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Andersen T, Tamhankar MA, Song JW. Diagnostic Modalities in Giant Cell Arteritis. Int Ophthalmol Clin 2023; 63:25-38. [PMID: 36963825 DOI: 10.1097/iio.0000000000000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
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Pelletier J, Koyfman A, Long B. High risk and low prevalence diseases: Open globe injury. Am J Emerg Med 2023; 64:113-120. [PMID: 36516669 DOI: 10.1016/j.ajem.2022.11.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Open globe injury (OGI) is a rare but serious condition that carries with it a high rate of morbidity. OBJECTIVE This review highlights the pearls and pitfalls of OGI, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION OGI refers to full-thickness injury to the layers of the eye. OGI can be caused by blunt or sharp trauma, and subtypes include penetration, perforation, intraocular foreign body (IOFB), globe rupture, or mixed types. OGI is more common in males and usually secondary to work-related injury, but in women it is most commonly associated with falls. Emergency clinicians should first assess for and manage other critical, life-threatening injuries. Following this assessment, a thorough eye examination is necessary. Computed tomography (CT) may suggest the disease, but it cannot definitively exclude the diagnosis. While point-of-care ultrasound (POCUS) is highly sensitive and specific for some findings in OGI, its use is controversial due to potential globe content extrusion. Management includes protecting the affected eye from further injury, preventing Valsalva maneuvers that could extrude ocular contents, updating tetanus vaccination status, administering broad-spectrum antibiotics, and ophthalmology consultation for surgical intervention to prevent the sequelae of blindness and endophthalmitis. CONCLUSION An understanding of OGI can assist emergency clinicians in diagnosing and managing this sight-threatening traumatic process.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Bridging the Gap between Ophthalmology and Emergency Medicine in Community-Based Emergency Departments (EDs): A Neuro-Ophthalmology Guide for ED Practitioners. Clin Pract 2021; 11:919-932. [PMID: 34940005 PMCID: PMC8700032 DOI: 10.3390/clinpract11040106] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/28/2021] [Accepted: 11/19/2021] [Indexed: 01/13/2023] Open
Abstract
Coordination of care for patients with neuro-ophthalmic disorders can be very challenging in the community emergency department (ED) setting. Unlike university- or tertiary hospital-based EDs, the general ophthalmologist is often not as familiar with neuro-ophthalmology and the examination of neuro-ophthalmology patients in the acute ED setting. Embracing image capturing of the fundus, using a non-mydriatic camera, may be a game-changer for communication between ED physicians, ophthalmologists, and tele-neurologists. Patient care decisions can now be made with photographic documentation that is then conveyed through HIPAA-compliant messaging with accurate and useful information with both ease and convenience. Likewise, external photos of the anterior segment and motility are also helpful. Finally, establishing clinical and imaging guidelines for common neuro-ophthalmic disorders can help facilitate complete and appropriate evaluation and treatment.
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Sammel AM, Xue M, Karsten E, Little CB, Smith S, Nguyen K, Laurent R. Limited utility of novel serological biomarkers in patients newly suspected of having giant cell arteritis. Int J Rheum Dis 2021; 24:781-788. [PMID: 33847438 DOI: 10.1111/1756-185x.14111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 01/08/2023]
Abstract
AIM Diagnosing and monitoring vascular activity in giant cell arteritis (GCA) is difficult due to the paucity of specific serological biomarkers. We assessed the utility of 8 novel biomarkers in an inception cohort of newly suspected GCA patients. METHOD Consecutive patients were enrolled between May 2016 and December 2017. Serum was collected within 72 hours of commencing corticosteroids and at 6 months. It was analyzed for levels of intra-cellular adhesion molecule 1, vascular endothelial growth factor (VEGF), pentraxin 3, von Willebrand factor and procalcitonin (5-plex R&D Systems multiplex assay) and interleukin (IL)6, IL12 and interferon-γ (high-sensitivity 3-plex ProcartaPlex multiplex assay). A GCA specific positron emission tomography / computed tomography (PET/CT) scan was performed at enrolment with uptake in each vascular territory graded and summed to derive a total vascular score (TVS). RESULTS For the 63 patients enrolled, 12 (19%) had a final diagnosis of biopsy-positive GCA and a further 9 had a clinical diagnosis of biopsy-negative GCA. None of the 8 biomarkers was significantly higher in GCA patients compared with those with alternative diagnoses, or demonstrated a positive correlation with the PET/CT TVS. This was in contrast to the C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) which were higher in the biopsy-positive GCA cohort (P < .04) and showed weak positive correlations with the TVS (correlation coefficient 0.34, P < .01). Procalcitonin did not distinguish between GCA and infection. Concentrations of CRP, ESR, VEGF and pentraxin 3 decreased between diagnosis and 6 months in GCA patients. CONCLUSION This study did not identify new serological biomarkers to assist in diagnosing or assessing the vasculitis burden in GCA.
