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Khalique MI, Arjunan M, Wood S, Mackie SL. The spectrum of giant cell arteritis through a rheumatology lens. Eye (Lond) 2024:10.1038/s41433-024-03153-7. [PMID: 38898105 DOI: 10.1038/s41433-024-03153-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/14/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Treatment of giant cell arteritis (GCA) aims initially to prevent acute visual loss, and subsequently to optimise long-term quality of life. Initial prevention of acute visual loss in GCA is well-standardised with high-dose glucocorticoid therapy but in the longer term optimising quality of life requires tailoring of treatment to the individual. The licensing of the IL-6 receptor inhibitor tocilizumab combined with advances in vascular imaging have resulted in many changes to diagnostic and therapeutic practice. Firstly, GCA is a systemic disease that may involve multiple vascular territories and present in diverse ways. Broadening of the "spectrum" of what is called GCA has been crystallised in the 2022 GCA classification criteria. Secondly, the vascular inflammation of GCA frequently co-exists with the extracapsular musculoskeletal inflammation of the related disease, polymyalgia rheumatica (PMR). Thirdly, GCA care must often be delivered across multiple specialities and healthcare organisations requiring effective interprofessional communication. Fourthly, both GCA and PMR may follow a chronic or multiphasic disease course; long-term management must be tailored to the individual patient's needs. In this article we focus on some areas of current rheumatology practice that ophthalmologists need to be aware of, including comprehensive assessment of extra-ocular symptoms, physical signs and laboratory markers; advanced imaging techniques; and implications for multi-speciality collaboration.
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Affiliation(s)
| | - Mousindha Arjunan
- Department of Ophthalmology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Samuel Wood
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah L Mackie
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Salvarani C, Padoan R, Iorio L, Tomelleri A, Terrier B, Muratore F, Dasgupta B. Subclinical giant cell arteritis in polymyalgia rheumatica: Concurrent conditions or a common spectrum of inflammatory diseases? Autoimmun Rev 2024; 23:103415. [PMID: 37625672 DOI: 10.1016/j.autrev.2023.103415] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/20/2023] [Indexed: 08/27/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common conditions in older adults. Their clinical connection has been recognized over time, with many patients experiencing both conditions separately, simultaneously or in temporal sequence to each other. Early GCA detection is essential to prevent vascular damage, but identifying subclinical GCA in PMR patients remains a challenge and routine screening is not standard practice. Subclinical GCA prevalence in newly diagnosed PMR patients ranges from 23 to 29%, depending on the screening method. Vessel wall imaging and temporal artery biopsy can detect subclinical GCA. Epidemiology and trigger factors show similarities between the two conditions, but PMR is more common than GCA. Genetic and pathogenesis studies reveal shared inflammatory mechanisms involving dendritic cells, pro-inflammatory macrophages, and an IL-6 signature. However, the inflammatory infiltrates differ, with extensive T cell infiltrates seen in GCA while PMR shows an incomplete profile of T cell and macrophage-derived cytokines. Glucocorticoid treatment is effective for both conditions, but the steroid requirements vary. PMR overall mortality might be similar to the general population, while GCA patients with aortic inflammatory aneurysms face increased mortality risk. The GCA-PMR association warrants further research. Considering their kinship, recently the term GCA-PMR Spectrum Disease (GPSD) has been proposed.
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Affiliation(s)
- Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia and Università di Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy.
| | - Luca Iorio
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, AP-HP, Paris, France
| | - Francesco Muratore
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia and Università di Modena and Reggio Emilia, Reggio Emilia, Italy
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Ahmed SB, Ahmad S, Pan H. Case Report and Literature Review of an Atypical Polymyalgia Rheumatica and Its Management. Int Med Case Rep J 2023; 16:873-885. [PMID: 38163043 PMCID: PMC10757773 DOI: 10.2147/imcrj.s440486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024] Open
Abstract
Polymyalgia rheumatica (PMR) is a systemic inflammatory disease of the elderly population that increases in incidence as age advances. It is characterised by the sudden or sub-acute onset of symptoms affecting the shoulder and pelvic girdles, often accompanied by constitutional symptoms. Due to the lack of consensual diagnostic criteria and specific laboratory or radiological investigations for PMR, its diagnosis can be very challenging, particularly because it can be mimicked or masked by other geriatric syndromes. PMR responds well to glucocorticoid treatment, but if left untreated, can lead to morbidity and poor quality of life. We present the case of an 87-year-old male who presented with a one-week history of localised pain in the left hip joint, later involving the contralateral hip. Previously able to ambulate unaided, his mobility was now severely impaired. Due to his Alzheimer's dementia and multiple comorbid geriatric conditions, extensive investigations were undertaken before a diagnosis of atypical PMR was reached. Treatment with a low dose of prednisolone led to a full recovery. This case highlights the inconsistency between an atypical presentation and the classic presentation of PMR and draws attention to the possibility of missed diagnosis in older, frail patients. Atypical symptomatology on top of cognitive impairment and language barriers can be easily overlooked and left untreated and could lead to severe adverse outcomes. Accurate diagnosis is crucial, as PMR is readily diagnosed, but the treatment with glucocorticoids, though generally straightforward, can pose challenges, particularly when dealing with polypharmacy and multiple coexisting health conditions.
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Affiliation(s)
- Saad Bilal Ahmed
- Monash Health Rehabilitation and Aged Care Services, Melbourne, Australia
| | - Saara Ahmad
- Department of Biological and Biomedical Sciences, The Aga Khan University, Karachi, Pakistan
| | - Hanmei Pan
- Monash Health Rehabilitation and Aged Care Services, Melbourne, Australia
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4
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Espígol-Frigolé G, Dejaco C, Mackie SL, Salvarani C, Matteson EL, Cid MC. Polymyalgia rheumatica. Lancet 2023; 402:1459-1472. [PMID: 37832573 DOI: 10.1016/s0140-6736(23)01310-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 06/04/2023] [Accepted: 06/22/2023] [Indexed: 10/15/2023]
Abstract
Polymyalgia rheumatica is an inflammatory disease producing pain and stiffness, mainly in the shoulders and pelvic girdle, in people older than 50 years. Elevation of acute phase reactants is common due to the inflammatory nature of the disease. Since there are no specific diagnostic tests, diagnosis requires the exclusion of other diseases with similar presentations. Imaging has helped to identify the pathological substrate of polymyalgia rheumatica and it is increasingly used to support clinical diagnosis or to detect coexistent giant cell arteritis. Although polymyalgia rheumatica does not clearly impair survival or organ function, it can have a detrimental effect on quality of life. Glucocorticoids at 12·5-25·0 mg prednisone per day are effective in inducing remission in most individuals but, when tapered, relapses occur in 40-60% of those affected and side-effects are common. Assessment of disease activity can be difficult because pain related to common comorbidities such as osteoarthritis and tendinopathies, can return when glucocorticoids are reduced, and acute phase reactants are increased less during flares in individuals undergoing treatment or might increase for other reasons. The role of imaging in assessing disease activity is not yet completely defined. In the search for more efficient and safer therapies, tocilizumab and sarilumab have shown efficacy in randomised controlled trials and additional targeted therapies are emerging. However, judicious risk-benefit balance is essential in applying therapeutic innovations to people with polymyalgia rheumatica.
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Affiliation(s)
- Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Christian Dejaco
- Department of Rheumatology, Medical University Graz, Graz, Austria; Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, Brunico, Italy
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy; Azienda Ospedaliera-Universitaria di Modena, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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5
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Oumerzouk J, El Filali O, Zbitou A, Slioui B, Belasri S, Kissani N. Neurological complications of giant cell arteritis: A study of 15 cases and a review of the literature. J Fr Ophtalmol 2023; 46:211-215. [PMID: 36642599 DOI: 10.1016/j.jfo.2022.06.013] [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: 05/18/2022] [Revised: 06/11/2022] [Accepted: 06/13/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Giant cell arteritis (GCA) is considered a neuro-ophthalmologic emergency. New-onset headache in patients aged 50 years and above with elevated erythrocyte sedimentation rate should prompt evaluation for GCA. MATERIAL AND METHODS Retrospective study of 15 patients presenting with GCA from 1991 to 2008 at the Mohamed V Military hospital at Rabat and Avicenne Military hospital of Marrakech. RESULTS Fifteen cases were recorded, with female predominance (male to female ratio 2:3) and a mean age of 63 years (range: 55-83 years). All patients (100%) presented with headache. The headache was isolated in 20% of cases and neuro-ophthalmic complications were found in 73% of cases. Biopsy was conclusive for GCA in 67% of cases and all of our patients were placed on steroids with spectacular improvement. CONCLUSION New-onset headache in patients aged 50 years and above should prompt evaluation for GCA. Steroids, especially during the acute phase, must be started urgently to avoid irreversible neurological impairment.
