Giant Cell Arteritis and Polymyalgia Rheumatica

Giant cell arteritis in China: a prospective investigation

The objective of this prospective study was to investigate further the clinical features of patients with giant cell (temporal) arteritis (GCA). All patients diagnosed from July 1999 to March 2001 at the Department of Neurology of the Second Xiangya Hospital in China were included. The final diagnosis was based on clinical manifestations, a temporal artery biopsy, response to steroid, and follow-up. The American College of Rheumatology (ACR) criteria for the classification of GCA were tested in the patients identified. Sixteen patients with GCA were identified; 13 (81.25%) patients fulfilled the 1990 ACR criteria for the classification of GCA. Clinical findings included the following: mean age at disease onset 43.13 years (range 28-60) and 81.25% of the patients under the age of 50 when the disease began; men 93.75%; the common initial symptoms including new headache 62.50% and.visual symptoms 18.75%; the common clinical findings at presentation including new headache 93.75%, temporal artery abnormality 81.25%, visual abnormality 56.25%, and fever 25.00%; raised erythrocyte sedimentation rate (ESR) 68.75%; and uncommon findings including jaw claudication, ptosis, fatigue, syncope, hemiparesis; all 16 patients underwent a temporal artery biopsy; inflammatory cell infiltration 68.75% in arterial wall, fragmented internal elastica 100.00%, fibrinoid necrosis 18.75%, smooth muscle cell changes 62.50%, and thrombosis in the lumen 31.25%. The mean time from symptom onset to suspicion of GCA or biopsy was 5.52 months (range 0.25-24.33); the initial diagnosis was wrong in 87.50% of patients. These examples are too small a number to permit definite conclusion. But the results suggest that GCA may not be a rare disorder in China, mean age at disease onset was relatively young, males may be more susceptible, the clinical features of GCA have not been widely appreciated yet, there was a delay between diagnosis and treatment, and initial diagnosis was wrong in many patients.

Epidemiology of the vasculitides

In summary, systemic vasculitides constitute a heterogeneous group of overlapping diseases that are somewhat more common than previously considered. Although the causes of vasculitis are largely unknown, epidemiologic studies have implicated geographic, genetic, and environmental factors. Ethnicity, various genes such as those of the MHC, gender, and environmental factors seem to account for the different incidence rates of these syndromes. GCA is the most common vasculitis in elderly people from Western countries. Small-sized cutaneous vasculitides, particularly HSP in children and HV in adults, are also common diseases. Increased physician awareness and the routine use of ANCA tests may contribute to an increase in the recognition of conditions such as WG and MPA.

Painful chewing and blindness: signs and symptoms of temporal arteritis

BACKGROUND

This case report illustrates the need to consider temporal arteritis in the differential diagnosis of jaw or tooth pain. This disease affects the cranial arteries, more frequently in women and usually in those older than age 60 years, causing jaw pain, visual symptoms, headache, scalp pain and sometimes blindness.

CASE DESCRIPTION

A 71-year-old man had jaw pain that increased with chewing and speaking, scalp tenderness and dimming vision. A temporal artery biopsy confirmed the diagnosis of temporal arteritis. Treatment with decreasing amounts of oral steroids over 23 months was successful in relieving his signs and symptoms and in saving his vision.

CLINICAL IMPLICATIONS

Patients with this disease may seek care from their dentist first. Jaw or tooth pain is the most reliable clinical symptom in the diagnosis of temporal arteritis. Diagnosis and timely referral for treatment with oral steroids can prevent blindness.

Polymyalgia rheumatica and giant cell arteritis

PMR and GCA are related conditions that seem to represent a continuum of disease. These conditions are relatively common and seem to be mediated by a cellular inflammatory response. Increasing evidence suggests an infectious cause (or causes) precipitating this immune response in genetically susceptible individuals. Whereas previously thought to affect primarily branch vessels of the aortic arch, GCA is now thought of as a disease in which proximal aortic involvement is frequent. Despite the potential for serious, even fatal complications, overall prognosis for patients with GCA or PMR is excellent. Corticosteroids remain the standard treatment, although not curative. Whereas the ESR is a useful indicator of disease activity, other markers which may be more precise such as creative protein and Il-6 seem to offer added information about disease activity.

Disease patterns and tissue cytokine profiles in giant cell arteritis

OBJECTIVE

To determine whether clinical heterogeneity in patients with giant cell arteritis (GCA) is correlated with different patterns in the tissue-specific inflammatory response.

