Giant cell arteritis: diagnosis and management

Primary Large Vessel Vasculitis: Takayasu Arteritis and Giant Cell Arteritis

Takayasu arteritis (TA) and Giant cell arteritis (GCA) are large vessel vasculitides, with TA targeting the aorta and its branches, and GCA targeting both large and medium-sized arteries. Early diagnosis of TA and GCA are of great importance, since delayed, inappropriate or no treatment can result in severe and permanent complications. Imaging plays a central role in establishing diagnosis, targeting lesions for confirmational diagnostic biopsy, specifically for GCA, and longitudinal disease evolution. In this article, we discuss imaging diagnosis of large artery vasculitis and the value of different imaging modalities.

The Adequate Number of Histopathology Cross-sections of Temporal Artery Biopsy in Establishing the Diagnosis of Giant Cell Arteritis

Purpose

To determine the appropriate number of histopathological cross-sections that are required for a conclusive diagnosis of giant cell arteritis (GCA).

Methods

In this cross-sectional study, the number of sections per slide for paraffin-embedded blocks for 100 randomly selected cases where GCA was suspected and those for negative temporal artery biopsies (TABs) were compared with the number of cross-sections per specimen for eight positive-TABs. All aforementioned examinations were conducted at our center from 2012 to 2016. Then, negative-TABs were retrieved and re-evaluated using light microscopy considering the histopathological findings of GCA.

Results

Ninety-five paraffin blocks were retrieved. The original mean biopsy length was 15.39 ± 7.56 mm. Comparison of the mean number of cross-sections per specimen for both the positive- and negative-TABs (9.25 ± 3.37 and 9.53 ± 2.46) showed that 9.87 ± 2.77 [95% confidence intervals (CI)] cross-sections per specimen were sufficient for a precise GCA diagnosis. There was no statistically significant difference in the mean biopsy length (P = 0.142) among the eight positive-TABs. Similarly, no significant difference was observed in the number of cross-sections per specimen (P = 0.990) for positive-TABs compared to those for the negative-TABs. After the retrieval of negative-TABs, the mean number of total pre- and post-retrieval cross-sections per specimen was 17.66 ± 4.43. Among all retrieved specimens, only one case (0.01%) showed the histopathological features of healed arteritis.

Conclusion

Positive-TABs did not reveal more histological cross-sections than the negative ones and increasing the number of cross-sections did not enhance the accuracy of TAB.

Giant Cell Arteritis (GCA): Pathogenesis, Clinical Aspects and Treatment Approaches

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Giant Cell Arteritis (GCA), or Horton’s Arteritis, is a chronic form of vasculitis of the large and medium vessels, especially involving the extracranial branches of the carotid arteries, in particular, the temporal artery, with the involvement of the axillary, femoral and iliac arteries too. Arterial wall inflammation leads to luminal occlusion and tissue ischemia, which is responsible for the clinical manifestations of the disease.

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A substantial number of patients affected by GCA present head and neck symptoms, including ocular, neurological and otorhinolaryngological manifestations.

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The aim of this article is to present pathogenesis, clinical aspects and treatment approaches of GCA manifestations.

Diagnostic Algorithm for Patients With Suspected Giant Cell Arteritis

BACKGROUND

To identify clinical and laboratory factors contributing to the diagnosis of giant cell arteritis (GCA) and develop a diagnostic algorithm for the evaluation of GCA.

METHODS

Retrospective review of 213 consecutive cases of temporal artery biopsy (TAB) seen at a single academic center over a 10-year period (2000-2009). Pathologic specimens were re-reviewed and agreement between the original and second readings was assessed. A composite clinical suspicion score was created by adding 1 point for each of the following criteria: anterior extracranial circulation ischemia, new onset headache, abnormal laboratory results (erythrocyte sedimentation rate, C-reactive protein (CRP), or platelet count), jaw claudication, abnormal or tender superficial temporal artery, constitutional symptoms, and polymyalgia rheumatica; one point was subtracted if a comorbid condition could explain a criterion.