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Affiliation(s)
- J Oumerzouk
- Neurology department, Military hospital Avicenne, Marrakech, Morocco; Neuroscience research laboratory, Marrakech Medical school, Cadi Ayyad university, Marrakech, Morocco.
| | - O El Filali
- Vascular surgery department, Military hospital Avicenne, Marrakech, Morocco
| | - A Zbitou
- Cardiovascular department, Military hospital Avicenne, Marrakech, Morocco
| | - B Slioui
- Radiology department, Military hospital Avicenne, Marrakech, Morocco
| | - S Belasri
- Radiology department, Military hospital Avicenne, Marrakech, Morocco
| | - N Kissani
- Neurology department, Mohamed VI hospital, Marrakesh, Morocco; Neuroscience research laboratory, Marrakech Medical school, Cadi Ayyad university, Marrakech, Morocco
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Haaversen AB, Brekke LK, Bakland G, Rødevand E, Myklebust G, Diamantopoulos AP. Norwegian society of rheumatology recommendations on diagnosis and treatment of patients with giant cell arteritis. Front Med (Lausanne) 2023; 9:1082604. [PMID: 36687436 PMCID: PMC9853546 DOI: 10.3389/fmed.2022.1082604] [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: 10/28/2022] [Accepted: 12/12/2022] [Indexed: 01/07/2023] Open
Abstract
Objective To provide clinical guidance to Norwegian Rheumatologists and other clinicians involved in diagnosing and treating patients with giant cell arteritis (GCA). Methods The available evidence in the field was reviewed, and the GCA working group wrote draft guidelines. These guidelines were discussed and revised according to standard procedures within the Norwegian Society of Rheumatology. The European Alliance of Associations for Rheumatology (EULAR) recommendations for imaging and treatment in large vessel vasculitis and the British Society for Rheumatology (BSR) guidelines for diagnostics and treatment in GCA informed the development of the current guidelines. Results A total of 13 recommendations were developed. Ultrasound is recommended as the primary diagnostic test. In patients with suspected GCA, treatment with high doses of Prednisolone (40-60 mg) should be initiated immediately. For patients with refractory disease or relapse, Methotrexate (MTX) should be used as the first-line adjunctive therapy, followed by tocilizumab (TCZ). Conclusion Norwegian recommendations for diagnostics and treatment to improve management and outcome in patients with GCA were developed.
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Affiliation(s)
| | - Lene Kristin Brekke
- Department of Rheumatology, Hospital for Rheumatic Diseases, Haugesund, Norway
| | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of Northern Norway, Tromsø, Norway
| | - Erik Rødevand
- Department of Rheumatology, St. Olav’s University Hospital, Trondheim, Norway
| | - Geirmund Myklebust
- Department of Research, Hospital of Southern Norway, Kristiansand, Norway
| | - Andreas P. Diamantopoulos
- Department of Infectious Diseases, Division of Internal Medicine, Akershus University Hospital, Lørenskog, Norway,*Correspondence: Andreas P. Diamantopoulos,
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Rheumatoid Arthritis and Related Disorders. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kushimoto K, Ayano M, Nishimura K, Nakano M, Kimoto Y, Mitoma H, Ono N, Arinobu Y, Akashi K, Horiuchi T, Niiro H. HLA-B52 allele in giant cell arteritis may indicate diffuse large-vessel vasculitis formation: a retrospective study. Arthritis Res Ther 2021; 23:238. [PMID: 34517892 PMCID: PMC8436550 DOI: 10.1186/s13075-021-02618-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/28/2021] [Indexed: 02/05/2023] Open
Abstract
Background This study aimed to identify new characteristics of elderly onset large-vessel vasculitis (EOLVV) by focusing on human leucocyte antigen (HLA) genotype, polymyalgia rheumatica (PMR), and affected vascular lesions observed on positron emission tomography/computed tomography (PET/CT) imaging. Methods We retrospectively studied 65 consecutive Japanese patients with large-vessel vasculitis (LVV) who had extracranial vasculitis lesions and underwent PET/CT imaging. PET/CT images were assessed using the semi-quantitative PET visual score of each affected vessel, and the PET vascular activity score (PETVAS) and number of affected vessels were calculated. Subjects were subsequently grouped based on age at onset, superficial temporal artery (STA) involvement, and presence of PMR and compared each group according to HLA genotype. Unsupervised hierarchical cluster analysis was used to identify the patients with similar characteristics in terms of affected vascular lesions detected through PET/CT imaging. The clinical characteristics and PET/CT findings of the population newly identified in this study were examined. Results Twenty-seven patients with EOLVV did not meet the American College of Rheumatology 1990 criteria for giant cell arteritis (GCA) and Takayasu arteritis and were considered as unclassified EOLVV (UEOLVV). The unsupervised hierarchical cluster analysis revealed that UEOLVV with PMR and large-vessel GCA (LV-GCA) formed a cluster of LVV with GCA features (i.e., PMR and/or STA involvement) when restricted to patients who were HLA-B52-positive. Patients who were HLA-B52-positive with LVV and GCA features had similar clinical characteristics and patterns of affected vessels and presented with diffuse LVV lesions. HLA-B52-positive patients who had LVV with GCA features also presented with higher PETVAS, more affected vessels, and lower rates of biologics usage and relapse compared to HLA-B52-positive patients with TAK. Conclusions Patients who had UEOLVV with PMR had similar characteristics to patients with LV-GCA. Patients who were HLA-B52-positive and had LVV with GCA features presented with diffuse vascular lesions and may comprise a core population of Japanese patients with EOLVV. The findings of HLA-B52 positivity and diffusely affected vessels in patients with EOLVV can be considered as suspicious findings of LV-GCA. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02618-4.
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Affiliation(s)
- Kazuo Kushimoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Cancer Stem Cell Research, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.
| | - Keisuke Nishimura
- Department of Endocrinology and Rheumatology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Miki Nakano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nobuyuki Ono
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Cooper J. Introducing an ANP-led temporal artery biopsy service for patients with suspected giant cell arteritis. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2021; 30:512-519. [PMID: 33983820 DOI: 10.12968/bjon.2021.30.9.512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Giant cell arteritis (GCA) is an uncommon autoimmune inflammatory vasculopathy that can lead to the destruction and occlusion of various arteries that consequently can cause serious complications such as stroke or sight loss. It is seen as a medical emergency. The most commonly affected vessel in GCA is the temporal artery in the side of the head, hence the condition is sometimes also referred to as 'temporal arteritis'. This article discusses the introduction of an advanced nurse practitioner-led temporal artery biopsy service.
