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Frank Buttgereit
- Department of Rheumatology and Immunology, University Hospital Charité, Berlin, Germany
| | - Hubert de Boysson
- Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen, Basse-Normandie, France
| | - Elisabeth Brouwer
- Rheumatology and Clinical Immunology, UMCG, Groningen, The Netherlands
| | | | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Christian Dejaco
- Rheumatology, Medical University Graz, Graz, Austria.,Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Nicole Hollinger
- Department of Internal Medicine, Rheumatology and Immunology, Medus Klinken, Karl-Albrechts-Universität Tübingen, Kirchheim-Teck, Germany
| | - Alfred Mahr
- Hospital Saint-Louis, University Paris Diderot, Paris, France
| | - Susan P Mollan
- Ophthalmology, University Hospitals Birmingham, Birmingham, UK.,Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Chetan Mukhtyar
- Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Cristina Ponte
- Rheumatology, Hospital de Santa Maria - CHLN, Lisbon Academic Medical Centre, Lisbon, Portugal.,Rheumatology Research Unit; Instituto de Medicina Molecular, Instituto de Medicina Molecular, Lisboa, Portugal
| | | | - Rajappa Sivakumar
- Stroke and Neurocritical Care, GLB Hospitals and Acute Stroke Centers, Chennai, India
| | - Xinping Tian
- Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | | | - Carl Turesson
- Department of Rheumatology, Skåne University Hospital, Malmö, Sweden
| | - Wolfgang Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel Krankenhaus Berlin, Berlin, Germany
| | - Peter M Villiger
- Rheumatology and Clinical Immunology / Allerg, University Hospital (Inselspital), Bern, Switzerland
| | - Richard Watts
- Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, UK
| | | | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
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15
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Chan FLY, Lester S, Whittle SL, Hill CL. The utility of ESR, CRP and platelets in the diagnosis of GCA. BMC Rheumatol 2019; 3:14. [PMID: 31008443 PMCID: PMC6456976 DOI: 10.1186/s41927-019-0061-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background To compare the utility of ESR, CRP and platelets for the diagnosis of GCA. Method A clinical diagnosis of GCA was determined by case-note review of 270 individuals (68% female, mean age 72 years) referred to a central pathology service for a temporal artery biopsy between 2011 and 2014. The highest levels of ESR, CRP and platelets (within 2 weeks of diagnosis) were documented. Evaluation of ESR, CRP and platelets for the diagnosis of GCA were compared using Receiver Operating Characteristic Area Under the Curve (ROC-AUC), and sensitivity/specificity at optimum cut-off values. Results GCA was clinically diagnosed in 139 (67%) patients, with 81 TAB positive. The AUC estimates for ESR, CRP and platelets were comparable (0.65 vs 0.72 vs 0.72, p = 0.08). The estimated optimal cut-off levels were confirmed at 50 mm/hour for ESR, and determined as 20 mg/L for CRP and 300 × 109/L for platelets. Sensitivity estimates for these three tests were comparable (p = 0.45) and ranged between 66% for ESR and 71% for platelets. Specificity estimates were also comparable (p = 0.11) and ranged between 57% for ESR and 68% for CRP. There was only moderate agreement between the three positive tests (agreement 67%, kappa: 0.34), and when considered collectively, CRP and platelet positive tests were independent predictors of GCA (p < 0.001), but the ESR was not (p = 0.76). Conclusion ESR, CRP and platelets are moderate, equivalent diagnostic tests for GCA, but may yield disparate results in individual patients. A combination of CRP and platelet tests may provide the best diagnostic utility for GCA.
