Giant cell arteritis in China: a prospective investigation

Case Report and Literature Review of an Atypical Polymyalgia Rheumatica and Its Management

Polymyalgia rheumatica (PMR) is a systemic inflammatory disease of the elderly population that increases in incidence as age advances. It is characterised by the sudden or sub-acute onset of symptoms affecting the shoulder and pelvic girdles, often accompanied by constitutional symptoms. Due to the lack of consensual diagnostic criteria and specific laboratory or radiological investigations for PMR, its diagnosis can be very challenging, particularly because it can be mimicked or masked by other geriatric syndromes. PMR responds well to glucocorticoid treatment, but if left untreated, can lead to morbidity and poor quality of life. We present the case of an 87-year-old male who presented with a one-week history of localised pain in the left hip joint, later involving the contralateral hip. Previously able to ambulate unaided, his mobility was now severely impaired. Due to his Alzheimer's dementia and multiple comorbid geriatric conditions, extensive investigations were undertaken before a diagnosis of atypical PMR was reached. Treatment with a low dose of prednisolone led to a full recovery. This case highlights the inconsistency between an atypical presentation and the classic presentation of PMR and draws attention to the possibility of missed diagnosis in older, frail patients. Atypical symptomatology on top of cognitive impairment and language barriers can be easily overlooked and left untreated and could lead to severe adverse outcomes. Accurate diagnosis is crucial, as PMR is readily diagnosed, but the treatment with glucocorticoids, though generally straightforward, can pose challenges, particularly when dealing with polypharmacy and multiple coexisting health conditions.

Biopsy-Proven Giant Cell Arteritis Associated Vision Loss in Chinese Subjects: A Case Series and Review of the Literature

Only a few case reports of biopsy-proven GCA (BpGCA)-associated vision loss in Chinese subjects have been published. We describe three elderly Chinese subjects with BpGCA who presented with vision loss. We also searched the literature in order to review BpGCA-associated blindness in Chinese subjects. Case 1 presented as simultaneous right ophthalmic artery occlusion and left anterior ischaemic optic neuropathy (AION). Case 2 presented as sequential bilateral AION. Case 3 presented as bilateral posterior ischaemic optic neuropathy and ocular ischaemic syndrome (OIS). The diagnosis was confirmed by temporal artery biopsy in all three. Magnetic resonance imaging (MRI) in Cases 1 and 2 demonstrated retrobulbar optic nerve ischaemia. Enhancement of the optic nerve sheath and inflammatory changes of the ophthalmic artery on enhanced orbital MRI was also noted in Cases 2 and 3. All of the subjects were treated with steroids, either intravenously or orally. In the literature review, 11 cases (17 eyes) of BpGCA-associated vision loss in Chinese subjects were found including AION, central retinal artery occlusion, combined AION and cilioretinal artery occlusion, and orbital apex syndrome. In the 14 cases (including ours), the median age at diagnosis was 77 years, and 9 (61.5%) were males. The most common extraocular manifestations were temporal artery abnormalities, headache, jaw claudication, and scalp tenderness. Thirteen (56.5%) eyes had visual acuity of no light perception at the initial visit and failed to respond to the treatment. Although rare, in elderly Chinese subjects with ocular ischaemic diseases, the diagnosis of GCA must be considered.

Giant cell arteritis: Its ophthalmic manifestations

Giant cell arteritis (GCA) is the most important medical emergency in ophthalmology, because its most dreaded complication is visual loss, which is preventable if these patients are diagnosed early and treated immediately and aggressively. This is a brief review of GCA, its ophthalmic manifestations, and how to diagnose and manage them.

Giant Cell Arteritis and COVID-19: Similarities and Discriminators. A Systematic Literature Review

OBJECTIVE

To identify shared and distinct features of giant cell arteritis (GCA) and coronavirus disease 2019(COVID-19) to reduce diagnostic errors that could cause delays in correct treatment.

METHODS

Two systematic literature reviews determined the frequency of clinical features of GCA and COVID-19 in published reports. Frequencies in each disease were summarized using medians and ranges.

RESULTS

Headache was common in GCA but was also observed in COVID-19 (GCA 66%, COVID-19 10%). Jaw claudication or visual loss (43% and 26% in GCA, respectively) generally were not reported in COVID-19. Both diseases featured fatigue (GCA 38%, COVID-19 43%) and elevated inflammatory markers (C-reactive protein [CRP] elevated in 100% of GCA, 66% of COVID-19), but platelet count was elevated in 47% of GCA but only 4% of COVID-19 cases. Cough and fever were commonly reported in COVID-19 and less frequently in GCA (cough, 63% for COVID-19 vs 12% for GCA; fever, 83% for COVID-19 vs 27% for GCA). Gastrointestinal upset was occasionally reported in COVID-19 (8%), rarely in GCA (4%). Lymphopenia was more common in COVID-19 than GCA (53% in COVID-19, 2% in GCA). Alteration of smell and taste have been described in GCA but their frequency is unclear.

