Polymyalgia rheumatica, giant-cell arteritis and blindness: a review and case report

Polymyalgia rheumatica and giant cell arteritis--rational diagnosis and treatment predicated and disordered prostaglandin metabolism

We suggest that polymyalgia rheumatica with giant cell arteritis (PR-GCA) is an arachidonic acid metabolites mediated disease which can be diagnosed more accurately and monitored more precisely for therapeutic benefits by the serial determinations of the major urinary prostaglandin F, serum urinary lysozymes, serum acid phosphatase, and serum angiotensin converting enzyme rather than by the erythrocyte sedimentation rate, and, when necessary by temporal artery biopsy. The pathogenetic role proposed for prostaglandins (PG) and, even more precisely perhaps, the leukotrienes in this disease is consistent with the several published clinical observations that non-steroidal anti-inflammatory drug treatment produces in some cases a therapeutic paradox of symptomatic relief with concurrent, if clinically silent, progression of the arteritis, even to blindness. Furthermore, the impressive response of PR-GCA to low maintenance dose steroid therapy, a clinical conundrum for decades, is rationally explained on the basis of depressed or obstructed PG metabolism early on in the metabolic cascade. These views warrant clinical evaluation, confirmation or correction in whole or in part, and may increase our understanding of PR-GCA.

Neurological complications of connective tissue and other "collagen-vascular" diseases

A variety of neurological complications may occur in the various connective tissue and "collagen-vascular" diseases. Most of these complications are due to vasculitis affecting various sites in the central or peripheral nervous system. While the evidence for definitive vasculitis in SLE is not strong, small vessel damage usually is present in anatomic sites which correlate well with clinical features. Although patients with rheumatoid arthritis also may have vasculitis, neurological complications are usually related to nerve compression by rheumatoid nodules or the arthritic process itself. Considerable controversy exists regarding the accuracy of various diagnostic tests. While corticosteroids are the mainstay of therapy for these conditions, there are no definitive studies proving their efficacy.

Cranial arteritis in otolaryngology

Cranial arteritis has the common presenting manifestations of headache and visual loss and is generally limited to elderly individuals. Nearly 50% of patients with the musculoskeletal disorder of polymyalgia rheumatica have an associated cranial arteritis, but the exact pathophysiologic relationship remains unclear. Although the literature suggests that otolaryngologic manifestations of cranial arteritis are infrequent, this report supports a contradictory viewpoint. Approximately 25% of patients with masticatory claudication, tongue pain, or frank lingual infarction. These oral manifestations should be recognized as indicators of a serious underlying arteritis.

Ophthalmic complications of giant cell arteritis

Temporal arteritis, or giant cell arteritis, is a common cause of blindness among older age groups. Classical and occult forms are described with particular reference to ocular symptomatology. Although the disease is self-limiting and usually subsides spontaneously within a year, prompt diagnosis and treatment are required if second eye involvement and blindness are to be prevented. Erythrocyte sedimentation rate is of major significance to diagnosis, but biopsy is necessary to prove or disprove the existence of temporal arteritis. Pathology, etiology, association with other disorders and laboratory studies are discussed. A regime of corticosteroid therapy is recommended and described in detail.