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Affiliation(s)
- John Cooper
- Advanced Nurse Practitioner, Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust
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10
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Emamifar A, Ellingsen T, Hermann AP, Hess S, Gerke O, Ahangarani Farahani Z, Syrak Hansen P, Jensen Hansen IM, Thye-Rønn P. Prognostic impacts of glucocorticoid treatment in patients with polymyalgia rheumatica and giant cell arteritis. Sci Rep 2021; 11:6220. [PMID: 33737697 PMCID: PMC7973518 DOI: 10.1038/s41598-021-85857-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 03/05/2021] [Indexed: 01/31/2023] Open
Abstract
Identifying comorbidities in polymyalgia rheumatica/giant cell arteritis (PMR/GCA) is crucial for patients' outcomes. The present study aimed to evaluate the impact of the inflammatory process and glucocorticoid treatment on aortic arterial stiffness and body composition in PMR/GCA. 77 patients with newly diagnosed PMR/GCA were treated with oral glucocorticoids and followed for 40 weeks. Aortic pulse wave velocity (PWV) was measured at baseline and during the follow-up period and compared to the results of temporal artery biopsy (TAB) and 18F-FDG PET/CT. Body composition was assessed by total body DXA at baseline and the end of the study. Of 77 patients (49 (63.6%) female, mean of age: (71.8 ± 8.0)), 64 (83.1%) had pure PMR, 10 (13.0%) concomitant PMR and GCA, and 3 (3.9%) pure GCA. Compared to baseline values, aortic PWV was initially decreased at week 16 (p = 0.010) and remained lower than baseline at week 28 (p = 0.002) and week 40 (p < 0.001), with no association with results of TAB and 18F-FDG PET/CT. Aortic PWV was significantly associated with age, male gender, left systolic and diastolic blood pressure, right diastolic blood pressure, and CRP. Total bone mineral content (BMC) was decreased in both genders (p < 0.001), while fat mass (FM) was significantly increased (p < 0.001). However, lean body mass did not significantly change during the study. Changes in FM were correlated with cumulative prednisolone dose (rho: 0.26, p = 0.031). Glucocorticoid treatment of patients with PMR/GCA had several prognostic impacts. Arterial stiffness was decreased due either to the treatment or a reduction in the inflammatory load. Additionally, treatment led to changes in body composition, including a decrease in BMC and FM excess.
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Affiliation(s)
- Amir Emamifar
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
- Diagnostic Center, Svendborg Hospital, OUH, Baagøes Allé 15, 5700, Svendborg, Denmark.
- Department of Rheumatology, Svendborg Hospital, OUH, Svendborg, Denmark.
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.
| | - Torkell Ellingsen
- Rheumatology Research Unit, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Anne Pernille Hermann
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Søren Hess
- Department of Radiology and Nuclear Medicine, Hospital of Southwest Jutland, Esbjerg, Denmark
- Faculty of Health Sciences, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Oke Gerke
- Research Unit of Clinical Physiology and Nuclear Medicine, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | | | - Per Syrak Hansen
- Diagnostic Center, Svendborg Hospital, OUH, Baagøes Allé 15, 5700, Svendborg, Denmark
| | | | - Peter Thye-Rønn
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Diagnostic Center, Svendborg Hospital, OUH, Baagøes Allé 15, 5700, Svendborg, Denmark
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Hammoda HMB, Al Saleh J, Mahmood K, Darwish OAHM, Musa MEA, Rezzek MS. Polymyalgia Rheumatica (PMR) and Lung Involvement: The Forgotten Association. Oman Med J 2020; 35:e105. [PMID: 32181007 PMCID: PMC7060987 DOI: 10.5001/omj.2020.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 12/19/2018] [Indexed: 11/16/2022] Open
Abstract
Polymyalgia rheumatica (PMR) is an inflammatory condition of unknown etiology, commonly occurring in the elderly and is associated with a good prognosis. Patients usually present with pain in the neck, shoulders, and hips. The onset is often abrupt and is associated with depression and flu-like symptoms. Lung involvement in patients with PMR is unusual. Here we report a rare case of a 66-year-old man who presented with clinical features of PMR and respiratory symptoms, namely exertional dyspnea and dry cough.
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12
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Dammacco R, Alessio G, Giancipoli E, Leone P, Cirulli A, Resta L, Vacca A, Dammacco F. Giant Cell Arteritis: The Experience of Two Collaborative Referral Centers and an Overview of Disease Pathogenesis and Therapeutic Advancements. Clin Ophthalmol 2020; 14:775-793. [PMID: 32210531 PMCID: PMC7073434 DOI: 10.2147/opth.s243203] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 01/29/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Giant cell arteritis (GCA), a chronic vasculitis of the large and medium-sized arteries, affects people >50 years of age. This study assessed the prevalence of visual manifestations and other clinical features at presentation in an Italian cohort of GCA patients. Recent advances in the pathophysiology, diagnosis, and therapy of GCA are also reviewed. Methods This retrospective, single-center study conducted by the ophthalmology and internal medicine clinics of one university recruited 56 patients from 2005 to 2016 and followed them for 11-54 months. Results Ocular involvement was diagnosed in 19 patients (33.9%), with permanent vision loss in 19.6% (7.1% of the cohort with bilateral vision loss). Arteritic anterior and posterior ischemic optic neuropathy were diagnosed in 11 patients (57.9%) and 1 patient (5.3%), respectively, cotton wool spots in 3 patients (15.8%), central retinal artery occlusion in 2 patients (10.5%), and anterior segment ischemia and multifocal choroidal ischemia in 1 patient each (5.3%). Polymyalgia rheumatica was associated with GCA in 44.6% of the patients. The most common extra-ocular manifestation was constitutional symptoms (82.1% of the patients). Large-vessel involvement, including of the ascending aorta, aortic arch, and left axillary artery, was diagnosed by magnetic resonance or computed tomography (CT) angiography and 18FDG positron emission/CT. Glucocorticoids (GCs) remain the standard-of-care worldwide, but methotrexate, provided as a steroid-sparing drug in 41% of the patients, resulted in earlier tapering, a lower cumulative dose of GCs, and a lower rate of relapse. Among the combinations of GCs and immunosuppressive drugs proposed to treat GCA, only tocilizumab has effectively induced and maintained disease remission. Conclusion According to our data and literature reports: a) GCA is a systemic disease; b) its diagnosis is expedited by the adjunct use of imaging techniques; c) insights into the pathogenesis of GCA may allow an improved, differentiated therapeutic approach.
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Affiliation(s)
- Rosanna Dammacco
- Department of Ophthalmology and Neuroscience, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Giovanni Alessio
- Department of Ophthalmology and Neuroscience, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Ermete Giancipoli
- Department of Biomedical Sciences, Ophthalmology Unit, University of Sassari, Sassari, Italy
| | - Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Anna Cirulli
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Leonardo Resta
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Medical School, Bari, Italy
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13
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Garland SG, Falk NP. Rheumatoid Arthritis and Related Disorders. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_120-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Treat to Target: A Valid Concept for Management of Polymyalgia Rheumatica and Giant Cell Arteritis? Rheum Dis Clin North Am 2019; 45:549-567. [PMID: 31564296 DOI: 10.1016/j.rdc.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common inflammatory diseases of the elderly. They have variable clinical courses and are usually treated with glucocorticoids (GCs). Relapses are frequent in both conditions. Physicians should balance the tradeoff of treatment-related adverse events and risk of relapse. The ultimate goal of treatment is control of the disease while maintaining patient well-being. A treat-to-target approach may achieve the aim of controlling inflammation and preserving patient's functioning and quality of life, and would require pursuit and evaluation of clinical, laboratory, imaging, and structural targets to tackle the different manifestations of GCA and PMR.
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Smutny T, Barvik I, Veleta T, Pavek P, Soukup T. Genetic Predispositions of Glucocorticoid Resistance and Therapeutic Outcomes in Polymyalgia Rheumatica and Giant Cell Arteritis. J Clin Med 2019; 8:jcm8050582. [PMID: 31035618 PMCID: PMC6572549 DOI: 10.3390/jcm8050582] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/04/2022] Open
Abstract
Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are closely related chronic inflammatory diseases. Glucocorticoids (GCs) are first-choice drugs for PMR and GCA, although some patients show poor responsiveness to the initial GC regimen or experience flares after GC tapering. To date, no valid biomarkers have been found to predict which patients are at most risk for developing GC resistance. In this review, we summarize PMR- and GCA-related gene polymorphisms and we associate these gene variants with GC resistance and therapeutic outcomes. A limited number of GC resistance associated-polymorphisms have been published so far, mostly related to HLA-DRB1*04 allele. Other genes such ICAM-1, TLR4 and 9, VEGF, and INFG may play a role, although discrepancies are often found among different populations. We conclude that more studies are required to identify reliable biomarkers of GC resistance. Such biomarkers could help distinguish non-responders from responders to GC treatment, with concomitant consequences for therapeutic strategy.