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Affiliation(s)
- Fiona Li Ying Chan
- The Rheumatology Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA 5011 Australia
| | - Susan Lester
- The Rheumatology Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA 5011 Australia
| | - Samuel Lawrence Whittle
- The Rheumatology Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA 5011 Australia
| | - Catherine Louise Hill
- The Rheumatology Department, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA 5011 Australia
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16
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Peral-Cagigal B, Pérez-Villar Á, Redondo-González LM, García-Sierra C, Morante-Silva M, Madrigal-Rubiales B, Verrier-Hernández A. Temporal headache and jaw claudication may be the key for the diagnosis of giant cell arteritis. Med Oral Patol Oral Cir Bucal 2018; 23:e290-e294. [PMID: 29680850 PMCID: PMC5945239 DOI: 10.4317/medoral.22298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 02/26/2018] [Indexed: 12/27/2022] Open
Abstract
Background Temporal artery biopsy (TAB) is a surgical procedure with a low positive yield. The purpose of this study is to determine which variables are the most important in the giant cell arteritis (GCA) diagnosis. The objective of this evaluation is to improve the percentage of positive temporal artery biopsy and if possible, avoid the biopsy in some cases. Material and Methods A retrospective clinical study consisted of 90 patients who had undergone TAB at the Río Hortega Hospital (Spain) from January 2009 to December 2016. Clinical findings, erythrocyte sedimentation rates (ESR) and other laboratory parameters, American College of Rheumatology (ACR) criteria for GCA score and biopsy results were recorded. Results Nineteen (21.1%) biopsies were positive for GCA. The mean age in positive TAB was 78.6 years old (SD 7.93), and 73.7% were female. Presence of temporal headache (p = 0.003), jaw claudication (p = 0.001), abnormal artery exploration (p = 0.023), elevated erythrocyte sedimentation rate (p = 0.035), CRP (p = 0.018) and platelets (p = 0.042), were significantly associated with GCA. Multivariate logistic regression revealed that the best predictors for the diagnosis of GCA are headache and jaw claudication, adjusted by sex, age, and temporal exploration. Conclusions TAB has benefit only for patients who score a 2 or 3 on the ACR criteria for GCA without biopsy. These findings highlight the need for a better diagnostic strategy for patients with suspected temporal arteritis. Key words:Giant cell arteritis, horton arteritis, vasculitis, temporal artery biopsy, jaw claudication, temporal headache.
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Affiliation(s)
- B Peral-Cagigal
- Servicio Regional de Cirugía Oral y Maxilofacial, Hospital Universitario del Río Hortega, C/Dulzaina n 2, 47012 Valladolid, Spain,
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17
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Papadakis M, Kaptanis S, Kokkori-Steinbrecher A, Floros N, Schuster F, Hübner G. Temporal artery biopsy in the diagnosis of giant cell arteritis: Bigger is not always better. Am J Surg 2018; 215:647-650. [PMID: 28877848 DOI: 10.1016/j.amjsurg.2017.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/07/2017] [Accepted: 08/21/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Marios Papadakis
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Helios Clinic, University Hospital Witten-Herdecke, Wuppertal, Germany.
| | - Sarantos Kaptanis
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London, UK
| | | | - Nikolaos Floros
- Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Frauke Schuster
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Helios Clinic, University Hospital Witten-Herdecke, Wuppertal, Germany
| | - Gunnar Hübner
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Helios Clinic, University Hospital Witten-Herdecke, Wuppertal, Germany
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18
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Moiseev SV, Smitienko I, Bulanov N, Novikov PI. The role of temporal artery biopsy in patients with giant-cell arteritis is debated. Ann Rheum Dis 2018; 78:e31. [DOI: 10.1136/annrheumdis-2018-213282] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 11/04/2022]
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19
