Giant cell arteritis

Giant Cell Arteritis: A Case-Based Narrative Review of the Literature

Purpose of Review

Giant cell arteritis (GCA) is a chronic, inflammatory condition, primarily affecting the medium and larger arteries. The purpose of this narrative review is to describe GCA in the context of headache and facial pain, based on a case and the available current literature. Understanding the etiology, pathophysiology, the associated conditions, and the differential diagnoses is important in managing GCA.

Recent Findings

In a patient presenting with unilateral facial/head pain with disturbances of vision, GCA should be considered in the differential diagnosis. There is an association of GCA with several comorbid conditions, and infections including coronavirus-19 (COVID-19) infection. Management of GCA primarily depends upon the identification of the affected artery and prompt treatment. Permanent visual loss and other serious complications are associated with GCA.

Summary

GCA is characterized by robust inflammation of large- and medium-sized arteries and marked elevation of systemic mediators of inflammation. An interdisciplinary approach of management involving the pertinent specialties is strongly recommended.

Usefulness of orbital colour Doppler ultrasound in vascular-related monocular vision loss

Acute, painless, monocular vision loss (APMVL) usually has a vascular aetiology. We conducted a prospective observational study from 2011 to 2018 to analyse the added value of colour Doppler imaging to assess orbital vessel blood flow in the diagnosis of APMVL. The study included 67 patients (39 [58.2%] men; mean age, 65.9 years [SD 13.7]) with APMVL evaluated at the Neurosonology Laboratory within the first 5 days of symptom onset, who were classified as having either transient or persistent monocular blindness. The blood flow in the ophthalmic and central retinal arteries was assessed using colour Doppler ultrasound with a linear 7.5-MHz transducer. Thirty-three (49.3%) patients presented transient monocular blindness, with reduced blood flow in either the ophthalmic or central retinal artery. The group with persistent vision loss included 24 cases of central retinal artery occlusion (CRAO) and 10 cases of ischaemic optic neuropathy (35.8% and 14.9%, respectively, of the total sample). These patients were older and had a higher prevalence of hypertension and mild carotid atherosclerosis. Orbital colour Doppler ultrasound (OCDUS) clarified the mechanism/cause of the ischaemia in 11 (16.4%) patients and showed abnormal flow in 46 (68.7%) patients, confirming the vascular origin in 19 (57.6%) of the transient monocular blindness cases. Lower peak systolic velocity was observed in patients with CRAO (p < 0.001), and a velocity < 10 cm/s in the central retinal artery was independently associated with the diagnosis of CRAO. OCDUS can be helpful in confirming the vascular cause and identifying the aetiology of APMVL.

Differential diagnosis of acute ocular pain: Teleophthalmology during COVID-19 pandemic - A perspective

Ocular pain is a common complaint which forces the patient to seek immediate medical attention. It is the primeval first response of the body to any severe condition of the eye such as trauma, infections and inflammation. The pain can be due to conditions directly affecting the eye and ocular adnexa; or indirect which would manifest as referred pain from other organ structures such as the central nervous system. Paradoxically, there are several minor and non-sight threatening conditions, which also leads to ocular pain and does not merit urgent hospital visits. In this perspective, we intend to provide guidelines to the practising ophthalmologist for teleconsultation when a patient complains of pain with focus on how to differentiate the various diagnoses that can be managed over teleconsultation and those requiring emergency care in the clinic. These guidelines can decrease unnecessary hospital visits, which is the need of the hour in the pandemic era and also beyond. Patients who are under quarantine and those who are unable to travel would be benefitted, and at the same time, the burden of increased patient load in busy hospital systems can be reduced.

Orbital Vasculitides-Differential Diagnosis

PURPOSE OF REVIEW

The orbit is subject to a variety of vascular insults that manifest with both specific and nonspecific patterns of vision compromise. The aim of the following review is to highlight the ophthalmic clinical features of systemic vasculitides that most frequently involve the orbit and differentiate them from the most common non-vasculitic orbital disorders.

RECENT FINDINGS

New studies continue to explore the autoimmune nature of vasculitic disease and seek to determine optimal use of newer therapies such as biologic agents. The pattern of ocular involvement in the context of clinical history allows the knowledgeable physician to distill a differential diagnosis into a specific or likely cause. Establishing a diagnosis in a timely fashion allows for a custom-tailored approach to therapy.