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Affiliation(s)
- Tomas Smutny
- Department of Pharmacology and Toxicology, Centre for Drug Development, Faculty of Pharmacy in Hradec Kralove, Charles University, 500 05 Hradec Kralove, Czech Republic.
| | - Ivan Barvik
- Institute of Physics, Faculty of Mathematics and Physics, Charles University, 121 16 Prague, Czech Republic.
| | - Tomas Veleta
- Department of Emergency Medicine, University Hospital in Hradec Kralove, 500 05 Hradec Kralove, Czech Republic.
| | - Petr Pavek
- Department of Pharmacology and Toxicology, Centre for Drug Development, Faculty of Pharmacy in Hradec Kralove, Charles University, 500 05 Hradec Kralove, Czech Republic.
| | - Tomas Soukup
- Division of Rheumatology, 2nd Department of Internal Medicine⁻Gastroenterology, Faculty of Medicine in Hradec Kralove, Charles University and University Hospital in Hradec Kralove, 500 05 Hradec Kralove, Czech Republic.
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Floris A, Piga M, Cauli A, Salvarani C, Mathieu A. Polymyalgia rheumatica: an autoinflammatory disorder? RMD Open 2018; 4:e000694. [PMID: 29955386 PMCID: PMC6018871 DOI: 10.1136/rmdopen-2018-000694] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/08/2018] [Indexed: 11/03/2022] Open
Affiliation(s)
- Alberto Floris
- Rheumatology and Rheumatology Unit, University Clinic AOU of Cagliari, Cagliari, Italy
| | - Matteo Piga
- Rheumatology and Rheumatology Unit, University Clinic AOU of Cagliari, Cagliari, Italy
| | - Alberto Cauli
- Rheumatology and Rheumatology Unit, University Clinic AOU of Cagliari, Cagliari, Italy
| | - Carlo Salvarani
- Rheumatology and Rheumatology Unit, Università di Modena e Reggio Emilia, Reggio Emilia, Italy.,Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alessandro Mathieu
- Rheumatology and Rheumatology Unit, University Clinic AOU of Cagliari, Cagliari, Italy
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Liozon E, de Boysson H, Dalmay F, Gondran G, Bezanahary H, Fauchais AL, Ly KH. Development of Giant Cell Arteritis after Treating Polymyalgia or Peripheral Arthritis: A Retrospective Case-control Study. J Rheumatol 2018; 45:678-685. [DOI: 10.3899/jrheum.170455] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2017] [Indexed: 11/22/2022]
Abstract
Objective.We investigated the development of giant cell arteritis (GCA) in patients with prior diagnoses of isolated polymyalgia rheumatica and/or peripheral arthritis (PMR/PA), and the potentially relevant characteristics of both illnesses in such patients.Methods.We retrospectively compared the features of 67 patients at the onset of PMR/PA, and their outcomes, to those of a random group of 65 patients with PMR/PA who did not develop late GCA. We also compared the features and outcomes of patients with late GCA to those of a random sample of patients with more usual GCA (65 with concurrent PMR/PA and 65 without).Results.Patients with late GCA represented 7.4% of all patients with GCA included in a large hospital-based inception cohort. PMR/PA preceded overt GCA by 27 months on average. Permanent visual loss developed in 10 patients, including 8 of 48 (17%) patients featuring cranial arteritis. A questionable female predominance was the only distinguishing feature of PMR/PA evolving into GCA; late GCA more often featured subclinical aortitis (OR 6.42, 95% CI 2.39–17.23; p < 0.001), headache (OR 0.44, 95% CI 0.19–1.03; p = 0.06), and fever (OR 0.29, 95% CI 0.13–0.64; p = 0.002) less often compared to the more usual form of GCA. Patients with either form of GCA experienced similar outcomes.Conclusion.A cranial arteritis pattern of late GCA is associated with a significant risk for ischemic blindness. However, compared to the usual form of GCA, late GCA is often less typical, with a higher frequency of silent aortitis. Patients with relapsing/refractory PMR may not be at increased risk for late GCA.
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18
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Milchert M, Brzosko M. Diagnosis of polymyalgia rheumatica usually means a favourable outcome for your patient. Indian J Med Res 2017; 145:593-600. [PMID: 28948949 PMCID: PMC5644293 DOI: 10.4103/ijmr.ijmr_298_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Polymyalgia rheumatica (PMR) is a unique disease of elderly people, traditionally diagnosed based on a clinical picture. A typical case is a combination of severe musculoskeletal symptoms and systemic inflammatory response with spectacular response to corticosteroids treatment. The severity of symptoms may be surprising in older patients where immunosenescence is normally expected. However, PMR may be diagnosed in haste if there is a temptation to use this diagnosis as a shortcut to achieve rapid therapeutic success. Overdiagnosis of PMR may cause more problems compared to underdiagnosis. The 2012 PMR criteria proposed by European League against Rheumatism/American College of Rheumatology aim to minimize the role of clinical intuition and build on more objective features. However, questions arise if this is possible in PMR. This has been discussed in this review.
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Affiliation(s)
- Marcin Milchert
- Department of Rheumatology, Internal Medicine & Geriatrics, Pomeranian Medical University, Szczecin, Poland
| | - Marek Brzosko
- Department of Rheumatology, Internal Medicine & Geriatrics, Pomeranian Medical University, Szczecin, Poland
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Li L, Neogi T, Jick S. Giant cell arteritis and vascular disease-risk factors and outcomes: a cohort study using UK Clinical Practice Research Datalink. Rheumatology (Oxford) 2017; 56:753-762. [PMID: 28077689 DOI: 10.1093/rheumatology/kew482] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate the associations between GCA and vascular diseases and other comorbidities in patients with GCA compared with non-vasculitis patients. Methods Using the UK-based Clinical Practice Research Datalink we identified 9778 newly diagnosed GCA patients in 1990-2014, and up to 10 non-vasculitis patients randomly matched to each case on age, sex, practice and years of history before cohort entry. We compared the distributions of 9 different pre-existing vascular diseases and 11 other comorbidities, and risks of incident vascular diseases and other comorbidities after cohort entry between GCA and non-vasculitis patients. Results Patients with GCA were more likely to have a history of vascular diseases and other comorbidities except myocardial infarction, type 2 diabetes, obesity and cancer, compared with non-vasculitis patients. Patients with GCA had increased risks for all types of incident vascular disease compared with non-vasculitis patients: adjusted hazard ratios were 1.57 (95% CI: 1.36, 1.82) for myocardial infarction, 1.41 (95% CI: 1.29, 1.55) for stroke, 1.75 (95% CI: 1.49, 2.06) for peripheral vascular disease, 1.98 (95% CI: 1.50, 2.62) for aortic aneurysm and 2.03 (95% CI: 1.77, 2.33) for venous thromboembolism. Patients with GCA also had increased risks for other incident comorbidities (type 2 diabetes, depression, etc.), but not for cancer. Conclusion Patients with GCA had more prior vascular diseases and other comorbidities before the diagnosis and they also had increased risks for incident vascular diseases and many other incident comorbidities after the diagnosis compared with non-vasculitis population.