RESULTS

Of the 204 TABs analyzed, pathologic findings were confirmatory in 49 (24.0%) and suggestive in 12 (5.9%). TAB-positive patients were more likely to be older (age 75.2 ± 7.8 vs 69.7 ± 11.0 years, P = 0.0002), complain of jaw claudication (relative-risk = 3.26, P = 0.0014), and have thrombocytosis (relative-risk = 3.3, P = 0.0072) and elevated CRP (relative-risk = 1.8, P = 0.037). None of the patients with a clinical score less than 2 had a positive TAB. Diabetes mellitus and kidney disease were often the explanation for the symptoms and abnormal clinical finding(s) that led to a negative TAB.

CONCLUSIONS

We propose a clinical algorithm that is highly predictive for a positive TAB and can be valuable in the evaluation process of suspected cases of GCA.

The thromboembolic risk in giant cell arteritis: a critical review of the literature

Giant cell arteritis is a systemic vasculitis characterized by granulomatous inflammation of the aorta and its main vessels. Cardiovascular risk, both for arterial and venous thromboembolism, is increased in these patients, but the role of thromboprophylaxis is still debated. It should be suspected in elderly patients suffering from sudden onset severe headaches, jaw claudication, and visual disease. Early diagnosis is necessary because prognosis depends on the timeliness of treatment: this kind of arteritis can be complicated by vision loss and cerebrovascular strokes. Corticosteroids remain the cornerstone of the pharmacological treatment of GCA. Aspirin seems to be effective in cardiovascular prevention, while the use of anticoagulant therapy is controversial. Association with other rheumatological disease, particularly with polymyalgia rheumatica is well known, while possible association with antiphospholipid syndrome is not established. Large future trials may provide information about the optimal therapy. Other approaches with new drugs, such as TNF-alpha blockades, Il-6 and IL-1 blockade agents, need to be tested in larger trials.

The diagnosis and treatment of giant cell arteritis

BACKGROUND

Giant cell arteritis (GCA) is the most common systemic vasculitis in persons aged 50 and above (incidence, 3.5 per 100,000 per year). It affects cranial arteries, the aorta, and arteries elsewhere in the body, e.g., in the limbs.

METHODS

We selectively review the pertinent literature, including guidelines and recommendations from Germany and abroad.

RESULTS

The typical symptoms of new-onset GCA are bitemporal headaches, jaw claudiacation, scalp tenderness, visual disturbances, systemic symptoms such as fever and weight loss, and polymyalgia. The diagnostic assessment comprises laboratory testing (erythrocyte sedimentation rate, C-reactive protein), imaging studies (duplex sonography, high-resolution magnetic resonance imaging, positron-emission tomography), and temporal artery biopsy. The standard treatment is with corticosteroids (adverse effects: diabetes mellitus, osteoporosis, cataract, arterial hypertension). A meta-analysis of three randomized controlled trials led to a recommendation for treatment with methotrexate to lower the recurrence rate and spare steroids. Patients for whom methotrexate is contraindicated or who cannot tolerate the drug can be treated with azathioprine instead.

CONCLUSION

Giant cell arteritis, if untreated, progresses to involve the aorta and its collateral branches, leading to various complications. Late diagnosis and treatment can have serious consequences, including irreversible loss of visual function.

Validity of the American College of Rheumatology criteria for the diagnosis of giant cell arteritis

PURPOSE

To assess the clinical utility of the American College of Rheumatology criteria for the diagnosis of giant cell arteritis (GCA) in patients with positive and negative temporal artery biopsies.

DESIGN

Retrospective case series of all patients undergoing temporal artery biopsy.

METHODS

Retrospective chart review of all patients seen in the Neuro-ophthalmology Service of the Wills Eye Institute undergoing biopsy. One hundred twelve patients were identified between October 2001 and May 2006. Charts were reviewed for American College of Rheumatology criteria, biopsy results, and progression of visual loss after diagnosis.

RESULTS

Nine of 35 patients (25.7%) with positive biopsies would not have been diagnosed with GCA using American College of Rheumatology criteria alone. An additional 16 patients (45.7%) met only 2 criteria and required the positive biopsy to establish the American College of Rheumatology diagnosis of GCA. Eleven of 39 patients (28.2%) with negative biopsies met the criteria and would have been diagnosed with GCA. Diagnostic agreement between the American College of Rheumatology criteria without biopsy results and biopsy results alone was 51.4%; with the addition of biopsy results to the criteria, this increased to 73.0%.

