Surgical pathology of cranial arteritis and polymyalgia rheumatica

Consensus statement on the processing, interpretation and reporting of temporal artery biopsy for arteritis

Giant cell arteritis (GCA) is the most common systemic vasculitis in adults in Europe and North America, typically involving the extra-cranial branches of the carotid arteries and the thoracic aorta. Despite advances in noninvasive imaging, temporal artery biopsy (TAB) remains the gold standard for establishing a GCA diagnosis. The processing of TAB depends largely on individual institutional protocol, and the interpretation and reporting practices vary among pathologists. To address this lack of uniformity, the Society for Cardiovascular Pathology formed a committee tasked with establishing consensus guidelines for the processing, interpretation, and reporting of TAB specimens, based on the existing literature. This consensus statement includes a discussion of the differential diagnoses including other forms of arteritis and noninflammatory changes of the temporal artery.

Imaging of giant cell arteritis - recent advances

Imaging is increasingly being used to guide clinical decision-making in patients with giant cell arteritis (GCA). While ultrasound has been rapidly adopted in fast-track clinics worldwide as an alternative to temporal artery biopsy for the diagnosis of cranial disease, whole-body PET/CT is emerging as a potential gold standard test for establishing large vessel involvement. However, many unanswered questions remain about the optimal approach to imaging in GCA. For example, it is uncertain how best to monitor disease activity, given there is frequent discordance between imaging findings and conventional disease activity measures, and imaging changes typically fail to resolve completely with treatment. This chapter addresses the current body of evidence for the use of imaging modalities in GCA across the spectrum of diagnosis, monitoring disease activity, and long-term surveillance for structural changes of aortic dilatation and aneurysm formation and provides suggestions for future research directions.

Clinical course and management of a consecutive series of patients with "healed temporal arteritis"

OBJECTIVE

To describe the clinical course and management of patients with a pathologic diagnosis of "healed" giant cell arteritis (GCA), and to determine whether previously published histological descriptions of healed arteritis can identify patients with a greater likelihood of clinically significant arteritis.

METHODS

All temporal artery biopsy reports between 1994 and 2003 were examined for a diagnosis of "healed arteritis." Two rheumatologists abstracted the medical record for presenting features, physical findings, comorbid conditions, and data on treatment and outcomes. One pathologist, blinded to the clinical data, reviewed all specimens and reinterpreted the biopsies according to published histological descriptions of healed arteritis.

RESULTS

Forty-seven patients with an initial pathologic diagnosis of healed arteritis were identified. In 54% of these patients, corticosteroid therapy did not change after the diagnosis of healed arteritis was documented in the pathology report. Seventy percent were ultimately treated with no corticosteroids or low-moderate corticosteroid regimens. Only 32% of the initial cases were confirmed upon review of the biopsies using standardized histological criteria. Patients with confirmed healed arteritis were more likely to have a documented history of polymyalgia rheumatica/GCA and a longer duration of corticosteroid treatment before biopsy. These patients were not more likely to have adverse outcomes.

CONCLUSION

In this case series, the diagnosis of healed arteritis had little effect on treatment decisions. In most cases, the initial pathologic diagnosis of healed arteritis was not confirmed when biopsies were reviewed by a single pathologist using uniform histological criteria.

Varicella zoster virus ischemic optic neuropathy and subclinical temporal artery involvement

OBJECTIVE

To demonstrate varicella zoster virus (VZV) infection in an asymptomatic extracranial (temporal) artery in a patient with ischemic optic neuropathy produced by VZV vasculopathy in whom the pathological changes were mistakenly identified as giant cell arteritis.

DESIGN

Case report.

SETTING

Teaching hospital, pathology and virology laboratory.

PATIENT

An 80-year-old man with left ophthalmic distribution zoster who developed left ischemic optic neuropathy.

INTERVENTION

An ipsilateral temporal artery biopsy revealed inflammation that was mistakenly identified as giant cell arteritis. The patient was initially treated with steroids but his condition did not improve. When the diagnosis of VZV vasculopathy was confirmed virologically and the patient was treated with intravenous acyclovir, his vision improved.

RESULTS

Pathological and virological studies provided proof of VZV vasculopathy in the asymptomatic temporal artery. Varicella zoster virus antigen was abundant in arterial adventitia and scattered throughout the media. With intravenous antiviral therapy, the patient's vision improved.

CONCLUSION

Although in previously studied patients who died of chronic VZV vasculopathy after 10 to 12 months, VZV antigen was present exclusively in the intima, collective analyses of chronic cases and the asymptomatic VZV-infected temporal artery suggest that virus enters arteries through the adventitia and spreads transmurally to the intima.