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Affiliation(s)
- Lin Li
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington
| | - Tuhina Neogi
- Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA, USA
| | - Susan Jick
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington
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20
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Yavne Y, Tiosano S, Watad A, Comaneshter D, Shoenfeld Y, Cohen AD, Amital H. Association between giant cell arteritis and thyroid dysfunction in a "real life" population. Endocrine 2017. [PMID: 28623469 DOI: 10.1007/s12020-017-1347-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Giant cell arteritis is a systemic autoimmune disorder which involves inflammation of medium to large vessels. The association between giant cell arteritis and autoimmune thyroid disorders has been investigated numerous times in the literature with inconsistent results. Our objective was to evaluate whether a genuine association exists between giant cell arteritis and thyroid dysfunction, which is often due to immune-mediated thyroid disease. METHODS Utilizing the medical database of Clalit Health Services, we compared the proportion of hypo and hyperthyroidisim between patients with giant cell arteritis and age-matched and gender-matched controls in a cross-sectional study. Univariate analysis was performed using Chi-square and student t-test and a multivariate analysis was performed using a logistic regression model. RESULTS Five thousand six hundred and sixty three giant cell arteritis patients and 23,308 age-matched and gender-matched controls were included in the study. The proportion of hypothyroidism amongst giant cell arteritis patients was increased in comparison with controls (18.2 vs. 6.91%, respectively, p-value < 0.001), as was hyperthyroidism (2.56 and 1.19% respectively, p-value < 0.001). Giant cell arteritis demonstrated an independent association with hypothyroidism on multivariate analysis (Odd Ratios 1.297, 95% Confidence Intervals 1.19-1.42), yet not with hyperthyroidism. CONCLUSIONS Giant cell arteritis patients have a higher proportion of hypothyroidism in comparison with matched controls. Physicians treating giant cell arteritis patients should consider screening for thyroid dysfunction on a regular basis.
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Affiliation(s)
- Yarden Yavne
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Shmuel Tiosano
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Abdulla Watad
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | | | - Yehuda Shoenfeld
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
| | - Arnon D Cohen
- Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Howard Amital
- Department of Medicine 'B', Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel.
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21
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Stephens MB, Gilliland WR. Rheumatoid Arthritis and Related Disorders. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Muratore F, Pazzola G, Pipitone N, Salvarani C. Recent advances in the diagnosis and treatment of polymyalgia rheumatica. Expert Rev Clin Immunol 2016; 12:1037-45. [DOI: 10.1080/1744666x.2016.1178572] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Narváez J, Estrada P, López-Vives L, Ricse M, Zacarías A, Heredia S, Gómez-Vaquero C, Nolla JM. Prevalence of ischemic complications in patients with giant cell arteritis presenting with apparently isolated polymyalgia rheumatica. Semin Arthritis Rheum 2015; 45:328-33. [DOI: 10.1016/j.semarthrit.2015.06.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/18/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
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Stellingwerff MD, Brouwer E, Lensen KJDF, Rutgers A, Arends S, van der Geest KSM, Glaudemans AWJM, Slart RHJA. Different Scoring Methods of FDG PET/CT in Giant Cell Arteritis: Need for Standardization. Medicine (Baltimore) 2015; 94:e1542. [PMID: 26376404 PMCID: PMC4635818 DOI: 10.1097/md.0000000000001542] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Giant cell arteritis (GCA) is the most frequent form of vasculitis in persons older than 50 years. Cranial and systemic large vessels can be involved. [¹⁸F] fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) is increasingly used to diagnose inflammation of the large arteries in GCA. Unfortunately, no consensus exists on the preferred scoring method. In the present study, we aim to define the optimal FDG PET/CT scoring method for GCA diagnosis using temporal artery biopsy and clinical diagnosis as the reference method. FDG PET/CT scans of GCA patients (12 glucocorticoid-naive, 6 on glucocorticoid treatment) and 3 control groups (inflammatory, atherosclerotic, and normal controls) were evaluated. We compared 2 qualitative visual methods (i.e. (1a) first impression and (1b) vascular uptake versus liver uptake) and 4 semiquantitative methods ((2a) SUVmax aorta, (2b) SUVmax aorta-to-liver ratio, (2c) SUVmax aorta-to-superior-caval-vein ratio, and (2d) SUVmax aorta-to-inferior-caval-vein ratio). FDG uptake pattern (diffuse or focal) and presence of arterial calcifications were also scored. Diagnostic accuracy of the visual method vascular versus liver uptake (1b) was highest when the cut-off point "vascular uptake higher than liver uptake" (sensitivity 83%, specificity 91%) was used. Sensitivity increased to 92% when patients on glucocorticoids were excluded from the analysis. Regarding the semiquantitative methods, the aorta-to-liver ratio (2b) with a cutoff of 1.03 had the highest diagnostic accuracy, with a sensitivity and specificity of 69% and 92%, respectively. Sensitivity increased to 90% when patients on glucocorticoids were excluded. The number of vascular segments with diffuse FDG uptake pattern was significantly higher in GCA patients without glucocorticoid use compared with all control patient groups. CRP was not significantly different between positive and negative FDG PET scans in the GCA group. Visual vascular uptake higher than liver uptake resulted in the highest diagnostic accuracy for the detection of GCA, especially in combination with a diffuse FDG uptake pattern. Of the semiquantitative methods, the aorta-to-liver SUVmax ratio (cutoff point = 1.03) had the highest diagnostic accuracy. The diagnostic accuracy increased when patients using glucocorticoids were excluded from the analyses.
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Affiliation(s)
- Menno D Stellingwerff
- From the Department of Rheumatology and Clinical Immunology (MDS, EB, K-JDFL, ABR, SA, KSMVDG); Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen (AWJMG, RHJAS); and Department of Biomedical Photonic Imaging, University of Twente, Enschede, The Netherlands (RHJAS)
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25
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Lavado-Pérez C, Martínez-Rodríguez I, Martínez-Amador N, Banzo I, Quirce R, Jiménez-Bonilla J, De Arcocha-Torres M, Bravo-Ferrer Z, Jiménez-Alonso M, López-Defilló J, Blanco R, González-Gay M, Carril J. 18F-FDG PET/CT for the detection of large vessel vasculitis in patients with polymyalgia rheumatica. Rev Esp Med Nucl Imagen Mol 2015. [DOI: 10.1016/j.remnie.2015.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Lavado-Pérez C, Martínez-Rodríguez I, Martínez-Amador N, Banzo I, Quirce R, Jiménez-Bonilla J, De Arcocha-Torres M, Bravo-Ferrer Z, Jiménez-Alonso M, López-Defilló JL, Blanco R, González-Gay MA, Carril JM. (18)F-FDG PET/CT for the detection of large vessel vasculitis in patients with polymyalgia rheumatica. Rev Esp Med Nucl Imagen Mol 2015; 34:275-81. [PMID: 26159505 DOI: 10.1016/j.remn.2015.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/26/2015] [Accepted: 05/27/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Polymyalgia rheumatica (PMR) may present together with large vessel vasculitis (LVV), and frequently requires a more intensive therapy. The aim of the study was to evaluate the impact of (18)F-FDG PET/CT in the diagnosis and management of LVV associated to PMR. MATERIAL AND METHODS This prospective study included 40 consecutive patients (27 women/13 men, 68.10±10.27 years) with PMR and suspicion of associated LVV submitted for (18)F-FDG PET/CT. A PET/CT scan was obtained 180 min after (18)F-FDG intravenous injection. A visual analysis was performed on the images. Five vascular regions were evaluated: supra-aortic trunks (SAT), thoracic aorta (TA), abdominal aorta (AA), iliac arteries (IA), and femoral/tibioperoneal arteries (FTA). The intensity of uptake was graded from 0 to 3. A final diagnosis of LVV was established in 26/40 patients (65%). RESULTS In the 26 patients with a diagnosis of LVV, the highest intensity of (18)F-FDG uptake was observed in the TA, SAT, and FTA. All of these patients showed uptake at the TA, with grade 2 and 3 in most cases. In 4 of the 14 patients without LVV, no uptake was observed in any vascular region, and in the other 10 patients only a grade 1 uptake was observed in 1 or to 2 territories. Out of the 20 treated LVV patients, (18)F-FDG PET/CT led to a therapeutic change in 17 (85%). CONCLUSION (18)F-FDG PET/CT was useful in identifying patients with LVV associated to PMR. The detection of vascular inflammation had an important impact, and led to a change of treatment in a high percentage of patients with LVV.