CONCLUSIONS

The current American College of Rheumatology criteria should not be used to diagnose GCA and all patients suspected of having GCA should undergo a temporal artery biopsy.

[Acute sectoral choroidal ischemia: a case report]

Sectoral choroidal ischemia is a classic sign of giant cell arteritis, although the latter is more typically associated with anterior ischemic optic neuropathy or central retinal artery occlusion. We report the case of an acute choroidal ischemia in a 68-year-old, one-eyed patient, who presented with deterioration of visual acuity and metamorphopsia in his left eye (his right eye was counting fingers due to high myopia). Fundus examination revealed retinal pigment epithelium (RPE) alterations and slow choroidal perfusion on fluorescein angiography. Macular Optical Coherence Tomography (OCT) showed a total disruption of the photoreceptor layer. Although prompt corticosteroid therapy preserved some vision, secondary macular retinal pigment epithelial changes limited the visual outcome. No other ophthalmological signs were observed in follow-up.

Systematic review of the literature and a case report informing biopsy-proven giant cell arteritis (GCA) with normal C-reactive protein

Giant cell arteritis (GCA) is a vasculitis of large- vessels. A markedly elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are characteristics of GCA, although temporal artery biopsy remains the gold standard for the diagnosis. We describe a case of biopsy-proven GCA showing a heavy infiltration of CD68 macrophages and CD3 T cells and with normal ESR and CRP levels at diagnosis. Key points (1) GCA may occur with normal ESR in a percentage of about 4 to 15 % (although the American College of Rheumatology classification criteria for giant cell arteritis include an ESR of 50 mm/h or more), while it can occur with normal ESR and normal CRP in a percentage of about 0.8 %. So, the clinical suspicion must be confirmed with a positive biopsy. (2) GCA patients with ESR >40 mm/h are characterized by higher incidence of headache and jaw claudication compared to patients with normal ESR. In our case, it occurred with normal ESR. (3) Color duplex ultrasonography is a noninvasive, easy, and inexpensive method for supporting a diagnosis of TA, with a high sensitivity and specificity. It can predict which patient will need TAB.

Non-infectious orbital vasculitides

Non-infectious vasculitides comprise a large number of diseases. Many of these diseases can cause inflammation within the orbit and a clinical presentation, which mimics numerous other processes. Orbital disease can often be the initial presentation of a systemic process and early diagnosis can help prevent long-term, potentially fatal consequences. The evaluation and treatment of non-infectious orbital vasculitides are often complicated and require a thorough understanding of the disease and underlying systemic associations. The long-term prognosis visually and systemically must be weighed against the risks and benefits of the treatment regimen. A large variety of corticosteroid formulations currently exist and are the mainstay of initial treatment. Traditional steroid-sparing immunosuppressive agents are also an important arsenal against these vasculitides. Recently, a new class of drugs called biologics, which target the various mediators of the inflammation cascade, may potentially provide more effective and less toxic treatment. This review aims to synthesize the current literature on non-infectious orbital vasculitides.

[Fever, redness, swelling, and pain in the submental region]

A 76-year-old woman presented with fever, redness, swelling, and pain under the chin. Some submental lymph nodes were detected by ultrasound and computed tomography. The diagnosis was a submental phlegmon, for which surgery was performed. The lymph nodes were removed, and antibiotic therapy with daily lavage was done. The histology of the lymph nodes suggested giant cell arteritis.

Improving therapeutic options for patients with giant cell arteritis

PURPOSE OF REVIEW

Glucocorticoids remain the mainstay of treatment of giant cell arteritis. The aim of this review is to establish the optimal schedule of glucocorticoid administration, and to ascertain which other treatments may be used as glucocorticoid-sparing agents.

RECENT FINDINGS

An initial dose of 40-60 mg/day of prednisone is usually adequate. Patients at risk of developing ischemic complications require dosages of around 1 mg/kg/day, whereas pulse glucocorticoid therapy is no more effective in preventing ischemic complications. In patients with longstanding disease or those at risk for glucocorticoid-related adverse events, methotrexate or azathioprine can be used as glucocorticoid-sparing drugs. Infliximab has been demonstrated to be efficacious in glucocorticoid-resistant disease in an open study, whereas a randomized controlled trial showed no efficacy in patients with recent-onset disease. Finally, two retrospective studies suggest that low-dose aspirin may decrease the rate of cranial ischemic complications secondary to giant cell arteritis.