Genetic Predispositions of Glucocorticoid Resistance and Therapeutic Outcomes in Polymyalgia Rheumatica and Giant Cell Arteritis

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are closely related chronic inflammatory diseases. Glucocorticoids (GCs) are first-choice drugs for PMR and GCA, although some patients show poor responsiveness to the initial GC regimen or experience flares after GC tapering. To date, no valid biomarkers have been found to predict which patients are at most risk for developing GC resistance. In this review, we summarize PMR- and GCA-related gene polymorphisms and we associate these gene variants with GC resistance and therapeutic outcomes. A limited number of GC resistance associated-polymorphisms have been published so far, mostly related to HLA-DRB1*04 allele. Other genes such ICAM-1, TLR4 and 9, VEGF, and INFG may play a role, although discrepancies are often found among different populations. We conclude that more studies are required to identify reliable biomarkers of GC resistance. Such biomarkers could help distinguish non-responders from responders to GC treatment, with concomitant consequences for therapeutic strategy.

Color duplex ultrasonography findings of temporal arteries in a case of giant cell arteritis: role in diagnosis and follow-up

Giant cell arteritis (GCA) is a systemic autoimmune disease that affects medium- and large-sized arteries. The diagnostic gold standard is the temporal artery biopsy, but it has limited sensitivity and some difficulties in reproducibility. Color duplex ultrasonography is a noninvasive, reproducible, and inexpensive method for diagnosis of temporal arteries involvement (temporal arteritis [TA]) in GCA with high sensitivity and specificity. We present the ultrasound findings at baseline and during follow-up in a case of TA in a patient with GCA.

A rare case of temporal arteritis with rheumatoid arthritis and interstitial lung disease mimicking pulpo-periodontal pathology

A 75-year-old male patient was planned for dental treatment due to pain of suspected pulpo-periodontal origin in relation to right maxillary first molar. Careful evaluation revealed the pain to be non-odontogenic in nature and led to the diagnosis of temporal arteritis with rheumatoid arthritis along with interstitial lung disease (ILD). Characteristic findings of temporal arteritis include headache, jaw claudication, visual loss, and constitutional symptoms (malaise, fever, weight loss, loss of appetite). Temporal artery biopsy (TAB) remains the gold standard for diagnosis. Additional diagnostic tests include blood tests (ESR, CRP). This article reports and discusses how the orofacial manifestations can lead to misdiagnosis of temporal arteritis. Hence, temporal arteritis should be included in the differential diagnosis of orofacial pain in the elderly especially to prevent complications like vision loss.

Temporal arteritis

Temporal or giant cell arteritis is an inflammation of medium and small extracranial vessels that may result in ocular ischemia, an aortitis followed by aortic dissection and peripheral limb ischemia. It should be considered a medical emergency due to the seriousness of end organ damage, in particular visual symptoms. While the presentation may be nonspecific, the presence of a tender temporal artery mandates a temporal artery biopsy. High-dose steroids should be begun the moment the diagnosis is considered and only withdrawn once it has been excluded. A gradual tapering of the steroid dose should occur over at least 1 year, with the consideration of the use of steroid-sparing agents if iatrogenic steroid complications occur. Careful monitoring of the response both clinically as well as with serial inflammatory markers is required.

Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis

Demyelinating optic neuritis (ON) is the most common cause of optic neuropathy typically presenting with a subacute painful visual loss. In 20% of patients with multiple sclerosis (MS), ON is the presenting symptom and half of the patients with isolated ON develop MS within 15 years. The diagnosis of ON plays an important role in neurological practice. A correct and early diagnosis is necessary to ensure optimal further investigations and treatment. Other causes of optic neuropathies such as connective tissue disorders, infectious diseases, tumours or ischaemic neuropathies are less frequent but clinical and therapeutic management can differ dramatically. We present five patients admitted to our hospital with suspected demyelinating ON, but the clinical work up revealed different causes of optic neuropathy. We discuss the differential diagnosis of ON and clinical red flags that require careful diagnostic assessment of other diseases. A workflow for the diagnosis of optic neuropathies is presented.

Diagnosis and management of giant cell arteritis: a review

PURPOSE OF REVIEW

This article aims to provide a review of giant cell arteritis (GCA) clinical features, differential diagnosis, treatment options, and recent literature.

RECENT FINDINGS

GCA, first described by Horton et al., is a systemic immune-mediated vasculitis affecting medium-sized and large-sized arteries. Characteristic findings include headache, jaw claudication, visual loss, and constitutional symptoms (malaise, fever, weight loss, loss of appetite). Localized GCA symptoms are the end-result of vascular insufficiency and tissue ischemia. Temporal artery biopsy (TAB) remains the gold standard for diagnosis. Additional diagnostic tests include blood tests (erythrocyte sedimentation rate, ESR; C-reactive protein, CRP; platelets) and imaging modalities (ultrasound of the arteries; fluorescein angiography, FA; MRI; and positron emission tomography, PET). The mainstay of management includes high-dose corticosteroids, and additional cytotoxic drugs, antitumor necrosis factor monoclonal antibody, and antiplatelet aggregation therapy may be used. The goal of treatment is to prevent ischemic damage and halt progression of visual loss in the affected eye and prevent involvement of the fellow eye.