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Affiliation(s)
- Anthony M Sammel
- Departments of Rheumatology, Nuclear Medicine and Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia.,Department of Rheumatology, Prince of Wales Hospital, Sydney, NSW, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Meilang Xue
- Sutton Arthritis Research Laboratory, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Christopher B Little
- Raymond Purves Bone and Joint Research Laboratories, Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Susan Smith
- Raymond Purves Bone and Joint Research Laboratories, Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Katherine Nguyen
- Departments of Rheumatology, Nuclear Medicine and Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Rodger Laurent
- Departments of Rheumatology, Nuclear Medicine and Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
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Impact of Temporal Artery Biopsy on Clinical Management of Suspected Giant Cell Arteritis. Ann Vasc Surg 2020; 69:254-260. [PMID: 32554192 DOI: 10.1016/j.avsg.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Temporal arteritis (TA) is a systemic inflammatory vasculitis of unclear etiology that affects medium-sized vessels. The gold standard for diagnosis has traditionally been histological, by temporal artery biopsy. Improved imaging modalities have been increasingly used to aid diagnosis and are recommended in the newest 2018 European (EULAR) guidelines.1 We hypothesize that a negative TA biopsy result does not change management in patients for whom TA is strongly suspected and that duplex ultrasound can be successfully used as a screening tool. METHODS This is a retrospective review of patients who underwent TA biopsy between May 1, 2012 and June 1, 2017. We reviewed patient's demographics, comorbidities, symptoms, histology, and treatment. We also present a small series of patients for whom ultrasound of the bilateral temporal arteries was performed. Radiology and pathology reports on these 7 patients were reviewed. RESULTS A total of 264 patients underwent temporal artery biopsies over the study period. Histology was positive in 21 (8.0%) and negative in 243 (92%) patients. In 74 (41%) patients with negative biopsies on steroids preoperatively, steroids were continued despite negative biopsy result. In prospective series, 7 patients underwent duplex ultrasound evaluation before scheduling for biopsy. Biopsy followed ultrasound in 4 cases, and in all 4 cases, histology was congruent with ultrasound findings. CONCLUSIONS The yield of temporal artery biopsy is low, and a negative biopsy alone often does not lead to termination of steroid therapy. Ultrasound may present a viable diagnostic tool to reduce the number of unnecessary temporal artery biopsies performed.
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Jewells VL, Latchaw RE. CNS Vasculitis-An Overview of This Multiple Sclerosis Mimic: Clinical and MRI Implications. Semin Ultrasound CT MR 2020; 41:296-308. [PMID: 32448486 DOI: 10.1053/j.sult.2020.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This article discusses central nervous system vasculitis, a clinical and MRI mimic of multiple sclerosis (MS). There is a paucity of discussion of vasculitis in the radiology literature, and many MS neurologists believe that vasculitis is underdiagnosed. Therefore, the authors hope that the readers will find this paper increases their knowledge about CNS vasculitis and improves their ability to differentiate MS from vasculitis.
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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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Mupparapu M, Ko E, Omolehinwa TT, Chhabra A. Neurologic Disorders of the Maxillofacial Region. Dent Clin North Am 2019; 64:255-278. [PMID: 31735232 DOI: 10.1016/j.cden.2019.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The maxillofacial region is complex in its anatomy and in its variation in the presentation of neurologic disorders. The diagnosis and management of neurologic disorders in clinical practice remains a challenge. A good understanding of the neurologic disorder in its entirety helps dentists in the diagnosis and appropriate referral to a specialist for further investigations and management of the condition. Neurologic disorders described in this article are under broad categories of sensory and motor disturbances as well as movement disorders and infections. This article summarizes the most common maxillofacial neurologic disorders that dentists might encounter in clinical practice.