SUMMARY

Glucocorticoids remain the cornerstone of therapy for giant cell arteritis. To achieve maximal efficacy but minimize glucocorticoid-related adverse reactions, dosage should be individually tailored. In patients with longstanding, recalcitrant disease, methotrexate, azathioprine or tumor necrosis factor-alpha inhibitors may be considered. Aspirin is recommended in all patients unless contraindicated. Osteoporosis prophylaxis should also be regularly implemented.

Influence of previous corticosteroid therapy on temporal artery biopsy yield in giant cell arteritis

OBJECTIVE

To determine the impact of prior corticosteroid treatment on temporal artery biopsy (TAB) yield to establish the diagnosis of giant cell arteritis (GCA).

METHODS

Retrospective study of a consecutive cohort of 78 patients clinically diagnosed and managed as GCA, who received corticosteroids before TAB.

RESULTS

Among the 78 patients, TAB was positive in 57 (73%) and negative in 21 (27%). No significant differences in the length of the specimen were found between the positive and negative biopsies. We grouped patients according to treatment duration before TAB. In those with newly diagnosed GCA treated with high-dose steroid therapy, the biopsy results were positive in 78% (35/45) of patients treated for less than 2 weeks, in 65% of those treated for 2 to 4 weeks (13/20), and in 40% of those treated for more than 4 weeks (2/5). We also observed 8 patients that developed GCA on a background of a prior history of polymyalgia rheumatica (PMR); in this group biopsy was positive in 88% of the cases, after a median duration of treatment of 180 +/- 172 days and an average daily dose of 7.1 +/- 1.4 mg/d.

CONCLUSION

The performance of TAB should not delay the prompt institution of steroid therapy on diagnosis of GCA, since the diagnostic yield of TAB seems valuable within 4 weeks of starting high-dose steroid treatment. In patients that developed GCA on a background of a prior history of PMR, a late TAB is also generally informative despite long-term treatment with low doses of corticosteroids.

Colour duplex sonography of temporal arteries before decision for biopsy: a prospective study in 55 patients with suspected giant cell arteritis

Although a temporal artery biopsy is the gold standard for the diagnosis of giant cell arteritis (GCA), there is considerable evidence that characteristic signs demonstrated by colour duplex sonography (CDS) of the temporal arteries may be of diagnostic importance. We aimed to test the hypothesis that CDS can replace biopsy in the algorithm for the approach to diagnose GCA. Bilateral CDS was performed in consecutive patients older than 50 years with clinically suspected GCA, as well as in 15 age- and gender-matched control subjects with diabetes mellitus and/or stroke and 15 healthy subjects, to assess flow parameters and the possible presence of a dark halo around the arterial lumen. Unilateral temporal artery biopsy was then performed in patients with suspected GCA, which was directed to a particular arterial segment in case a halo was detected in CDS. Final diagnoses, after completion of a 3-month follow-up in 55 patients, included GCA (n = 22), polymyalgia rheumatica (n = 12), polyarteritis nodosa, Wegener's, and Adamantiades-Behçet's diseases (n = 3), and neoplastic (n = 8) and infectious diseases (n = 10). A dark halo of variable size (0.7-2.0 mm) around the vessel lumen was evident at baseline CDS in 21 patients (in 12 and 9 uni- or bilaterally, respectively) but in none of the controls. The presence of unilateral halo alone yielded 82% sensitivity and 91% specificity for GCA, whereas the specificity reached 100% when halos were found bilaterally. Blood-flow abnormal parameters (temporal artery diameter, peak systolic blood-flow velocities, stenoses, occlusions) were common in GCA and non-GCA patients, as well as in healthy and atherosclerotic disease-control, elderly subjects. At follow-up CDS examinations performed at 2 and 4 weeks after initiation of corticosteroid treatment for GCA, halos disappeared in all 18 patients (9 and 9, respectively). We conclude that CDS, an inexpensive, non-invasive, and easy-to-perform method, allows a directional biopsy that has an increased probability to confirm the clinical diagnosis. Biopsy is not necessary in a substantial proportion of patients in whom bilateral halo signs can be found by CDS.