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Ing E, Pagnoux C, Tyndel F, Sundaram A, Hershenfeld S, Ranalli P, Chow S, Le T, Lutchman C, Rutherford S, Lam K, Bedi H, Torun N. Lower ocular pulse amplitude with dynamic contour tonometry is associated with biopsy-proven giant cell arteritis. Can J Ophthalmol 2017; 53:215-221. [PMID: 29784156 DOI: 10.1016/j.jcjo.2017.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 08/29/2017] [Accepted: 10/10/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To determine the role of the ocular pulse amplitude (OPA) from Pascal dynamic contour tonometry in predicting the temporal artery biopsy (TABx) result in patients with suspected giant cell arteritis (GCA). DESIGN Prospective validation study. PARTICIPANTS Adults aged 50 years or older who underwent TABx from March 2015 to April 2017. METHODS Subjects on high-dose glucocorticoids more than 14 days or without serology before glucocorticoid initiation were excluded. The OPA from both eyes was obtained and averaged just before TABx of the predominantly symptomatic side. The variables chosen for the a priori prediction model were age, average OPA, and C-reactive protein (CRP). Erythrocyte sedimentation rate (ESR), platelets, jaw claudication, and eye findings were also recorded. In this study, subjects with a negative biopsy were considered not to have GCA, and contralateral biopsy was performed if the clinical suspicion for GCA remained high. An external validation set (XVAL) was obtained. RESULTS Of 109 TABx, 19 were positive and 90 were negative. On univariate logistic regression, the average OPA had 0.60 odds for positive TABx (p = 0.03), with no statistically significant difference in age, sex, CRP, ESR, or jaw claudication. In suspected GCA, an OPA of 1 mm Hg had positive likelihood ratio 4.74 and negative likelihood ratio 0.87 for positive TABx. Multivariate regression of the prediction model using optimal mathematical transforms (inverse OPA, log CRP, age >65 years) had area under the receiver operating characteristic curve (AUROC) = 0.85 and AUROCXVAL = 0.81. CONCLUSIONS OPA is lower in subjects with biopsy-proven GCA and is a statistically significant predictor of GCA.
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Affiliation(s)
- Edsel Ing
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont.
| | - Christian Pagnoux
- Department of Medicine, Rheumatology, University of Toronto Medical School, Toronto, Ont
| | - Felix Tyndel
- Department of Medicine, Neurology, University of Toronto Medical School, Toronto, Ont
| | - Arun Sundaram
- Department of Medicine, Neurology, University of Toronto Medical School, Toronto, Ont
| | - Seymour Hershenfeld
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Paul Ranalli
- Department of Medicine, Neurology, University of Toronto Medical School, Toronto, Ont
| | - Shirley Chow
- Department of Medicine, Rheumatology, University of Toronto Medical School, Toronto, Ont
| | - Tran Le
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Carla Lutchman
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Susan Rutherford
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Kay Lam
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Harleen Bedi
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto, Ont
| | - Nurhan Torun
- Harvard Medical School, Beth Israel Deaconess Hospital, Boston Department of Ophthalmology, Boston, MA
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20
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Ing EB, Lahaie Luna G, Toren A, Ing R, Chen JJ, Arora N, Torun N, Jakpor OA, Fraser JA, Tyndel FJ, Sundaram AN, Liu X, Lam CT, Patel V, Weis E, Jordan D, Gilberg S, Pagnoux C, Ten Hove M. Multivariable prediction model for suspected giant cell arteritis: development and validation. Clin Ophthalmol 2017; 11:2031-2042. [PMID: 29200816 PMCID: PMC5703153 DOI: 10.2147/opth.s151385] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose To develop and validate a diagnostic prediction model for patients with suspected giant cell arteritis (GCA). Methods A retrospective review of records of consecutive adult patients undergoing temporal artery biopsy (TABx) for suspected GCA was conducted at seven university centers. The pathologic diagnosis was considered the final diagnosis. The predictor variables were age, gender, new onset headache, clinical temporal artery abnormality, jaw claudication, ischemic vision loss (VL), diplopia, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and platelet level. Multiple imputation was performed for missing data. Logistic regression was used to compare our models with the non-histologic American College of Rheumatology (ACR) GCA classification criteria. Internal validation was performed with 10-fold cross validation and bootstrap techniques. External validation was performed by geographic site. Results There were 530 complete TABx records: 397 were negative and 133 positive for GCA. Age, jaw claudication, VL, platelets, and log CRP were statistically significant predictors of positive TABx, whereas ESR, gender, headache, and temporal artery abnormality were not. The parsimonious model had a cross-validated bootstrap area under the receiver operating characteristic curve (AUROC) of 0.810 (95% CI =0.766–0.854), geographic external validation AUROC’s in the range of 0.75–0.85, calibration pH–L of 0.812, sensitivity of 43.6%, and specificity of 95.2%, which outperformed the ACR criteria. Conclusion Our prediction rule with calculator and nomogram aids in the triage of patients with suspected GCA and may decrease the need for TABx in select low-score at-risk subjects. However, misclassification remains a concern.