METHODS

Twenty-three patients with typical histomorphologic findings of GCA were grouped according to the presence or absence of jaw claudication and/or visual abnormalities, fever, concomitant polymyalgia rheumatica (PMR), and histologic evidence of giant cell formation. The inflammatory response in temporal artery biopsy specimens was characterized by semiquantification of cytokine messenger RNA (mRNA) transcripts using reverse transcriptase-polymerase chain reaction, followed by oligonucleotide hybridization with cytokine-specific probes. Clinical patterns were then correlated with profiles of tissue cytokines.

RESULTS

Inflammatory cytokines were expressed in all temporal artery tissues. In situ synthesis of interleukin-2 (IL-2), interferon-gamma (IFN gamma), and IL-1 beta mRNA, but not of IL-10 and IL-12 mRNA, distinguished different patterns of inflammation, and these patterns correlated with clinical manifestations of the disease. Patients with evidence of ischemic symptoms, indicated by jaw claudication and/or visual symptoms, typically expressed higher concentrations of IFN gamma mRNA (P = 0.008) and IL-1 beta mRNA (P = 0.02). Presence of fever was correlated with lower copy numbers of IFN gamma (P = 0.02). Formation of giant cells in the granulomatous infiltrates was associated with the local synthesis of IFN gamma mRNA (P = 0.003). Tissue from GCA patients with concomitant PMR contained higher levels of IL-2 mRNA transcripts (P = 0.001).

CONCLUSION

Variations in the clinical presentation of GCA were correlated with cytokine mRNA expression in the affected temporal arteries. Differences in the effector functions of tissue-infiltrating T cells distinguished disease patterns in which either local ischemic symptoms or systemic involvement was dominant, or in which there was co-occurrence of PMR. Definition of different patterns of inflammation in GCA might, therefore, facilitate the design of differentiated therapeutic approaches.

Aortic dissection in giant-cell arteritis

Twenty-three cases of aortic dissection in patients with giant-cell arteritis are reviewed and an additional case is reported. Forty-six percent presented catastrophically with aortic dissection and no prior history of giant cell arteritis. Eighty percent died within 2 weeks of the event; four patients had successful surgical grafts. There was diffuse involvement of the aorta with giant cells in 89%, but dissecting tears occurred primarily in the proximal aorta in 85% of cases. The majority of cases with a preceding history of giant cell arteritis were on low doses of steroid or on no treatment at the time of dissection, and the median erythrocyte sedimentation rate of these patients was 62 mm/h (range 21-98). Evidence of some form of hypertension, whether acute or chronic, mild or severe, was found in 77% of patients. Inadequate treatment of giant-cell arteritis and underlying hypertension (treated or untreated) are potential factors leading to aortic dissection in these patients.

Common rheumatologic diseases in elderly patients

OBJECTIVE

To review common rheumatologic disorders that affect elderly patients and emphasize the unique diagnostic and therapeutic challenges inherent in the management of rheumatologic diseases in this age-group.

DESIGN

We summarize our approach to treatment and management of specific rheumatologic problems in geriatric patients and discuss pertinent studies from the literature.

RESULTS

Among the spectrum of rheumatologic disorders frequently encountered in the elderly population are polymyalgia rheumatica, fibromyalgia, giant cell arteritis, crystalline arthropathies (gout and pseudogout), and degenerative joint disease. The initial manifestations of these rheumatologic diseases in elderly patients may differ from the typical findings in younger patients. Geriatric patients may have nonspecific complaints, a decline in physical function, or even confusion. Because of physiologic changes associated with aging and a decrease in functional reserves, elderly patients are susceptible to adverse effects of pharmacologic therapy (including nonsteroidal anti-inflammatory medications, corticosteroids, narcotic analgesics, allopurinol, and colchicine). Clinicians should be alert for such problems as hepatotoxicity and occult gastrointestinal blood loss. Comorbid conditions such as cardiovascular disease and cognitive impairment may complicate management strategies and may limit the goals of both surgical intervention and rehabilitation programs in elderly patients.

CONCLUSION

Rheumatologic disorders in geriatric patients pose special challenges to primary-care physicians. In the selection of optimal pharmacologic and nonpharmacologic therapeutic modalities, clinicians should focus on maintaining or improving the patient's quality of life and level of independent function.