An approach to the diagnosis and management of systemic vasculitis

The systemic vasculitides are a complex and often serious group of disorders which, while uncommon, require careful management in order to ensure optimal outcome. In most cases there is no known cause. Multi-system disease is likely to be fatal without judicious use of immunosuppression. A prompt diagnosis is necessary to preserve organ function. Comprehensive and repeated disease assessment is a necessary basis for planning therapy and modification of treatment protocols according to response. Therapies typically include glucocorticoids and, especially for small and medium vessel vasculitis, an effective immunosuppressive agent. Cyclophosphamide is currently the standard therapy for small vessel multi-system vasculitis, but other agents are now being evaluated in large randomized trials. Comorbidity is common in patients with vasculitis, including the cumulative effects of potentially toxic therapy. Long-term evaluation of patients is important in order to detect and manage relapses.

Giant cell (temporal) arteritis: an overview and update

Giant cell arteritis is a systemic disease that continues to be a sight-threatening medical emergency requiring prompt recognition and treatment in order to avoid devastating ophthalmic consequences. Although there have been advances in the genetic and immunologic understanding of the underlying pathogenesis of the disease, the exact etiology of the condition, to date, remains unclear. Visual manifestations of giant cell arteritis are the common mode of presentation, making the ophthalmologist critically responsible for early diagnosis and treatment. Although temporal artery biopsy remains the only confirmatory procedure, newer laboratory investigations and blood flow studies with fundus fluorescein angiography have aided in the diagnosis of temporal giant cell arteritis. Maintenance of a high index of clinical suspicion is essential to institute prompt adequate treatment, especially in atypical cases. Corticosteroids remain the mainstay of treatment of giant cell arteritis. Recently, immunosuppressive agents as secondary steroid-sparing drugs have been used, particularly in some steroid-resistant cases. A wider recognition of the disease will minimize the prevalence of irreversible visual loss among patients with giant cell arteritis.

Audit of the management of suspected giant cell arteritis in a large teaching hospital

BACKGROUND

The diagnosis of giant cell arteritis (GCA) is often confirmed by an early temporal artery (TA) biopsy of adequate length. Treatment of this condition with high-dose corticosteroids may be associated with significant morbidity, including osteoporosis.

AIM

To audit current management of patients with suspected GCA at Auckland Healthcare, a large teaching hospital.

METHODS

We performed a retrospective chart review of all TA biopsies from January 1996 to June 2000. A total of 117 biopsies from 111 patients was audited. Of these patients, 37/111 (33%) had a final clinical diagnosis of GCA (GCA patients). The areas of interest for audit were waiting time for TA biopsy, length of sample, initial corticosteroid therapy and osteoporosis prophylaxis.

RESULTS

The mean waiting time for biopsy for all patients was 5.6 days (range 0-42 days). This time varied from 9.3 days for rheumatology patients to 2.6 days for ophthalmology patients (P = 0.003). Only 44/117 (37.6%) specimens measured more than 10 mm. For GCA patients, the median initial oral prednisone dose was 60 mg/day. Osteoporosis prophylaxis was prescribed in 24/37 (65%) GCA patients, most commonly cyclical etidronate.

CONCLUSIONS

There is significant variation in the management of GCA within our institution. This audit has highlighted several areas where improvement could be made, particularly in streamlining the process of obtaining TA biopsy and in promoting the use of osteoporosis prophylaxis.

Immunohistochemical analysis of arterial wall cellular infiltration in Buerger's disease (endarteritis obliterans)

PURPOSE

The diagnosis of Buerger's disease has depended on clinical symptoms and angiographic findings, whereas pathologic findings are considered to be of secondary importance. Arteries from patients with Buerger's tissue were analyzed histologically, including immunophenotyping of the infiltrating cells, to elucidate the nature of Buerger's disease as a vasculitis.

METHODS

Thirty-three specimens from nine patients, in whom Buerger's disease was diagnosed on the basis of our clinical and angiographic criteria between 1980 and 1995 at Nagoya University Hospital, were studied. Immunohistochemical studies were performed on paraffin-embedded tissue with a labeled streptoavidin-biotin method.

RESULTS

The general architecture of vessel walls was well preserved regardless of the stage of disease, and cell infiltration was observed mainly in the thrombus and the intima. Among infiltrating cells, CD3(+) T cells greatly outnumbered CD20(+) B cells. CD68(+) macrophages or S-100(+) dendritic cells were detected, especially in the intima during acute and subacute stages. All cases except one showed infiltration by the human leukocyte antigen-D region (HLA-DR) antigen-bearing macrophages and dendritic cells in the intima. Immunoglobulins G, A, and M (IgG, IgA, IgM) and complement factors 3d and 4c (C3d, C4c) were deposited along the internal elastic lamina.

CONCLUSION

Buerger's disease is strictly an endarteritis that is introduced by T-cell mediated cellular immunity and by B-cell mediated humoral immunity associated with activation of macrophages or dendritic cells in the intima.