CONCLUSION

Overlapping features of GCA and COVID-19 include headache, fever, elevated CRP and cough. Jaw claudication, visual loss, platelet count and lymphocyte count may be more discriminatory. Physicians should be aware of the possibility of diagnostic confusion. We have designed a simple checklist to aid evidence-based evaluation of patients with suspected GCA.

Comparisons of clinical manifestations and prognosis between giant cell arteritis patients with or without sensorineural hearing loss: A retrospective study of Chinese patients

Auditory manifestations has rarely been mentioned in studies concerning giant cell arteritis (GCA). This study explores the proportion of hearing loss (HL) in Chinese GCA patients and investigates the differences in clinical features between GCA patients with and without HL.The study retrospectively reviewed the clinical records of 91 patients diagnosed with GCA at Peking Union Medical College Hospital (PUMCH) from November 1998 to October 2017. GCA diagnoses were reconfirmed according to the American College of Rheumatology 1990 criteria. Diagnosis of HL was made based on a patient's symptoms combined with physical examination or ear-nose-throat (ENT) audiometry tests. Subgroup analysis was conducted according to the occurrence of HL.Totally 23 patients (25.3%) had HL. A higher percentage of males (65.2% vs 38.2%, p = 0.025) was seen in HL group. Symptoms such as headache (91.3% vs 61.2%, p = 0.011), visual loss (56.5% vs 32.4%, p = 0.039) and CNS symptoms (39.1% vs 17.6%, p = 0.035) were more frequent in HL group. Moreover, they were more likely to have smoking history (p = 0.019), lower lymphocyte count (p = 0.049), positive ANA or APL (p = 0.047, p = 0.017) or negative biopsy results (p = 0.015). Symptom like myalgia (26.1% vs 66.2%, p = 0.001) as well as comorbid disease like coronary artery disease (p = 0.037) and hypertension (p = 0.040) was more frequent in patients without HL. Either C-reactive protein (90.91 ± 65.86 vs 76.05 ± 61.15 mg/L, p = 0.347) or erythrocyte sedition rate (83.04 ± 29.61 vs 93.69 ± 26.78 mm/h, p = 0.136) was high in both groups but the differences were not significant. Meanwhile, no significant differences were found in age, disease course, vascular involvement or prognosis between the two groups. Unilateral HL tended to happen at the same side with unilateral headache, visual loss, scalp tenderness or jaw claudication.HL is probably not rare in GCA patients and is more frequently to be seen in patients presented with headache, visual loss or CNS symptoms. Differentiation of HL is necessary for specialists and GCA should be considered as a potential diagnosis especially in HL patients with high inflammatory markers. Auditory assessment should be conducted in GCA management.

Diagnostic delay for giant cell arteritis - a systematic review and meta-analysis

BACKGROUND

Giant cell arteritis (GCA), if untreated, can lead to blindness and stroke. The study's objectives were to (1) determine a new evidence-based benchmark of the extent of diagnostic delay for GCA and (2) examine the role of GCA-specific characteristics on diagnostic delay.

METHODS

Medical literature databases were searched from inception to November 2015. Articles were included if reporting a time-period of diagnostic delay between onset of GCA symptoms and diagnosis. Two reviewers assessed the quality of the final articles and extracted data from these. Random-effects meta-analysis was used to pool the mean time-period (95% confidence interval (CI)) between GCA symptom onset and diagnosis, and the delay observed for GCA-specific characteristics. Heterogeneity was assessed by I ² and by 95% prediction interval (PI).

RESULTS

Of 4128 articles initially identified, 16 provided data for meta-analysis. Mean diagnostic delay was 9.0 weeks (95% CI, 6.5 to 11.4) between symptom onset and GCA diagnosis (I ² = 96.0%; P < 0.001; 95% PI, 0 to 19.2 weeks). Patients with a cranial presentation of GCA received a diagnosis after 7.7 (95% CI, 2.7 to 12.8) weeks (I ² = 98.4%; P < 0.001; 95% PI, 0 to 27.6 weeks) and those with non-cranial GCA after 17.6 (95% CI, 9.7 to 25.5) weeks (I ² = 96.6%; P < 0.001; 95% PI, 0 to 46.1 weeks).

CONCLUSIONS

The mean delay from symptom onset to GCA diagnosis was 9 weeks, or longer when cranial symptoms were absent. Our research provides an evidence-based benchmark for diagnostic delay of GCA and supports the need for improved public awareness and fast-track diagnostic pathways.

A Retrospective Study of Chinese Patients With Giant Cell Arteritis (GCA): Clinical Features and Factors Associated With Severe Ischemic Manifestations

