Acute upper limb ischemia, a rare presentation of giant cell arteritis

Disease stratification in GCA and PMR: state of the art and future perspectives

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions characterized by systemic inflammation, a predominant IL-6 signature, an excellent response to glucocorticoids, a tendency to a chronic and relapsing course, and older age of the affected population. This Review highlights the emerging view that these diseases should be approached as linked conditions, unified under the term GCA-PMR spectrum disease (GPSD). In addition, GCA and PMR should be seen as non-monolithic conditions, with different risks of developing acute ischaemic complications and chronic vascular and tissue damage, different responses to available therapies and disparate relapse rates. A comprehensive stratification strategy for GPSD, guided by clinical findings, imaging and laboratory data, facilitates appropriate therapy and cost-effective use of health-economic resources. Patients presenting with predominant cranial symptoms and vascular involvement, who usually have a borderline elevation of inflammatory markers, are at an increased risk of sight loss in early disease but have fewer relapses in the long term, whereas the opposite is observed in patients with predominant large-vessel vasculitis. How the involvement of peripheral joint structures affects disease outcomes remains uncertain and understudied. In the future, all cases of new-onset GPSD should undergo early disease stratification, with their management adapted accordingly.

Critical arm ischemia-a rare presentation of giant cell arteritis

Giant cell arteritis can rarely present as severe ischemia of the upper limbs. The initial management includes high-dose oral glucocorticoids. However, when patients do not respond to medical therapy, surgical revascularization might be required to reinstitute limb perfusion. We present the case of a 68-year-old woman who had presented with critical arm ischemia that necessitated carotid–brachial artery bypass after initial oral steroid therapy had failed. We have delineated our surgical approach and technical considerations to potentially help increase the long-term patency of the bypass.

Giant cell arteritis as unusual cause of critical arm ischemia

Giant cell arteritis is an inflammatory vasculopathy of unknown etiology that typically affects the carotid artery and its branches. Symptomatic involvement of upper extremity arteries is uncommon. We report a case of a 70-year-old woman with polymyalgia rheumatica who presented with critical arm ischemia, constitutional symptoms, and elevated erythrocyte sedimentation rate. Urgent revascularization by a carotid-brachial artery bypass was performed. Histopathologic evaluation of a specimen obtained intraoperatively from the occluded axillary artery confirmed the diagnosis, and corticosteroid therapy was initiated. Large-vessel vasculitis should be considered a rare differential diagnosis in occlusive disease of the upper extremity.