Oral and ocular/orbital manifestations of temporal arteritis: a disease with deceptive clinical symptoms and devastating consequences

Temporal arteritis (TA) is a chronic, systemic vasculitis most often presenting with severe headaches localized in the temporal region, low-grade fever, anorexia, weight loss and generalized malaise. Besides these typical characteristics, a number of vague and non-specific oral and/or ocular symptoms may also be present. A search using Medline (1955-2006) was performed for unusual oral and ocular/orbital presentations of TA. A variety of oral and ocular/orbital manifestations associated with TA have been reported. These can mislead physicians, causing a delay in establishing a diagnosis and initiating treatment. Increased awareness is necessary for the prompt recognition of this potentially devastating disease. Particularly, dentists and ophthalmologists should include TA in their differential diagnosis, as they may be the first to deal with these patients.

Prevalence of a Normal C-Reactive Protein with an Elevated Erythrocyte Sedimentation Rate in Biopsy-Proven Giant Cell Arteritis

OBJECTIVE

The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory tests that have been said to have a strong correlation with a positive temporal artery biopsy in patients with suspected giant cell arteritis (GCA). Published reports suggest that the CRP is a more sensitive diagnostic indicator of GCA and can be elevated when the ESR is normal. It is also clear that the CRP and ESR can both be normal or both be elevated in patients with biopsy-proven GCA and that the CRP can be elevated when the ESR is normal. The purpose of this study was to ascertain if the CRP can be normal when the ESR is elevated in biopsy-proven GCA.

DESIGN

Retrospective, longitudinal, comparative study.

PARTICIPANTS

One hundred nineteen patients from 6 major tertiary-care university-affiliated medical centers.

METHODS

The charts from 119 patients with temporal artery biopsies positive for GCA were reviewed for age, gender, pretreatment ESR, and pretreatment CRP.

MAIN OUTCOME MEASURES

The ESR in millimeters per hour Westergren was graded as normal or abnormal based on 2 validated formulas. The CRP was graded as normal or abnormal based on established criteria set forth in the literature as well as at The Johns Hopkins Hematology laboratory.

RESULTS

In this study, the ESR had a sensitivity of 76% to 86%, depending on which of 2 formulas were used, whereas an elevated CRP had a sensitivity of 97.5%. The sensitivity of the ESR and CRP together was 99%. Only 1 of the 119 patients (0.8%) presented with a normal ESR and normal CRP (double false negative); 2 patients (1.7%) had a normal CRP despite an elevated ESR according to both formulas.

CONCLUSION

Although most patients with GCA have both an elevated ESR and CRP, there can be nonconcordance of the 2 blood tests. Although such nonconcordance is most often a normal ESR but an elevated CRP, the finding of an elevated ESR and a normal CRP also is consistent with GCA. The use of both tests provides a slightly greater sensitivity for the diagnosis of GCA than the use of either test alone.

Novel therapeutic strategies for large vessel vasculitis

Giant cell arteritis and Takayasu's arteritis are systemic vasculitides that cause inflammation of large arteries and their branches. Both have similar histology, but differ in their age of onset. Corticosteroids have been the mainstay of treatment for the past 50 years but are limited by the potential toxicity that may occur in almost 60% of patients. This limitation has lead to the investigation of alternative agents for the treatment of these diseases.

Anterior segment ischaemia with giant cell arteritis

CASE REPORT

A 69-year-old male presented with bilateral blurred vision, left periocular pain, and headache. Ocular examination revealed a right optic neuropathy and left anterior segment ischaemia. An elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) raised suspicion of giant cell arteritis (GCA), which was confirmed by temporal artery biopsy. Treatment with intravenous methylprednisolone followed by a gradually reducing dose of oral prednisolone improved vision in both eyes.

COMMENTS

GCA typically affects large- and medium-sized vessels. It is a recognised cause of anterior ischaemic optic neuropathy. Anterior segment ischaemia is usually caused by disease of the anterior ciliary arteries not typically affected by GCA. This case illustrates that GCA can rarely cause anterior segment ischaemia, without posterior segment involvement in the same eye.