Polymyalgia rheumatica and temporal arteritis: a retrospective study of 111 patients

There is no unanimity as to whether polymyalgia rheumatica (PMR) and temporal arteritis (TA) are two distinct diseases or different features of one disease. The objective of this study was to assess the value of histological findings of temporal artery biopsy and the efficacy and complications of drug therapy as well as the frequency of malignancies. It was carried out as a retrospective follow-up study. One hundred eleven patients (89 PMR, 14 TA and 8 PMR+TA) were studied. In 56 patients with PMR a temporal artery biopsy was performed; in none of these biopsies was active arteritis found. Of the 19 patients with TA or PMR+TA, where a temporal artery biopsy was performed, arteritis was found in 15 patients. Reactivation occurred in 27 patients: 4 patients using NSAIDs and 23 patients using corticosteroids. Side effect of the medication included vertebral compression in 10 patients, most of whom were using corticosteroids. Malignancies were diagnosed in 12 of the 111 patients. Most malignancies were diagnosed long before or after the diagnosis of PMR. In case of a PMR diagnosed by the clinician a biopsy of the temporal artery has no value, while the yield of this diagnostic procedure is high in TA. Reactivation was seen quite often and warrants a prolonged period of medical treatment.

Polymyalgia rheumatica and giant cell arteritis in emergency department patients

Elderly patients with undiagnosed polymyalgia rheumatica and giant cell arteritis are not uncommon, and they may present to the emergency department with nonspecific physical complaints. We describe the cases of two patients who had the "typical" constellation of symptoms. It is important that emergency physicians consider the diagnosis and provide appropriate testing, therapy, and follow-up.

The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis

Criteria for the classification of giant cell (temporal) arteritis were developed by comparing 214 patients who had this disease with 593 patients with other forms of vasculitis. For the traditional format classification, 5 criteria were selected: age greater than or equal to 50 years at disease onset, new onset of localized headache, temporal artery tenderness or decreased temporal artery pulse, elevated erythrocyte sedimentation rate (Westergren) greater than or equal to 50 mm/hour, and biopsy sample including an artery, showing necrotizing arteritis, characterized by a predominance of mononuclear cell infiltrates or a granulomatous process with multinucleated giant cells. The presence of 3 or more of these 5 criteria was associated with a sensitivity of 93.5% and a specificity of 91.2%. A classification tree was also constructed using 6 criteria. These criteria were the same as for the traditional format, except that elevated erythrocyte sedimentation rate was excluded, and 2 other variables were included: scalp tenderness and claudication of the jaw or tongue or on deglutition. The classification tree was associated with a sensitivity of 95.3% and specificity of 90.7%.

Neurologic manifestations of giant cell arteritis

Giant cell arteritis (GCA) is a common vasculitic disease in the elderly, with a multitude of neurologic manifestations including, but not limited to, stroke and blindness. Many uncommon manifestations are often unrecognized and proper diagnosis and treatment delayed. This review focuses on the pathophysiology and neurologic symptoms of GCA, with special emphasis on the diversity of ocular involvement.

Anticardiolipin antibodies in patients with autoimmune diseases: isotype distribution and clinical associations

A prospective study of IgG and IgM isotypes of anticardiolipin antibodies (aCL) was performed in a series of 167 patients with various autoimmune diseases, including rheumatic and nonrheumatic disorders, and in a group of 100 healthy blood donors. The IgG aCL serum was regarded as positive if a binding index (BI) greater than 2.85 (3.77 SD) was detected and a BI greater than 4.07 (3.90 SD) was defined as positive for IgM aCL. Forty patients (24%) were found to be positive for IgG and/or IgM aCL. IgG aCL were detected in 23% of patients with systemic lupus erythematosus (SLE), in 9% with idiopathic thrombocytopenic purpura, in 7% with progressive systemic sclerosis, and in 6% with dermatomyositis-polymyositis. IgM aCL were present in 43% patients with primary biliary cirrhosis, in 33% with rheumatoid arthritis, in 22% with SLE, and in 8% with giant-cell arteritis. IgG aCL were found to have a significant association with thrombosis and thrombocytopenia, and IgM and aCL with haemolytic anaemia and neutropenia, in SLE but not in the other autoimmune diseases. The identification of these differences in the aCL isotype associations, depending on the autoimmune disorder, may improve the clinical usefulness of these tests.

