Polymyalgia rheumatica and systemic giant cell arteritis. Bioptic findings of the subclavian arteries in a case of aortic arch syndrome

Ultrasonography in the diagnosis and follow-up of giant cell arteritis

Colour Doppler ultrasonography is the first measure to allow objective bedside assessment of GCA. This article discusses the evidence using the OMERACT filter. Consensus definitions for ultrasonographic changes were agreed upon by a Delphi process, with the 'halo' and 'compression' signs being characteristic. The halo is sensitive to change, disappearing within 2-4 weeks of starting glucocorticoids. Ultrasonography has moderate convergent validity with temporal artery biopsy in a pooled analysis of 12 studies including 965 participants [κ = 0.44 (95% CI 0.38, 0.50)]. The interobserver and intra-observer reliabilities are good (κ = 0.6 and κ = 0.76-0.78, respectively) in live exercises and excellent when assessing acquired images and videos (κ = 0.83-0.87 and κ = 0.88, respectively). Discriminant validity has been tested against stroke and diabetes mellitus (κ=-0.16 for diabetes). Machine familiarity and adequate examination time improves performance. Ultrasonography in follow-up is not yet adequately defined. Some patients have persistent changes in the larger arteries but these do not necessarily imply treatment failure or predict relapses.

[Giant cell arteritis-related upper/lower limb vasculitis]

Upper/lower limb vasculitis has been considered an uncommon manifestation of giant cell arteritis, occurring in 3 to 16% of patients. Upper/lower limb vasculitis is still associated with significant morbidity, leading to limb/toe amputation in 5.6 to 15.8% of patients. Yearly clinical vascular examination should be performed systematically to screen upper/lower limb vasculitis at an early stage in patients with giant cell arteritis. Duplex ultrasound has proved to be a reliable non-invasive imaging method for detecting arterial stenoses of the upper/lower limbs in patients with giant cell arteritis. Patients with giant cell arteritis-related upper/lower limb vasculitis should undergo routine investigations to detect underlying aortic complications, concomitant aortic localizations being encountered in more than 50% of cases. Prednisone is the first-line therapy at an initial dose of 0.7-1 mg/kg daily. Prevention of platelet aggregation with low-dose aspirin is potentially effective in preventing ischemic complications of GCA. The indication of surgical therapy should be based on the severity of giant cell arteritis-related upper/lower limb clinical symptoms to avoid unnecessary morbidity in the course of interventional therapy.

Long-term follow-up of upper and lower extremity vasculitis related to giant cell arteritis: a series of 36 patients

We conducted this retrospective study to determine the prevalence of giant cell arteritis (GCA) in patients exhibiting nonatherosclerotic upper and/or lower extremity arterial involvement and to evaluate the clinical features and long-term outcome of those patients.From January 1997 to March 2008, 36 consecutive patients in the Department of Internal Medicine at the University of Rouen medical center received a diagnosis of symptomatic upper/lower extremity vasculitis related to GCA. In the 36 patients, upper/lower extremity vasculitis preceded the initial GCA diagnosis in 7 patients (19.4%), it was identified in association with GCA in 13 patients (36.1%), and it developed after the onset of GCA in the remaining 16 patients (44.4%). GCA clinical manifestations were severe resulting in ischemic complications of the extremities in 10 patients (27.8%). GCA-related large-vessel involvement was located in the upper extremity alone in 21 patients (58.3%), the lower extremity alone in 7 patients (19.4%), and both the upper and lower extremities in 8 patients (22.2%).Arterial involvement in GCA patients with upper extremity vasculitis was distributed in the subclavian (55.6%), axillary (47.2%), and brachial (22.2%) arteries. In patients with lower extremity vasculitis, involvement included the internal iliac artery (11.1%), common femoral artery (13.9%), superficial femoral artery (33.3%), deep femoral artery (5.6%), and popliteal and anterior tibial arteries (5.6%). Aortic localizations were common in GCA patients with upper/lower extremity vasculitis (68.9% of cases).All patients were given steroid therapy at a median daily dose of 1 mg/kg initially. Reconstructive study was performed in 10 patients (27.8%): venous bypass graft (n = 6), angioplasty (n = 1), thromboendarteriectomy (n = 2), or thrombectomy (n = 1); 2 other patients with extremity ischemia underwent amputation. The median observation time was 32 months; the outcome of upper/lower extremity vasculitis was disappearance of clinical symptoms (44.4%), improvement of clinical manifestations (44.4%), and deterioration of clinical manifestations (11.1%). At last follow-up, the median daily dose of prednisone was 6 mg. Steroid therapy could be discontinued in 12 patients (33.3%).We found that upper/lower extremity vasculitis is not uncommon in patients with GCA, and may be present in the early acute phase of GCA. Nevertheless, because upper/lower extremity vasculitis occurs during the course of GCA, yearly clinical vascular examinations may be adequate to screen for upper/lower extremity vasculitis at an early stage in GCA patients. Early diagnosis of GCA-related upper/lower extremity vasculitis is crucial, and can result in decreased severe ischemic complications. Because aortic localizations were common, GCA patients with upper/lower extremity vasculitis should undergo routine investigations for underlying life-threatening aortic complications (aortic ectasia/aneurysm). We also suggest that patients exhibiting aortic complications should undergo routine clinical vascular examination to detect upper/lower extremity vasculitis.

Large vessel vasculitis without temporal artery involvement: isolated form of giant cell arteritis?

Diffuse arterial involvement in giant cell arteritis (GCA) is well recognized. By contrast, GCA clinically isolated to large vessels without cephalic, rheumatologic or systemic symptoms represents a much rarer manifestation of the disease. We report the cases of 4 elderly women presenting with a diffuse and symptomatic occlusive disease without the typical signs of temporal arteritis, in whom biological, angiographic or pathological findings were suggestive of GCA. Medium to high dose oral corticosteroids were given to the 4 patients, in combination with various revascularization procedures, allowing a fair clinical response. Large vessel arteritis should be considered in elderly women with diffuse non-atherosclerotic occlusive disease and elevated erythrocyte sedimentation rate, even if typical features of GCA are lacking. In those cases, a long-term treatment with corticosteroids is mandatory, but surgical or angioplastic revascularization is often required.

Giant cell arteritis (Horton's disease) of the axillary artery--case reports

The authors recently observed 2 elderly female patients with ischemic pain of the upper extremity as the first manifestation of giant cell arteritis. They presented with rest pain of both upper extremities and even gangrene of the thumb in 1 case. Subclavian and radial pulses were absent while peripheral pulses in the lower limbs were preserved. The angiography was so typical that the diagnosis of inflammatory arteritis was made, despite negative temporal artery biopsy. The patient with thumb gangrene was successfully operated on, the occlusive axillary lesions being bypassed by a long venous carotid humeral bypass graft. A biopsy of the axillary artery showed a granulomatous lymphoplasmocellular infiltration. A high-dose corticotherapy (24 mg daily) was begun in both cases, with dramatic improvements of general state, lowering of the erythrocyte sedimentation rate, and even reapparition of a reduced radial pulse in 1 patient. The authors discuss the incidence, symptoms, diagnosis, and treatment of systemic giant cell arteritis, with special attention to extracranial involvement. These case reports may broaden the knowledge of the diverse manifestations of giant cell arteritis and of its systemic character with widespread vascular involvement.