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Affiliation(s)
- C Lavado-Pérez
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - I Martínez-Rodríguez
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain.
| | - N Martínez-Amador
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - I Banzo
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - R Quirce
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - J Jiménez-Bonilla
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - M De Arcocha-Torres
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - Z Bravo-Ferrer
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - M Jiménez-Alonso
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - J L López-Defilló
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - R Blanco
- Department of Rheumatology, Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - M A González-Gay
- Department of Rheumatology, Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
| | - J M Carril
- Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain
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Rheumatoid Arthritis and Related Disorders. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_120-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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28
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Muratore F, Kermani TA, Crowson CS, Green AB, Salvarani C, Matteson EL, Warrington KJ. Large-vessel giant cell arteritis: a cohort study. Rheumatology (Oxford) 2014; 54:463-70. [PMID: 25193809 DOI: 10.1093/rheumatology/keu329] [Citation(s) in RCA: 219] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare baseline variables, treatment and outcomes in patients with large-vessel GCA (LV-GCA), primarily of the upper extremities, with those with cranial disease (C-GCA). METHODS All patients >50 years of age with radiographic evidence of subclavian LV-GCA diagnosed between 1 January 1999 and 31 December 2008 were identified and compared with those with biopsy-positive C-GCA diagnosed in the same period. RESULTS The study included 120 LV-GCA patients and 212 C-GCA patients. Compared with C-GCA, patients with LV-GCA were younger [68.2 years (s.d. 7.5) vs 75.7 (7.4), P < 0.001] and had longer duration of symptoms at GCA diagnosis (median 3.5 vs 2.2 months, P < 0.001). A history of PMR was more common in LV-GCA patients (26% vs 15%, P = 0.012), but a smaller proportion had cranial symptoms (41% vs 83%, P < 0.001) and vision loss (4% vs 11%, P = 0.035). ACR classification criteria for GCA were satisfied in 39% of LV-GCA patients and 95% of C-GCA patients (P < 0.001). Compared with C-GCA, patients with LV-GCA had more relapses (4.9 vs 3.0/10 person-years, P < 0.001), higher cumulative corticosteroid (CS) doses at 1 year [11.4 g (s.d. 5.9) vs 9.1 (s.d. 3.7), P < 0.001] and required longer treatment (median 4.5 vs 2.2 years, P < 0.001). CONCLUSION Although patients with LV-GCA had a lower rate of vision loss, they had a higher relapse rate and greater CS requirements. The ACR criteria for GCA are inadequate for the classification of patients with LV-GCA.
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Affiliation(s)
- Francesco Muratore
- Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Tanaz A Kermani
- Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA. Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Abigail B Green
- Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Carlo Salvarani
- Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Eric L Matteson
- Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA. Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Medicine, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy, Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, Division of Rheumatology, Department of Medicine, Division of Biostatistics, Department of Health Sciences Research and Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
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Association of ferritin antibodies with Takayasu arteritis. Clin Rheumatol 2014; 33:1523-6. [PMID: 25178778 DOI: 10.1007/s10067-014-2764-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 08/24/2014] [Indexed: 10/24/2022]
Abstract
Takayasu arteritis (TA) is difficult to diagnose because diagnostic biomarkers have not yet been established. In a previous study, we detected autoantibodies against the human ferritin heavy chain protein (HFC) in the sera of patients with giant cell arteritis (GCA) and/or polymyalgia rheumatica (PMR). The aim of this study is to evaluate the frequency of autoantibodies against HFC in TA. We established seven ELISA assays for the detection of autoantibodies against HFC. We used the full-length recombinant HFC expressed in Escherichia coli or one of six different HFC peptides as autoantigens: 1-18Aa (98.8 % purity), 19-45Aa (98.8 % purity), 52-78Aa (98.3 % purity), 79-104Aa (98.8 % purity), 105-143Aa (98.4 % purity) and 145-183Aa (98.5 % purity). We collected sera from 48 patients with TA, 36 patients with systemic lupus erythematosus (SLE), 35 patients with arteriosclerosis, 133 patients with febrile diseases, which are known to generate unspecific autoantibodies, and 50 blood donors, which served as controls. The best results were obtained using the ferritin peptides as antigens. By combining the results from the different ELISAs that detect autoantibodies against the HFC peptides 19-44A, 79-104A and 105-144A, we were able to detect ferritin peptide antibodies in 30/48 (62 %) of the TA patients. The frequency was lower than in early GCA and PMR (previous study showed up to 92 %). Positive results were observed in 0/50 (0 %) of the control blood donors, 10/36 (28 %) of the SLE patients, 4/35 (11 %) of the arteriosclerosis patients and 27/133 (20 %) of the fever patients. Considering the lack of biomarkers for TA, autoantibodies against HFC peptides could act as useful markers for TA.
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Giant cell arteritis: a systematic review of the qualitative and semiquantitative methods to assess vasculitis with 18F-fluorodeoxyglucose positron emission tomography. BIOMED RESEARCH INTERNATIONAL 2014; 2014:574248. [PMID: 25254211 PMCID: PMC4165737 DOI: 10.1155/2014/574248] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 07/28/2014] [Indexed: 01/12/2023]
Abstract
Giant cell arteritis (GCA) is the most common vasculitis affecting medium and large vessels. It shows a close clinical association with polymyalgia rheumatica (PMR), a musculoskeletal inflammatory disorder, which is clinically characterized by girdles pain and stiffness. 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) is an effective tool for the diagnosis, grading, and follow-up of patients affected by GCA involving the aorta and its proximal branches, but the lack of a standardized method for the assessment of vascular inflammation remains a critical issue, potentially leading to misclassification. In our systematic review, including 19 original articles for a total of 442 GCA patients (with or without PMR symptoms) and 535 healthy controls, we described the different qualitative, semiquantitative and combined methods that have been proposed throughout the literature for assessing the presence and grading the severity of GCA-related vascular inflammation on 18F-FDG PET scans, focusing on the diagnostic performance and examining their respective advantages and limitations. The majority of the included studies adopted qualitative methods of PET image analysis, which are less sensitive but more specific than semiquantitative ones. Among the semiquantitative approaches, the aortic-to-blood pool uptake ratio of the aortic arch seems to be the most accurate method.
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De Bandt M. Current diagnosis and treatment of polymyalgia rheumatica. Joint Bone Spine 2014; 81:203-8. [DOI: 10.1016/j.jbspin.2013.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2013] [Indexed: 12/01/2022]
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A rare cause of pericardial effusion: giant cell arteritis. Case Rep Rheumatol 2014; 2014:424295. [PMID: 24523978 PMCID: PMC3910070 DOI: 10.1155/2014/424295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 12/08/2013] [Indexed: 11/23/2022] Open
Abstract
Giant cell arteritis is a granulomatous vasculitis characterized by medium or large sized vessel involvement. Although extracranial branches of the carotid artery are typically involved, involvement of aorta and its major branches can also be seen. Cardiac involvement has been encountered less frequently and pericardial effusion is rarely encountered. In this paper, a case has been presented in which pericardial effusion was determined during the examination and diagnosis was giant cell arteritis.
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Große K, Schmidt RE, Witte T, Baerlecken NT. Epitope mapping of antibodies against ferritin heavy chain in giant cell arteritis and polymyalgia rheumatica. Scand J Rheumatol 2013; 42:215-9. [PMID: 23682607 DOI: 10.3109/03009742.2012.733959] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES In a previous study we found an association between antibodies against the human ferritin heavy chain (HFC) protein and giant cell arteritis (GCA) and/or polymyalgia rheumatica (PMR), especially in GCA/PMR patients prior to glucocorticoid treatment. Antibodies against the N-terminal part of ferritin were present in 92% of untreated patients, 69% of patients with disease flare, and 13% of patients in remission. These antibodies appeared to be markers for the early detection of a disease complex usually diagnosed with considerable delay. Our aim in this study was to optimize the diagnostic test by epitope mapping of antibodies against HFC using peptide antigens in enzyme-linked immunosorbent assays (ELISAs). METHOD We evaluated serum samples from a selected group of GCA/PMR patients in whom the sensitivity of antibodies against the N-terminal ferritin peptide was only 35%. Patients with late-onset rheumatoid arthritis (LORA), patients with fever, patients with granulomatosis with polyangiitis (GPA), patients without any autoimmune disease at age > 65 years, and blood donors served as controls. RESULTS By combining different ELISAs we were able to increase the frequency of human ferritin peptide antibodies in GCA/PMR (p < 0.0001) without significantly altering the false-positive rate (FPR) of the diagnostic test. The frequency of antibodies against human ferritin peptide increased from 53% to 74% in GCA/PMR patients with disease flare, from 29% to 40% in GCA/PMR patients in partial remission, and from 8% to 45% in GCA/PMR patients in complete remission. CONCLUSIONS The potential diagnostic test for GCA/PMR can be improved by combining three human ferritin peptide antibodies.