A retrospective study was performed on 70 giant cell arteritis (GCA) patients in Peking Union Medical College Hospital (PUMCH). The aim of this study was to describe the clinical features of these Chinese GCA patients and explore the possible associated factors for severe ischemic manifestations. Medical charts of all patients were reviewed, and the demographic, clinical, and laboratory data were analyzed. The mean age at disease onset was 65.2 years old, and the ratio of male to female was 1:1. Fever and headache were most prominent symptoms at onset, which occurred in 51.4% and 30.0% of patients, respectively. Common manifestations at diagnosis were constitutional symptoms (85.7%), headache (68.8%), visual impairment (38.6%), jaw claudication (30%), scalp tenderness (30%), and concurrent polymyalgia rheumatic (27.1%). No significant difference in clinical manifestations between genders was observed. Comparisons between patients with and without severe ischemic manifestations including jaw claudication, permanent visual loss, or cerebrovascular accident had shown that fever and asthenia were significantly less frequent in patients with severe ischemic manifestations (P = 0.006 and 0.023, respectively), and the mean value of erythrocyte sedimentation rate (ESR) was significantly lower in patients with severe ischemic manifestations than patients without (P = 0.001). History of smoking was more frequent in patients with severe ischemic manifestations (P = 0.038). This is the largest group of GCA patients from China so far. When compared our data with patients reported in the literature, this series of GCA patients were younger and without female predominance. The clinical manifestations of patients in this report were similar to other studies except for a higher prevalence of constitutional symptoms. The results of this study indicated that lower systemic inflammatory response and the history of smoking might be associated with severe ischemic damages.

Temporal arteritis: A case series from south India and an update of the Indian scenario

OBJECTIVE

To study the clinical, pathological and prognostic profile of patients with temporal arteritis in India.

MATERIALS AND METHODS

The study was conducted in a tertiary care center from south India from 2005 to 2010 in the departments of neurology and medicine. The details of all patients that satisfied the ACR 1990 criteria for diagnosis of temporal arteritis were reviewed. The clinical presentation, laboratory parameters and biopsy findings of the patients were analyzed and compared with other studies from India done over the last decade.

RESULTS

A total of 15 patients were diagnosed with temporal arteritis. The male:female ratio was 1.5:1. The mean age of onset was 67.58 years. Mean time for detection after onset of symptoms was 2.56 months. Typical manifestations included headache (100%), temporal artery tenderness (100%), jaw claudication (20%), polymyalgia rheumatica (53%) and visual manifestations (20%). The erythrocyte sedimentation rate was elevated in all patients. Biopsy was done in 13 patients, with 11 of them being positive. All patients responded to steroids well, with most patients being symptom-free within the first 48 h of treatment.

CONCLUSIONS

Temporal arteritis seems to be underdiagnosed in India, with all patients previously misdiagnosed, and with a mean time from symptom onset to diagnosis of 2.5 months. The clinical presentation of temporal arteritis in India appears to be similar to that of the West, with no gender preference and a slightly younger age group.

Pathogenesis of giant cell arteritis: More than just an inflammatory condition?

Giant cell arteritis (GCA) is characterized by intimal hyperplasia and luminal obstruction leading to ischemic manifestations involving extra-cranial branches of carotid arteries and aorta. Histopathological lesions involve all layers of the arterial wall and are associated with multinucleated giant cells, fragmented internal elastic lamina and polymorphic cellular infiltrates, including T lymphocytes and macrophages. The pathophysiology of GCA is still poorly understood. After dendritic cell activation, CD4(+) T lymphocytes, T helper 1 (Th1) cells, produce interferon gamma and modulate macrophage activation and functions, and Th17 cells produce interleukin 17 (IL-17), which can induce cytokine production by macrophages and fibroblasts. Macrophages in the adventitia produce pro-inflammatory cytokines such as IL-1, IL-6 and tumor necrosis factor alpha. These cytokines promote arterial wall and systemic inflammation. Questions remain regarding the nature of the antigen(s) triggering dendritic cell activation and the mechanisms underlying vascular remodeling. Here we review recent advances in the pathogenesis of GCA, with emphasis on the interactions between cells of the immune system and components of the vessel wall, including vascular smooth muscle cells and endothelial cells, leading to vascular remodeling. Finally, we propose new areas of investigation that could help understand the triggering factors and key pathogenic events in GCA.

Giant cell arteritis in Alaska Natives

OBJECTIVE

To investigate the incidence of biopsy-proven giant cell arteritis in the Native population of Alaska.

DESIGN

Retrospective review of medical diagnostic and Current Procedural Terminology (CPT) codes.

PARTICIPANTS

110,000 Alaska Native patients.

METHODS

We conducted a retrospective review of medical diagnostic codes for temporal arteritis, giant cell arteritis, and anterior ischemic optic neuropathy in the medical records of 110,000 Alaska Native patients seen between 1983 and 2003. We examined this same database in search of the CPT code for the temporal artery biopsy procedure. We also re-examined all temporal artery biopsy specimens that had been reported as positive.

RESULTS

We identified 122 patients whose diagnostic codes matched those of giant cell arteritis, temporal arteritis, or anterior ischemic optic neuropathy. We found that of 20 temporal artery biopsies that had been performed on this group, only 4 were reported to have had positive results. On re-examination of pathologic specimens, 1 of the 4 was found not to meet the latest pathologic criteria for this disease, leaving only 3 cases of biopsy-proven giant cell arteritis. The calculated incidence of giant cell arteritis in the Alaska Native population is approximately 1/100,000 in those over 50 years old.

CONCLUSIONS

Compared with previous epidemiologic studies performed worldwide, our review suggests a very low incidence of biopsy-proven giant cell arteritis among Alaska Natives.