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Affiliation(s)
- Edsel B Ing
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto
| | | | - Andrew Toren
- Department of Ophthalmology, University of Laval, Quebec, QC
| | - Royce Ing
- Toronto Eyelid, Strabismus and Orbit Surgery Clinic, Toronto, ON, Canada
| | - John J Chen
- Mayo Clinic, Department of Ophthalmology and Neurology
| | - Nitika Arora
- Mayo Clinic, Department of Ophthalmology, Rochester, MN
| | - Nurhan Torun
- Department of Surgery, Division of Ophthalmology, Harvard Medical School, Boston, MA
| | | | - J Alexander Fraser
- Department of Clinical Neurological Sciences and Ophthalmology, Western University, London
| | - Felix J Tyndel
- Department of Medicine, University of Toronto Medical School, Toronto, ON, Canada
| | - Arun Ne Sundaram
- Department of Medicine, University of Toronto Medical School, Toronto, ON, Canada
| | - Xinyang Liu
- Department of Medicine, Fudan University Shanghai Medical College, Shanghai, People's Republic of China
| | - Cindy Ty Lam
- Department of Ophthalmology and Vision Sciences, University of Toronto Medical School, Toronto
| | - Vivek Patel
- Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ezekiel Weis
- Departments of Ophthalmology, Universities of Alberta and Calgary, Edmonton and Calgary, AB
| | - David Jordan
- Department of Ophthalmology, University of Ottawa, Ottawa, ON
| | - Steven Gilberg
- Department of Ophthalmology, University of Ottawa, Ottawa, ON
| | | | - Martin Ten Hove
- Department of Ophthalmology, Queen's University, Kingston, ON
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21
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Bowling K, Rait J, Atkinson J, Srinivas G. Temporal artery biopsy in the diagnosis of giant cell arteritis: Does the end justify the means? Ann Med Surg (Lond) 2017; 20:1-5. [PMID: 28663795 PMCID: PMC5479941 DOI: 10.1016/j.amsu.2017.06.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 06/07/2017] [Accepted: 06/11/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early temporal artery biopsy is recommended in all patients with suspected cranial GCA (Giant Cell Arteritis) by the BSR (British Society of Rheumatology) and BHPR (British Health Professionals in Rheumatology) guidelines. This should be performed within one week ideally. AIM To assess ACR (American College of Rheumatology) score at presentation and whether temporal artery biopsy result affects clinical management of the clinically suspected GCA patient. METHOD Case records of all temporal artery biopsies performed within January 2012 until December 2014 were analysed for size and result of biopsy and this was correlated to clinical management following result. RESULTS 129 temporal arteries were biopsied with a total of 17 positive biopsy results. 10 biopsy samples were insufficient to confirm or refute GCA. 8 patients within the biopsies negative for GCA had their prednisolone therapy stopped. 5 patients had unknown follow up, with the remainder (89, 87.3%) of the patients continued prednisolone management for treatment of GCA for at least 6 weeks. CONCLUSION Overall 13.2% of our biopsies were positive for GCA and 87.3% of biopsy negative patients continued prednisolone therapy on clinical grounds. In the face of new diagnostic tests (high resolution MRI (Magnetic Resonance Imaging), colour duplex USS (Ultra Sound Scan) and PET (Positive Emission Topography) can we justify invasive surgery to all patients on histological grounds when the results may not alter management? Further investigation is needed directly comparing newer imaging modalities to histology.