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Affiliation(s)
- K Große
- Department of Immunology and Rheumatology, Medical University Hannover, Germany
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Abstract
GCA is the prime medical emergency in ophthalmology because it may result in loss of vision in 1 or both eyes. This vision loss is preventable if patients are diagnosed early and treated immediately with high doses of corticosteroids.
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Denniston AK, Gayed M, Carruthers D, Gordon C, Murray PI. Rheumatic Disease. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00080-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The natural history of asymptomatic positron emission tomography: positive giant cell arteritis after a case of self-limiting polymyalgia rheumatica. Mod Rheumatol 2012; 22:942-6. [PMID: 22710835 DOI: 10.1007/s10165-012-0689-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 05/28/2012] [Indexed: 10/28/2022]
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Kennedy S. Polymyalgia rheumatica and giant cell arteritis: an in-depth look at diagnosis and treatment. ACTA ACUST UNITED AC 2012; 24:277-85. [PMID: 22551331 DOI: 10.1111/j.1745-7599.2012.00717.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To provide an in-depth synthesis of the literature on polymyalgia rheumatic (PMR) and giant cell arteritis (GCA) that will assist the primary care nurse practitioner (NP) in recognizing the variety of symptom presentations, accurately evaluating laboratory data, developing a plan of care that includes current treatment guidelines, and adroitly managing patients for improved outcomes. DATA SOURCES A thorough search of the literature was conducted including MEDLINE, CIHAHL, and PubMed encompassing the decades from the 1970s to the present. CONCLUSIONS Because of the varied and vague symptom presentations of PMR and GCA, primary healthcare providers often misdiagnose these pathologies, delaying treatment and relief of suffering. Textbooks descriptions often omit supplemental content necessary to understand the intricacies of the presenting symptoms, diagnostic tests needed for work-up, and specific treatment for these overlapping pathologies. IMPLICATIONS FOR PRACTICE Because PMR and GCA often present in the primary care setting, NPs must maintain a high index of suspicion when a patient over 60 years of age presents with vague complaints such as headache, weakness, anorexia, and malaise. Arriving at an accurate diagnosis in a timely fashion will lead to appropriate treatment and minimize patient suffering.
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Affiliation(s)
- Sally Kennedy
- College of Nursing, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Parameters related to a positive test result for FDG PET(/CT) for large vessel vasculitis: a multicenter retrospective study. Clin Rheumatol 2012; 31:861-71. [PMID: 22322206 DOI: 10.1007/s10067-012-1945-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 12/04/2011] [Accepted: 01/19/2012] [Indexed: 10/14/2022]
Abstract
The purpose of this study was to identify clinical and laboratory parameters that may improve the effectiveness of the use of fluorodeoxyglucose positron emission tomography ((18)F-FDG PET)(/CT) for diagnosing large vessel vasculitis (LVV), and secondarily to assess the contribution of (18)F-FDG PET/CT in finding other diagnoses for patients without signs of LVV on the scan. A multicenter retrospective study of (18)F-FDG PET(/CT) scans performed between January 2000 and December 2009 for clinical suspicion of LVV was conducted. A total of 304 (18)F-FDG PET(/CT) scans were included, of which 62 (20%) were positive and 242 (80%) were negative for LVV. Univariate analysis showed that patients with a positive scan were older (65.9 ± 13.4 versus 58.6 ± 16.5 years, p = 0.002), were more frequently female (76% versus 55%, p = 0.002), more often had a history of temporal arteritis (10% versus 3%, p = 0.044), less frequently had artralgia (31% versus 67%, p = 0.000), and had higher thrombocyte counts (434 ± 161 versus 373 ± 168 × 10(9)/l, p = 0.049) and a higher erythrocyte sedimentation rate (ESR) (72.6 ± 31.0 versus 51.4 ± 30.5 mm/h, p = 0.001) than patients with a negative scan. In the multivariate analysis, only artralgia (OR 0.091; 95% CI 0.023-0.366) and ESR (OR 1.024; 95% CI 1.002-1.046) remained statistically significant predictors. The presence of artralgia is a statistically significant negative predictor and an elevated ESR a statistically significant positive predictor of LVV showing up on (18)F-FDG PET(/CT). A reliable prediction of the outcome of the scan, based on these two parameters, is not possible however. (18)F-FDG PET(/CT) allows early diagnosis of LVV and may discover occult inflammatory or neoplastic disorders.
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Anterior uveitis as an initial manifestation of polymyalgia rheumatica. Case Rep Med 2011; 2011:621241. [PMID: 21629812 PMCID: PMC3099222 DOI: 10.1155/2011/621241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Accepted: 03/15/2011] [Indexed: 11/23/2022] Open
Abstract
A 74-year-old woman without contributory medical history presented with acute iridocyclitis in the right eye. Although the iridocyclitis disappeared within two weeks under topical steroid, she complained of acute progressing bilateral shoulder pain and morning stiffness of upper extremities. She was diagnosed as having polymyalgia rheumatica (PMR), and iridocyclitis was considered as its related manifestation. PMR and giant cell arteritis (GCA) are closely related conditions and frequently occur together. GCA with uveitis has been rarely noted. However, ocular symptoms in PMR have not been previously mentioned. This is a first reported case of PMR presented with uveitis, without a complication of GCA. This anterior uveitis might be caused by ischemia of the posterior ciliary arteries and their branches.
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Stroke in the setting of giant cell arteritis: a case report. Case Rep Med 2011; 2010:549258. [PMID: 21209814 PMCID: PMC3014822 DOI: 10.1155/2010/549258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Accepted: 11/22/2010] [Indexed: 11/18/2022] Open
Abstract
WE DESCRIBE AN UNUSUAL COMPLICATION OF A COMMON DISEASE: stroke presenting in a man recently diagnosed with polymyalgia rheumatica. Initial inflammatory markers were misleading. We discuss pitfalls in diagnosis, and approach to management.
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Hazleman BL. Giant Cell Arteritis. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00052-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Kang JH, Sheu JJ, Lin HC. Polymyalgia Rheumatica and the Risk of Stroke: A Three-Year Follow-Up Study. Cerebrovasc Dis 2011; 32:497-503. [DOI: 10.1159/000332031] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 08/10/2011] [Indexed: 11/19/2022] Open
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Abstract
Vasculitis or angiitis refers to a group of inflammatory disorders of the blood vessels that cause structural damage to the affected vessel, including thickening and weakening of the vessel wall, narrowing of its lumen, and, usually, vascular necrosis. Systemic vasculitis is classified according to the vessel size and histopathologic and clinical features. Vasculitides with small vessel involvement typically include Henoch-Schönlein purpura and cryoglobulinemia. Polyarteritis nodosa and Wegener granulomatosis are small- and medium-sized vessel vasculitides, whereas temporal arteritis and Takayasu arteritis involve large vessels. In this article, the authors provide a review of the neurologic presentations of the major systemic vasculitides.