Temporal arteritis: cell composition and the possible pathogenetic role of cell-mediated immunity

A biopsy specimen exhibiting the typical morphologic characteristics of temporal arteritis was studied by using light immunofluorescent, and electron microscopy and immunohistochemical techniques. The granulomatous lesion consisted of clusters of macrophages, epithelioid cells, giant cells, and the peripheral lymphocyte mantle, and was localized mainly in the media. Neutrophils were rare, and fibrinoid necrosis was absent. In immunofluorescent and immunohistochemical studies, no significant deposition of immunoglobulins or complement was observed. Immunohistochemical study with monoclonal antibodies to leukocyte surface antigens demonstrated that the central aggregated granulomatous infiltrate consisted of OKTM1+, Leu-M3+, HLA-DR+ epithelioid macrophages and multinucleated giant cells, whereas OKT8+, HLA-DR+ (suppressor/cytotoxic) T cells predominated in the peripheral lymphocyte mantle. These findings suggest that cell-mediated immunity, especially T cell-regulated granulomatous reaction, may play an important role in the pathogenesis of temporal arteritis. By electron microscopy, smooth muscle cells often exhibited closely attached macrophages, epithelioid cells, and giant cells, and displayed a variety of cell injuries. It therefore seems likely that smooth muscle cells are a primary target of the granulomatous reaction.

Update on systemic necrotizing vasculitis

The systemic necrotizing vasculitides are classified into vasculitic syndromes on the basis of the pattern of clinical and pathologic involvement. The vasculitides have certain common clinical and laboratory abnormalities. Systemic necrotizing vasculitis is diagnosed on the basis of clinical features, and the vascular nature of the disease is determined by biopsy of involved tissue or angiography. The outcome is dependent on the extent of visceral involvement. Vascular inflammation influences the physiologic features of the vessel and may trigger vasoconstriction. Although glucocorticoids combat the inflammation, they may augment vasoconstriction and platelet aggregation. These effects must be considered in designing a management approach and in evaluating the cause and management of ischemic complications.

Late-onset systemic lupus erythematosus presenting as polymyalgia rheumatica

Two patients (male, 60 and 66 years of age) who developed systemic lupus erythematosus (SLE) in the 6th decade are described. Both patients presented with a polymyalgia rheumatica (PMR) syndrome. In both cases there was an underlying muscle involvement (nonspecific in the first case and true myositis in the second case) as well as findings compatible with nonclassic type of temporal arteritis.

Polymyalgia rheumatica: a syndrome associated with HLA-DR4 antigen

HLA class II antigens were determined in 65 patients with biopsy-proven giant cell arteritis (GCA). An increase in DR4 antigen frequency was found in the patients (40%) compared with that in 200 healthy controls (20%) (Pcorr less than 0.05). DR4 was significantly more frequent in GCA patients with polymyalgia rheumatica (PMR) than in those without PMR (58.8% versus 19.3%) (P less than 0.005). HLA-DR4 frequency in GCA patients without PMR was similar to that in the control population (20%). Patients with severe, disabling PMR had DR4 more frequently (90%) than did those with moderate symptoms who required medical care because of cranial arteritis manifestations (41.6%) (P less than 0.05). We conclude that, in GCA patients, association with DR4 is mainly related to the manifestation of the disease as PMR. We discuss clinical and immunogenetic similarities between PMR and other DR4-associated rheumatic disorders. Common immunopathogenic mechanisms leading to clinical overlap among them are suggested.

Rheumatoid arthritis: clinical considerations in diagnosis and management

Advances in the understanding of the immune response, in immunogenetics, and in better identification of microbial agents that produce arthritis have made possible more accurate diagnosis of rheumatoid arthritis. Epidemiologic study of groups of rheumatoid patients and their response to therapy has provided a broader perspective of the disease's course and management. Therapy must be guided by the acute or chronic phase of the disease and must embrace chemical, psychologic, and physical modalities to achieve the goals of pain relief and the restoration of immune balance. Rheumatoid arthritis can no longer be considered benign since it impairs the duration as well as the quality of life. Therapy should be aggressive depending upon the predictors of more destructive disease.

Pulmonary artery obstruction due to giant cell arteritis

Giant cell arteritis is often referred to in the context of polymyalgia rheumatica with temporal artery involvement. There are, however, more malignant forms of presentation of this necrotizing arteritis involving either the great vessels of the aorta or, occasionally, the pulmonary arteries. Our case relates to giant cell arteritis presenting as pulmonary artery obstruction in a patient without polymyalgia rheumatica or extensive aortic or proximal great vessel involvement.