Arteriitis temporalis (Riesenzellarteriitis)

Giant cell arteritis (arteritis temporalis) is the most common form of systemic vasculitis in the elderly. A series of symptoms such as new-onset headache, jaw claudication, proximal myalgia, weight loss, and fever may lead to the diagnosis. However, there is also a silent or occult presentation with minor or no systemic symptoms, especially no headache. A number of laboratory values (erythrocyte sedimentation rate, CRP, fibrinogen, thrombocytes, and cardiolipin antibodies) indicate giant cell arteritis, but none of this proves the diagnosis. Temporal artery biopsy is the gold standard for diagnosis of giant cell arteritis. Due to skip lesions, a negative result does not exclude the diagnosis. The most important complication of giant cell arteritis is visual loss in one or both eyes due to AION or retinal artery occlusion. Usually, visual loss is irreversible even with therapy. Corticosteroids are the drug of choice to treat giant cell arteritis. Therapy is required for a long time, monitored by parameters of inflammation (ESR, CRP).

Does temporal artery biopsy influence the management of temporal arteritis?

BACKGROUND

Temporal arteritis (TA) is the commonest form of primary vasculitis. Symptoms are variable, and therefore the diagnosis (or exclusion) of TA is often difficult. Surgeons are frequently asked to perform a temporal artery biopsy (TAB), but whether the histological result actually influences clinical management is unclear.

AIM

To assess whether, in routine clinical practice, a TAB affects clinical decision-making in patients with suspected TA.

DESIGN

Retrospective audit.

METHODS

All patients who underwent a TAB in a single hospital over a 2-year period were identified. This included patients referred from different specialist departments. Individual patient records were examined to document the TAB result, and in particular, the timings of commencement and discontinuation of corticosteroid therapy.

RESULTS

A total of 44 patients were included. TAB was positive in seven patients and negative in 37. In 31, there was no change in their clinical management despite a negative biopsy result: 18 continued with corticosteroids for >6 months with a clinical diagnosis of TA, and in 13 patients a decision to stop steroids, or an alternative diagnosis, was made before the biopsy result was known.

DISCUSSION

In this retrospective study, only a small number of TABs provided positive histological confirmation of TA, and in most patients undergoing TAB, there was little evidence that clinical decision-making with respect to corticosteroid therapy was influenced by the TAB result.

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.

Neuro-Ophthalmic Emergencies for the Neurologist

A variety of acute neurologic disorders present with visual signs and symptoms. In this review the authors focus on those disorders in which the clinical outcome is dependent on timely and accurate diagnosis. The first section deals with acute visual loss, specifically optic neuritis, ischemic optic neuropathy (ION), retinal artery occlusion, and homonymous hemianopia. The authors include a discussion of those clinical features that are helpful in distinguishing between inflammatory and ischemic optic nerve disease and between arteritic and nonarteritic ION. The second section concerns disc edema with an emphasis on the prevention of visual loss in patients with increased intracranial pressure. The third section deals with abnormal ocular motility, and includes orbital inflammatory disease, carotid-cavernous fistulas, painful ophthalmoplegia, conjugate gaze palsies, and neuromuscular junction disorders. The final section concerns pupillary abnormalities, with a particular emphasis on the dilated pupil and on carotid artery dissection. Throughout there are specific guidelines for the management of these disorders, and areas are highlighted in which there is ongoing controversy.

IS TEMPORAL ARTERY BIOPSY A WORTHWHILE PROCEDURE?

BACKGROUND

Temporal artery biopsy (TAB) has been accepted as the gold standard for the diagnosis of giant cell arteritis (GCA) or temporal arteritis (TA) even though it is of low sensitivity and specificity. Current medical practice recommends commencing high dose steroids before performing a biopsy, and the continued use of long-term steroids even if biopsy is negative but clinical suspicion of the diagnosis is high. The aim of the present study is to determine if TAB results actually changes the management of patients suspected of GCA or TA.

METHODS

Retrospective case note analysis of 70 consecutive patients with TAB over 5 years (1999-2003) from Royal Melbourne Hospital (RMH), Melbourne, Australia.