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Affiliation(s)
- K. Bowling
- Peninsula Deanery, Torbay Hospital, South Devon Healthcare Trust, Lawes Bridge, Torquay, TQ2 7AA, United Kingdom
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22
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The 2016 revised ACR criteria for diagnosis of giant cell arteritis – Our case series: Can this avoid unnecessary temporal artery biopsies? INTERNATIONAL JOURNAL OF SURGERY OPEN 2017. [DOI: 10.1016/j.ijso.2017.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Cristaudo AT, Mizumoto R, Hendahewa R. The impact of temporal artery biopsy on surgical practice. Ann Med Surg (Lond) 2016; 11:47-51. [PMID: 27699002 PMCID: PMC5037119 DOI: 10.1016/j.amsu.2016.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/16/2016] [Accepted: 09/18/2016] [Indexed: 12/01/2022] Open
Abstract
Background Giant cell arteritis (GCA) has the potential to cause irreversible blindness and stroke in affected patients [1–4]. Temporal artery biopsy (TAB) remains the gold standard test for GCA [6–8]. Recent literature suggests that TAB does not change management of patients with suspected GCA and that ultrasound scan (USS) may be sufficient enough alone to confirm the diagnosis [9–11,13]. The aim of this study is to therefore determine the impact of TAB on current surgical practice and emergency theatre services. Materials and Methods A retrospective clinical study was performed of patients who had undergone TAB at the Caboolture Hospital from January 2010 to September 2015. Demographic and clinical data was collected from patient's medical records in regards to GCA. Results A total of 55 TAB were performed on 50 patients. Only two TAB were positive for GCA. Thirty-eight (76%) patients had a pre-TAB ACR criteria score of ≥3. Pre-operative corticosteroids were administered in forty-five (90%) patients, on average 4 ± 10 days pre-TAB. Mean time to TAB was 1.6 ± 1.6 days following their booking. Ninety-one percent of TAB were performed by surgical registrars. All TAB were performed using local anaesthesia alone. Conclusions TAB is an expensive procedure with a low positive yield. Recent evidence suggests promising results with USS in diagnosing GCA. With the exceedingly low positive TAB results found in this study, patients with suspected GCA should be investigated in accordance with the above algorithm. The routine use of USS will reduce the number of negative TAB performed. TAB remains the gold standard test for diagnosing GCA. This study aims to determine the impact of TAB on current surgical practice. TAB alone is an expensive procedure with a low positive yield. Recent evidence suggests promising results with USS in diagnosing GCA.
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Affiliation(s)
- Adam Thomas Cristaudo
- Department of General Surgery, Caboolture Hospital, QLD, 4510, Australia; Westmead Research Centre for Evaluation of Surgical Outcomes, Department of Surgery, University of Sydney, Westmead Hospital, Westmead, NSW, 2145, Australia
| | - Ryo Mizumoto
- Department of General Surgery, Caboolture Hospital, QLD, 4510, Australia
| | - Rasika Hendahewa
- Department of General Surgery, Caboolture Hospital, QLD, 4510, Australia
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24
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Moiseev S, Novikov P, Meshkov A, Smitienko I. Biological agents for giant cell arteritis: treat to target. Ann Rheum Dis 2016; 75:e58. [PMID: 27401743 DOI: 10.1136/annrheumdis-2016-210061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 06/19/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Sergey Moiseev
- Clinic of Nephrology, Internal and Occupational Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Pavel Novikov
- Clinic of Nephrology, Internal and Occupational Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alexey Meshkov
- Clinic of Nephrology, Internal and Occupational Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ilya Smitienko
- Russian University of Peoples' Friendship, Moscow, Russia
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25
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Management of giant cell arteritis: Recommendations of the French Study Group for Large Vessel Vasculitis (GEFA). Rev Med Interne 2016; 37:154-65. [DOI: 10.1016/j.revmed.2015.12.015] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 11/17/2022]
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26