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Affiliation(s)
- Mel Mupparapu
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA.
| | - Eugene Ko
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA
| | - Temitope T Omolehinwa
- University of Pennsylvania School of Dental Medicine, 240 S 40th Street, Philadelphia, PA 19104, USA
| | - Avneesh Chhabra
- UT Southwestern Medical Center, Harry Hines Boulevard, Dallas, TX 75390, USA
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Abstract
PURPOSE OF REVIEW Vision is often threatened or lost by acute ischemic damage to the optic nerves. Such pathology most often affects the anterior portion of the nerve and is visible on funduscopic examination. Ischemic optic neuropathy is associated with typical vascular risk factors and with one systemic disease in particular: giant cell arteritis (GCA). This article provides an overview of the three major classes of ischemic optic neuropathy, including information on risk factors, differential diagnosis, evaluation, and management. RECENT FINDINGS Optical coherence tomography provides precise anatomic imaging in ischemic optic neuropathy, showing neural loss weeks before it is visible on examination. Refinements of optical coherence tomography reveal optic nerve microvasculature and may assist in understanding pathogenesis and verifying diagnosis. New diagnostic algorithms and cranial vascular imaging techniques help define the likelihood of GCA in patients with ischemic optic neuropathy. Finally, intraocular drug and biological agent delivery holds promise for nonarteritic ischemic optic neuropathy, whereas newer immunologic agents may provide effective steroid-sparing treatment for GCA. SUMMARY It is essential to recognize ischemic optic neuropathy upon presentation, especially to determine the likelihood of GCA and the need for immediate steroid therapy. A broad differential diagnosis should be considered so as not to miss alternative treatable pathology, especially in cases with retrobulbar optic nerve involvement.
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Dardick JM, Esenwa CC, Zampolin RL, Ustun B, Ayesha B, Kirchoff-Torres KF, Liberman AL. Acute Lateral Medullary Infarct due to Giant Cell Arteritis: A Case Study. Stroke 2019; 50:e290-e293. [PMID: 31495325 DOI: 10.1161/strokeaha.119.026566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Joseph M Dardick
- From the Albert Einstein College of Medicine, Bronx, NY (J.M.D.)
| | - Charles C Esenwa
- Saul R. Korey Department of Neurology (C.C.E., K.F.K.-T., A.L.L.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Richard L Zampolin
- Department of Radiology (R.L.Z.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Berrin Ustun
- Department of Pathology (B.U.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Bibi Ayesha
- Division of Rheumatology, Department of Medicine (B.A.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Kathryn F Kirchoff-Torres
- Saul R. Korey Department of Neurology (C.C.E., K.F.K.-T., A.L.L.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Ava L Liberman
- Saul R. Korey Department of Neurology (C.C.E., K.F.K.-T., A.L.L.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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Abstract
Purpose: To present a rare case of scleritis associated with a prior diagnosis of giant cell arteritis (GCA) that was unresponsive to glucocorticoids, nonsteroidal anti-inflammatory drugs (NSAIDs), methotrexate, and azathioprine, but reached and maintained a full remission with tocilizumab.Observations: A 62-year-old Caucasian female presented with scleritis and headache. Four years earlier, the patient was diagnosed with GCA. Treatment with topical and systemic NSAIDs, prednisone and diverse disease-modifying antirheumatic drugsonly had a partial effect on the scleritis whilst the arthralgia and headaches increased. Despite the absence of laboratory evidence of active GCA, tocilizumab was started and the scleritis and headaches disappeared within several days. Prednisone could be fully tapered within 3 months and to date, 12 months after the start of tocilizumab, the patient has maintained a sustained remission.Conclusions: Our patient demonstrates that tocilizumab might represent a therapeutic option for scleritis, and its further evaluation for this severe ocular disease is worthwhile.
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Affiliation(s)
- Huub J Poelman
- Department of Ophthalmogy, Erasmus MC, Rotterdam, The Netherlands
| | - Paul L A Van Daele
- Internal Medicine, Section Allergology & Clinical Immunology, Erasmus MC, Rotterdam, The Netherlands
| | - A Rothova
- Department of Ophthalmogy, Erasmus MC, Rotterdam, The Netherlands
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Pfeil A, Oelzner P, Hellmann P. The Treatment of Giant Cell Arteritis in Different Clinical Settings. Front Immunol 2019; 9:3129. [PMID: 30733723 PMCID: PMC6353794 DOI: 10.3389/fimmu.2018.03129] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/18/2018] [Indexed: 12/31/2022] Open
Abstract
This paper aims to raise awareness of the different disease courses, comorbidities, and therapy situations in patients with giant cell arteritis (GCA), which require a differentiated approach and often a deviation from current treatment guidelines. With the approval of tocilizumab (TOC), which specifically binds to both soluble and membrane-bound IL-6 receptor and inhibits IL-6 receptor-mediated signaling, the spectrum of available effective treatment options has been significantly broadened. TOC yields an extensive range of possible applications that go beyond a glucocorticoid-saving effect. In this context, the treatment of GCA is dependent on the disease course as well as the associated comorbidities. The different stages of GCA in association to co-morbidities require a detailed treatment strategy.
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Affiliation(s)
- Alexander Pfeil
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Peter Oelzner
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
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