Color duplex ultrasonography in the diagnosis of temporal arteritis

BACKGROUND

The diagnosis of temporal arteritis usually requires a biopsy of the temporal artery. We examined the usefulness of color duplex ultrasonography in patients suspected of having temporal arteritis.

METHODS

In this prospective study, all patients seen in the departments of rheumatology and ophthalmology from January 1994 to October 1996 who had clinically suspected active temporal arteritis or polymyalgia rheumatica were examined by duplex ultrasonography. The final diagnoses, made according to standard criteria, were temporal arteritis in 30 patients, 21 with biopsy-confirmed disease; polymyalgia rheumatica in 37; and negative histologic findings and a diagnosis other than temporal arteritis or polymyalgia rheumatica in 15. We also studied 30 control patients matched for age and sex to the patients with arteritis. Two ultrasound studies were performed and read before the biopsies; one ultrasonographer was unaware of the clinical information.

RESULTS

In 22 (73 percent) of the 30 patients with temporal arteritis, ultrasonography showed a dark halo around the lumen of the temporal arteries. The halos disappeared after a mean of 16 days (range, 7 to 56) of treatment with corticosteroids. Twenty-four patients (80 percent) had stenoses or occlusions of temporal-artery segments, and 28 patients (93 percent) had stenoses, occlusions, or a halo. No halos were identified in the 82 patients without temporal arteritis; 6 (7 percent) had stenoses or occlusions. For each of the three types of abnormalities identified by ultrasonography, the interrater agreement was > or =95 percent.

CONCLUSIONS

There are characteristic signs of temporal arteritis that can be visualized by color duplex ultrasonography. The most specific sign is a dark halo, which may be due to edema of the artery wall. In patients with typical clinical signs and a halo on ultrasonography, it may be possible to make a diagnosis of temporal arteritis and begin treatment without performing a temporal-artery biopsy.

Current concepts in giant cell (temporal) arteritis

Giant cell (temporal) arteritis continues to be a sight-threatening, systemic vasculitis with a poorly understood pathogenesis. The characteristic granulomatous inflammation of the vessel wall commonly leads to local ischemia. Recent advances in immunological investigations have characterized the cellular components of the disease process, but the etiology has so far remained unresolved. A reappraisal of the clinical features of giant cell (temporal) arteritis demonstrates the heterogeneity of the manifestations of the disease, including ischemic optic neuropathy. A range of new laboratory investigations and blood flow studies with color Doppler imaging have demonstrated promising roles, with respect to diagnosis and long-term follow-up. Prompt diagnosis and expeditious treatment require a high index of clinical suspicion, particularly for atypical cases. Corticosteroids remain the treatment of choice, other immuno-suppressive agents being used as second line steroid-sparing agents. Giant cell (temporal) arteritis leads to increased vascular and visual morbidity and, if untreated, may prove fatal. To maintain high standards of management of this enigmatic disorder, ophthalmologists need to be aware of the clinical spectrum of giant cell (temporal) arteritis and currently available diagnostic tests and treatment strategies.

Large vessel vasculitis without temporal artery involvement: isolated form of giant cell arteritis?

Diffuse arterial involvement in giant cell arteritis (GCA) is well recognized. By contrast, GCA clinically isolated to large vessels without cephalic, rheumatologic or systemic symptoms represents a much rarer manifestation of the disease. We report the cases of 4 elderly women presenting with a diffuse and symptomatic occlusive disease without the typical signs of temporal arteritis, in whom biological, angiographic or pathological findings were suggestive of GCA. Medium to high dose oral corticosteroids were given to the 4 patients, in combination with various revascularization procedures, allowing a fair clinical response. Large vessel arteritis should be considered in elderly women with diffuse non-atherosclerotic occlusive disease and elevated erythrocyte sedimentation rate, even if typical features of GCA are lacking. In those cases, a long-term treatment with corticosteroids is mandatory, but surgical or angioplastic revascularization is often required.

Clinical usefulness of biopsy in giant cell arteritis

To evaluate the diagnostic usefulness of temporal artery biopsy in the diagnosis of giant cell arteritis, the clinical records of 98 patients who underwent this procedure between 1984 and 1992 were reviewed. The biopsies were positive for giant cell arteritis in 13 (13%) cases. In addition, 9 patients with negative biopsy were considered to have giant cell arteritis based on clinical examination, while 76 patients had other diagnoses. About 90% of the patients with giant cell arteritis were women. Evaluating the clinical features and laboratory findings, a history of headache, a combination of headache and the erythrocyte sedimentation rate > 40 mm/h and a combination of headache and temporal tenderness were significantly more common among patients with positive diagnosis than among the other patients.

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.