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Baseline clinical predictors of an ultimate giant cell arteritis diagnosis in patients referred to temporal artery biopsy. Clin Rheumatol 2016; 35:1817-22. [PMID: 26925851 DOI: 10.1007/s10067-016-3221-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 02/20/2016] [Accepted: 02/21/2016] [Indexed: 10/22/2022]
Abstract
The diagnosis of giant cell arteritis (GCA) is based on clinical grounds and confirmed by characteristic histological findings on temporal artery biopsy (TAB). Patients may be diagnosed with GCA based on clinical grounds only, despite negative histological findings. We aimed to investigate which baseline clinical and laboratory features best predict an ultimate diagnosis of giant cell arteritis among patients referred to TAB. We retrospectively analyzed 224 patients who underwent TAB in our hospital between 2000 and 2014. Patients were diagnosed with GCA if TAB was positive for GCA, or by clinical grounds only despite a negative biopsy, provided they fulfilled the American College of Rheumatology 1990 criteria. Baseline clinical and laboratory features were obtained from medical records. Predictors of an ultimate GCA diagnosis were investigated. Overall, 82 patients were diagnosed with GCA-57 had histological evidence of GCA and 25 were diagnosed with GCA despite a negative biopsy. One hundred and forty-two patients were not diagnosed with GCA. Predictors of an eventual diagnosis of GCA in a multivariate logistic regression analysis were headache (OR = 6; p < 0.001), jaw claudication (OR 4.5; p = 0.007), erythrocyte sedimentation rate (ESR) (OR = 1.5; p = 0.032) and platelet count (OR = 1.74; p = 0.004). Among patients referred to TAB, headache, jaw claudication, ESR, and thrombocyte levels are predictors for an ultimate diagnosis of GCA. These clinical and laboratory features should be considered when contemplating the diagnosis and treatment of GCA.
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27
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A case of stroke and blindness. Can J Neurol Sci 2013; 40:728-33. [PMID: 23968950 DOI: 10.1017/s0317167100015006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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28
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Abstract
Thromboangiitis obliterans, or Buerger disease, is a chronic nonatherosclerotic endarteritis manifesting as inflammation and thrombosis of distal extremity small and medium-sized arteries resulting in relapsing episodes of distal extremity ischemia. Takayasu arteritis is a rare syndrome characterized by inflammation of the aortic arch, pulmonary, coronary, and cerebral vessels, presenting with cerebrovascular symptoms, myocardial ischemia, or upper extremity claudication in young, often female, patients. Kawasaki disease is a small- and medium-vessel acute systemic vasculitis of young children, with morbidity and mortality stemming from coronary artery aneurysms. Microscopic polyangiitis, Churg-Strauss syndrome, and Wegener granulomatosis are systemic small-vessel vasculitides, affecting arterioles, capillary beds and venules, and each presenting with variable effects on the pulmonary, renal and gastrointestinal systems.
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Affiliation(s)
- William Wu
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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29
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Ton E, Kruize AA. When and how to perform biopsies in a patient with a (suspected) connective tissue disease. Best Pract Res Clin Rheumatol 2013; 27:209-36. [DOI: 10.1016/j.berh.2013.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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30
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Stengl KL, Buchert R, Bauknecht H, Sobesky J. A hidden giant: Wallenberg syndrome and aortal wall thickening as an atypical presentation of a giant cell arteritis. BMJ Case Rep 2013; 2013:bcr-2012-006994. [PMID: 23456154 DOI: 10.1136/bcr-2012-006994] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of a 73-year-old woman with a brainstem stroke presenting as Wallenberg syndrome. By transoesophageal echocardiography and combined 18F-fluordeoxyglucose positron emission and CT (18F-FDG PET/CT), the diagnosis of large artery vasculitis owing to giant cell arteritis was confirmed. In the absence of classical clinical signs, the examination of the large extracranial vessels by ultrasound and 18F-FDG PET/CT played the key role in detecting a widespread vasculitis.
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