SUMMARY

Further research is warranted concerning the immunogenetics of GCA. Further treatment trials are also needed to develop more specific and sensitive diagnostic tests and new corticosteroid-sparing treatment modalities.

[Clinical aspects of temporal arteritis: course variations up to fatal complications]

BACKGROUND

Arteritis temporalis (AT) shows a variable course of the disease and may lead to transient or permanent visual loss.

PATIENTS AND METHODS

In a retrospective consecutive case series 66 patients with suspected AT were followed up of which 65 underwent arterial biopsy. Symptoms, therapy and complications were followed up.

RESULTS

Of the patients 32 (49.2%) revealed a positive histological finding in unilateral (55.4%) or bilateral (44.6%) biopsy. Of these 3 (9.4%) suffered a severe or fatal outcome: two with extensive ischemia of the vertebrobasilar system (one fatal) and one patient died due to acute pancreatitis, a rare side effect of systemic steroid therapy.

CONCLUSION

When systemically apparent, arteritis temporalis can progress to reduction of general health, cerebral ischemia and organ infarction. Therefore, AT is a serious disease requiring interdisciplinary, immediate diagnostics and prompt therapy.

Increased angiotensin II type 1 receptor expression in temporal arteries from patients with giant cell arteritis

PURPOSE

Currently, giant cell arteritis (GCA) is primarily treated with corticosteroids or immunomodulating agents, but there is interest in identifying other noncorticosteroid alternatives. Similarities exist in the injury pathways between GCA and atherosclerosis. Angiotensin II is a vasoactive peptide involved in vessel inflammation during atherosclerosis, and angiotensin II receptor inhibitors are effective in preventing atherosclerosis. The present study was performed to elucidate the role of angiotensin type 1 (AT(1)) and type 2 (AT(2)) receptors in GCA.

DESIGN

Experimental retrospective immunohistochemical study of temporal arteries using archival formalin-fixed, paraffin-embedded tissue.

PARTICIPANTS

Ten patients with GCA and 10 control patients, who were clinically suspected of having GCA but were diagnosed as not having GCA, were included.

METHODS

Immunohistochemistry, using anti-AT(1) and anti-AT(2) antibodies, was performed on formalin-fixed and paraffin-embedded temporal arteries.

MAIN OUTCOME MEASURES

AT(1) and AT(2) receptor immunostaining intensity was quantified.

RESULTS

Hematoxylin-eosin-stained sections of temporal arteries from patients with GCA showed intimal hyperplasia, internal elastic lamina degeneration, and band-shaped infiltrates of inflammatory cells, including lymphocytes, histocytes, and multinucleated giant cells. AT(1) receptor staining was primarily observed in the medial layer of the temporal arteries and was higher in the patients with GCA than in the control patients. This was a result of increased AT(1) receptor immunostaining of both vascular smooth muscle cells and infiltrating inflammatory cells. Only faint immunostaining was seen for AT(2) receptors, primarily in the endothelial cells, and to a lesser extent on the smooth muscle cells. Immunostaining with antibodies for the AT(2) receptor was similar in the patients with GCA and in controls.

CONCLUSIONS

These results suggest that AT(1) receptors play a role in the development of GCA. Inhibition of the angiotensin system may thus provide a noncorticosteroid alternative for the treatment of GCA.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Tongue necrosis as first symptom of giant cell arteritis (GCA)

Giant cell arteritis (GCA) is the most common systemic vasculitis affecting people over the age of 50 years, especially in the western world. Nevertheless, the initial diagnosis can be tricky, as some of the patients present at first time with a real unusual initial manifestation. One of these can be tongue necrosis, which is according to the literature in accordance with scalp necrosis, the rarest initial manifestation form of GCA. We describe two patients who presented with tongue necrosis as initial symptom of GCA. The diagnosis was made by the American College of Rheumatology criteria, biopsy and duplex sonography of their temporal arteries. A typical halo was seen as a sign of intimal edema. The patients were put on corticosteroids immediately after diagnosis was proven and their symptoms improved quickly.

Giant cell arteritis: an updated review

Giant cell arteritis (GCA) is the most common primary vasculitis of adults. The incidence of this disease is practically nil in the population under the age of 50 years, then rises dramatically with each passing decade. The median age of onset of the disease is about 75 years. As the ageing population expands, it is increasingly important for ophthalmologists to be familiar with GCA and its various manifestations, ophthalmic and non-ophthalmic. A heightened awareness of this condition can avoid delays in diagnosis and treatment. It is well known that prompt initiation of steroids remains the most effective means for preventing potentially devastating ischaemic complications. This review summarizes the current concepts regarding the immunopathogenetic pathways that lead to arteritis and the major phenotypic subtypes of GCA with emphasis on large vessel vasculitis, novel modalities for disease detection and investigative trials using alternative, non-steroid therapies.