Giant cell arteritis and secondary amyloidosis: the natural history

Case report: Rapid development of amyloid A amyloidosis in temporal arteritis with SAA1.3 allele; An unusual case of intestinal amyloidosis secondary to temporal arteritis

Temporal arteritis (TA) is a large-vessel vasculitis mostly seen in older patients. Amyloid A (AA) amyloidosis secondary to a chronic inflammation induces multiple organ dysfunctions, including a dysfunction of the gastrointestinal tract. Herein, we present a case of TA complicated by AA amyloidosis that was resistant to oral and intravenous steroids. An 80-year-old man with a history of new-onset headache, jaw claudication, and distended temporal arteries was referred to our department. On admission, the patient presented with tenderness and a subcutaneous temporal nodule in both temple arteries. Ultrasonography of the nodule revealed an anechoic perivascular halo surrounding the right temporal artery. Following the diagnosis of TA, high-dose prednisolone therapy was initiated. However, the patient presented with recurrent abdominal pain and refractory diarrhea. Due to the unclear origin of refractory diarrhea, an extensive workup, including biopsy of the duodenal mucosa, was performed. Endoscopy revealed chronic inflammation in the duodenum. Immunohistochemical analysis of duodenal mucosal biopsy samples revealed AA amyloid deposition resulting in the diagnosis of AA amyloidosis. After tocilizumab (TCZ) administration, refractory diarrhea reduced; however, the patient died of intestinal perforation 1 month after the start of TCZ administration. Gastrointestinal involvement was the main clinical manifestation of AA amyloidosis in the present case. This case highlights the importance of bowel biopsy screening for amyloid deposition in patients with unexplained gastrointestinal tract symptoms, even in a recent onset of large-vessel vasculitis. In the present case, the carriage of the SAA1.3 allele likely contributed to the rare association of AA amyloidosis with TA.

A rare presentation of kidney failure in a patient with giant cell arteritis: case report and review of literature

Although giant cell arteritis, also called temporal arteritis, is the most common primary vasculitis in the elderly, an association with AA amyloidosis has rarely been reported. AA amyloidosis is a disorder that results from the extracellular deposition of proteolytic cleavage products of serum amyloid A, which occurs in the setting of long-standing inflammation. We present a case of a patient with giant cell arteritis who developed a rapidly deteriorating kidney function, due to AA amyloidosis. Early recognition of this rare phenomenon is crucial as prompt treatment may be beneficial in the salvage of renal function.

[Giant cell aortitis complicated by AA amyloidosis diagnosed with imaging techniques: Report of a case]

INTRODUCTION

AA amyloidosis is a common but severe complication of many chronic inflammatory processes of infectious, autoimmune, or neoplastic origin. It frequently leads to renal damage, often presenting as a nephrotic syndrome. Giant cell arteritis is a common inflammatory arteritis in elderly people, but rarely complicated by AA amyloidosis.

CASE REPORT

We report an 87-year-old female who presented with a nephrotic syndrome and a chronic inflammation, in whom the kidney biopsy showed secondary amyloidosis. Etiological investigations concluded an amyloidosis related to giant cell pan-aortitis, whereas there were no typical clinical signs for this diagnosis. Outcome was rapidly unfavourable despite the treatment.

CONCLUSION

In case of chronic inflammation of unknown origin in elderly patients, aortitis complicating a giant cell arteritis should be looked for with imaging techniques, as clinical diagnosis of this presentation is difficult, whereas delayed diagnosis exposes to severe or fatal issues.

Systemic amyloidosis: a challenge for the rheumatologist

Amyloidosis comprises a group of diseases characterized by the extracellular deposition of insoluble fibrillar proteins. This mechanism generates different clinical syndromes depending on the site and extent of organ involvement. Amyloidosis is classified into categories of systemic and localized disease. Systemic amyloidosis is further subdivided into a hereditary familial form (for example, ATTR amyloidosis), a reactive form (AA amyloidosis), dialysis-related (Abeta(2)M) amyloidosis and immunoglobulin light chain (AL) amyloidosis. Treatment can be symptomatic, directed at the affected organ, or can be directed at reducing the production of the abnormal proteins with different strategies. Despite advances in treatment, the prognosis is still poor and depends on the underlying disease as well as the type and degree of dysfunction in involved organs. Early diagnosis is essential because patients with advanced disease are generally unable to undergo intensive therapy. Patients with systemic amyloidosis often present to a rheumatologist not only because the disease can include musculoskeletal and articular symptoms but also because it can be associated with chronic rheumatic diseases. This Review discusses the clinical features of amyloidosis and its rheumatic manifestations. The various types of amyloidosis, as well their prognosis and treatment, are also presented.

Giant cell arteritis

Giant cell arteritis (GCA), temporal arteritis or Horton's arteritis, is a systemic vasculitis which involves large and medium sized vessels, especially the extracranial branches of the carotid arteries, in persons usually older than 50 years. Permanent visual loss, ischaemic strokes, and thoracic and abdominal aortic aneurysms are feared complications of GCA. The treatment consists of high dose steroids. Mortality, with a correct treatment, in patients with GCA seems to be similar that of controls.

Amyloidosis of medium-sized arteries presenting as perioral mass: a case report

We report a case of amyloidosis localized to the medium-sized arteries of the face and presenting as prominent perioral swelling. The condition was identified as primary AL-type amyloidosis on the basis of immunohistochemical reactivity, predominantly for anti-lambda light chain antibody within amyloid deposits. Subsequent radiographic and laboratory evaluation of the patient disclosed multiple myeloma. Although amyloid deposits were subsequently detected in the temporal arteries, evidence of widespread amyloidosis has not been observed after 1 year of follow-up. To the best of our knowledge, this is the first report of myeloma-associated amyloidosis mainly localized to the medium-sized arteries of the face.