RESULTS

Histology revealed five (7%) positive biopsies, five (7%) of 'healed arteritis', and 60 (86%) negative biopsies. After excluding 15 patients who were lost to follow up, management of 13 (23.6%) patients was influenced by the biopsy results: seven with negative biopsies had steroids discontinued while six patients with biopsies showing positive and healed arteritis continued on steroids. Management of 42 (76.4%) patients was not altered following biopsy results: 11 with negative biopsy continued on steroids, 19 never started because of low clinical suspicion and 12 ceased steroids some time after biopsy as there was no symptomatic improvement.

CONCLUSION

With the management of 76.4% of patients unchanged following biopsy, some may argue that these patients underwent unnecessary surgery. However, TAB is a minor procedure that can yield important results for the management of GCA, which if untreated can lead to serious complications. We believe TAB should be performed where there is clinical suspicion of GCA.

Are steroids alone sufficient for the treatment of giant cell arteritis?

Glucocorticosteroids are the cornerstone of treatment of giant cell arteritis. An initial dose of prednisone or its equivalent of at least 40-60mg per day as single or divided dose is usually adequate. Glucocorticosteroids may prevent, but usually do not reverse, visual loss. A treatment course of 1-2 years is often required. Some patients, however, have a more chronic-relapsing course and may require low doses of glucocorticosteroids for several years. Glucocorticosteroid-related adverse events are common. In studies on immunosuppressant agents, methotrexate has been used as a glucocorticosteroid-sparing drug with conflicting results. This drug may, however, be given to patients who need high doses of glucocorticosteroids to control active disease and who have serious side effects. A recent pilot study found that infliximab was efficacious in patients with glucocorticosteroid-resistant giant cell arteritis. However, randomized controlled trials are required to define the role of anti-tumor necrosis factor-alpha agents in the treatment of giant cell arteritis. Finally, low-dose aspirin has been shown in a recent retrospective study to decrease the rate of cranial ischemic complications secondary to giant cell arteritis. It is conceivable that the definition of different patterns of inflammation in giant cell arteritis in the future might facilitate the design of differentiated therapeutic approaches.

Subtotal tongue necrosis in delayed diagnosed giant-cell arteritis: a case report

Giant-cell arteritis (GCA) is a chronic systemic vasculitis of large- and medium-sized vessels, mainly affecting elderly patients. Headache, vision impairment, jaw claudication, and scalp tenderness are common symptoms. However, diagnosis can be difficult because GCA can affect almost every vascular pathway and lead to a variety of possible manifestations. We report the case of a belated diagnosed GCA, resulting in nearly complete necrosis of the mobile part of the tongue, visual impairment, and neurologic as well as intestinal ischemic symptoms. Aggressive immunosuppressive treatment resolved the symptoms, but the patient remained severely morbid because of bilateral necrosis of the mobile part of the tongue. In any case of unclear ischemic symptoms in an elderly patient, one must keep GCA in mind as the possible culprit disease.

Recovery of vision after bilateral arteritic central retinal artery occlusion

A case is reported of a patient with bilateral central retinal artery occlusion secondary to giant cell arteritis. After treatment the vision recovered in one eye but remained poor in the other eye. Treatments employed are discussed with particular attention drawn to differences in the treatment of each eye and suggestions are made for treatment of similar cases.

Update on giant cell arteritis

PURPOSE OF REVIEW

Giant cell arteritis (GCA) is the most common form of systemic vasculitis that causes visual loss in the elderly. This review highlights current concepts dealing with the diagnosis, treatment, and visual prognosis of patients with GCA.

RECENT FINDINGS

Recent evidence suggests that recovery of visual function in patients with visual loss from GCA is poor. An algorithm has been constructed to assist clinicians in the evaluation and management of patients suspected of having GCA.

SUMMARY

Despite a number of new adjunctive agents, corticosteroids remain the standard treatment in patients with GCA.

The eye in cardiac and cardiovascular disease

There is an extensive range of cardiac and cardiovascular disease that can have ophthalmic manifestations and only the most commonly occurring examples are discussed below. The eye in diabetes is discussed in a separate article in this series.