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Carolei A, Sacco S. Headache attributed to arteritis, cerebral venous thrombosis, and other vascular intracranial disturbances. HANDBOOK OF CLINICAL NEUROLOGY 2010; 97:529-540. [PMID: 20816454 DOI: 10.1016/s0072-9752(10)97048-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Headache with variable characteristics and associated signs and symptoms may occur in all forms of arteritis. Giant cell arteritis, one of the most common forms, involves branches of the external and, more rarely, of the internal carotid arteries. It occurs in patients over the age of 50 and is characterized by fever, new-onset headache, prominence and tenderness of the temporal artery, claudication of the masticatory muscles on chewing, amaurosis fugax, and visual loss. Headache is the initial symptom in 48% of patients and is present in 90%. Primary central nervous system angiitis is a rare and highly fatal disease in which headache is one of the most frequent symptoms despite the fact that, given its non-specific characteristics, it is of little diagnostic relevance. Headache may also be attributed to several secondary central nervous system arteritides such as Behçet's disease, Takayasu disease, polyarteritis nodosa, Kawasaki disease, Wegener's granulomatosis, systemic lupus erythematosus, and vasculitits caused by viruses, bacteria, fungi, rickettsiae, and protozoa. Thrombosis of the cerebral veins and sinuses is a distinct cerebrovascular disorder that, unlike arterial stroke, most often affects young adults and children. Headache is the most frequent but least specific symptom of venous sinus thrombosis, being present in more than 90% of patients. Headache can also be attributed to other vascular intracranial disorders such as cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), benign (or reversible) angiopathy of the central nervous system, and pituitary apoplexy.
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Affiliation(s)
- Antonio Carolei
- Department of Neurology, University of L'Aquila, L'Aquila, Italy.
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Brandt HRC, Arnone M, Valente NYS, Sotto MN, Criado PR. [Medium and large vessel vasculitis]. An Bras Dermatol 2009; 84:55-67. [PMID: 19377760 DOI: 10.1590/s0365-05962009000100008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Accepted: 12/26/2008] [Indexed: 12/26/2022] Open
Abstract
Vasculitis comprises a broad group of syndromes characterized by inflammation and necrosis on the walls of blood vessels, resulting in narrowing or occlusion of the lumen. The distribution of involved blood vessel varies considerably and serves as the basis for one classification of vasculitic syndromes: large vessels (Takayasu arteritis, giant cell arteritis); medium and small muscular arteries (polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, vasculitis in rheumatic diseases); and small vessels ("hypersensitivity" vasculitis, Henoch-Schonlein purpura, microscopic polyangiitis, cryoglobulinemia). This article reviews medium and large vessel vasculitis and current treatment options; it also presents a comprehensive approach to diagnosing and treating patients with suspected cutaneous vasculitis.
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A case of cold agglutinin disease in the course of treatment for polymyalgia rheumatica. Mod Rheumatol 2009; 19:427-30. [PMID: 19340395 DOI: 10.1007/s10165-009-0167-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 03/10/2009] [Indexed: 10/20/2022]
Abstract
A 60-year-old male who had been treated for polymyalgia rheumatica (PMR) with Raynaud's phenomenon was admitted to our hospital with acrocyanosis and rapid progressive anemia. Hemolytic anemia with reduction of haptoglobin and cold agglutinin was detected, and the patient had a negative Donath-Landsteiner test. A skin biopsy from his toe revealed microthromboembolism without vasculitis, resulting in the diagnosis of cold agglutinin disease (CAD). This is a first case report of CAD complicated with PMR.
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Abstract
Polymyalgia rheumatica and giant-cell arteritis are closely related disorders that affect people of middle age and older. They frequently occur together. Both are syndromes of unknown cause, but genetic and environmental factors might have a role in their pathogenesis. The symptoms of polymyalgia rheumatica seem to be related to synovitis of proximal joints and extra-articular synovial structures. Giant-cell arteritis primarily affects the aorta and its extracranial branches. The clinical findings in giant-cell arteritis are broad, but commonly include visual loss, headache, scalp tenderness, jaw claudication, cerebrovascular accidents, aortic arch syndrome, thoracic aorta aneurysm, and dissection. Glucocorticosteroids are the cornerstone of treatment of both polymyalgia rheumatica and giant-cell arteritis. Some patients have a chronic course and might need glucocorticosteroids for several years. Adverse events of glucocorticosteroids affect more than 50% of patients. Trials of steroid-sparing drugs have yielded conflicting results. A greater understanding of the molecular mechanisms involved in the pathogenesis should provide new targets for therapy.
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Affiliation(s)
- Carlo Salvarani
- Unit of Rheumatology, Arcispedale S Maria Nuova, Reggio Emilia, Italy.
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Cantini F, Niccoli L, Nannini C, Bertoni M, Salvarani C. Diagnosis and treatment of giant cell arteritis. Drugs Aging 2008; 25:281-97. [PMID: 18361539 DOI: 10.2165/00002512-200825040-00002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Giant cell arteritis (GCA) is a chronic granulomatous vasculitis of unknown aetiology occurring in the elderly. It affects the cranial branches of the arteries originating from the aortic arch and is usually associated with markedly elevated acute-phase reactants. In 10-15% of cases the extra-cranial branches of the aortic arch are involved. GCA is closely related to polymyalgia rheumatica (PMR), although the relationship between the two disorders is still unclear. New-onset headache, scalp tenderness, jaw claudication, temporal artery abnormalities on physical examination, visual symptoms and associated PMR represent the most typical and frequent features of the disease. Systemic manifestations, including fever, anorexia and weight loss, are observed in 50% of cases. Less frequent manifestations are related to the central or peripheral nervous systems, the respiratory tract and extra-cranial large-vessel involvement. As GCA is characterized by a wide spectrum of clinical manifestations, it is important to recognize the different onset patterns of the disease and related diagnostic steps. The diagnosis is relatively straightforward in the presence of typical cranial manifestations, but it may be challenging in the case of a normal erythrocyte sedimentation rate, occult GCA or in patients with isolated extra-cranial features. Temporal artery biopsy still represents the gold standard for diagnosis, while the role of ultrasonography, high-resolution magnetic resonance imaging and positron emission tomography should be better addressed. Corticosteroids remain the therapy of choice. Data supporting the usefulness of antiplatelet agents and anticoagulants combined with corticosteroids to prevent ischaemic complications as well as the corticosteroid-sparing effect of methotrexate and anti-tumour necrosis factor-alpha drugs are limited and non-conclusive.
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Affiliation(s)
- Fabrizio Cantini
- 2nd Division of Medicine, Rheumatology Unit, Hospital Misericordia e Dolce, Prato, Italy.
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Hernández-Rodríguez J, Font C, García-Martínez A, Espígol-Frigolé G, Sanmartí R, Cañete JD, Grau JM, Cid MC. Development of ischemic complications in patients with giant cell arteritis presenting with apparently isolated polymyalgia rheumatica: study of a series of 100 patients. Medicine (Baltimore) 2007; 86:233-241. [PMID: 17632265 DOI: 10.1097/md.0b013e318145275c] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Several studies suggest that patients with giant cell arteritis (GCA) presenting with isolated polymyalgia rheumatica (PMR) with no cranial symptoms are at low risk of suffering GCA-related ischemic events. However, the issue remains controversial. In the current study we assessed the development of ischemic events in a large series of GCA patients who suffered from apparently isolated PMR during the main course of their disease. One hundred GCA patients presenting with PMR only for at least 2 months were selected from among 347 individuals with biopsy-proven GCA. Clinical manifestations and their chronologic appearance before diagnosis were recorded. Seventy-three patients presented with isolated PMR for a median of 8 months (range, 2 mo-5 yr) and later developed cranial symptoms for a median of 3 weeks (range, 0 wk-1 yr), which eventually led to GCA diagnosis (Group 1). The remaining 27 patients, after presenting a self-limiting course of dismissed mild cranial symptoms lasting for a median of 2 weeks (range, 1 wk-4 mo), developed PMR, which was their chief complaint for a median of 3 months (range, 2 mo-1.5 yr) and the reason for medical evaluation (Group 2). Twenty (27.4%) patients in Group 1 suffered disease-related ischemic complications at the time of diagnosis. No patient in Group 2 developed ischemic events. Patients with GCA presenting with apparently isolated PMR are not a benign subset and have a significant risk of developing ischemic complications. Among them, the only patients who appear to be at low risk of developing ischemic events are those in whom a self-limiting episode of cranial symptoms can be recorded.
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Affiliation(s)
- José Hernández-Rodríguez
- From Vasculitis Research Unit, Department of Internal Medicine (JH-R, CF, AGM, GE-F, JMG, MCC) and Department of Rheumatology (RS, JDC), Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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