Giant cell arteritis presenting as interstitial lung disease

Interstitial Lung Disease in Giant Cell Arteritis: Review of 23 Patients

BACKGROUND/OBJECTIVE

Giant cell arteritis (GCA) is a large-vessel vasculitis with systemic manifestations. A few case reports have described a possible association of GCA with interstitial lung disease (ILD). The primary aim of the present study was to describe the pattern, severity, and course of ILD in patients with GCA.

METHODS

This medical records review study evaluated adult patients presenting to Mayo Clinic in Rochester, MN, from January 1, 1997, through December 31, 2018, who had the diagnoses of GCA and ILD. Clinical, laboratory, and radiologic data were analyzed.

RESULTS

In total, 23 patients were in the study. Median (range) age was 78 (58-93) years, and 14 (61%) were women. Six patients (26%) had a cough at GCA diagnosis. At ILD diagnosis, 15 patients had respiratory symptoms, including dyspnea (n = 12, 52%), dry cough (n = 6, 26%), wheezing (n = 1, 4%), and chest pain (n = 1, 4%). On initial chest computed tomography, the most common pattern of ILD was probable usual interstitial pneumonia (n = 7, 30%), indeterminate for usual interstitial pneumonia (n = 5, 22%), and combined pulmonary fibrosis and emphysema (n = 3, 13%). Airway abnormalities were present in 10 patients: 6 with bronchial wall thickening, 2 with bronchiectasis, and 2 with both. At follow-up computed tomography, 8 patients had ILD progression. Three patients with cough improved after initiation of glucocorticoid therapy.

CONCLUSIONS

Interstitial lung disease and airway abnormalities may be associated with GCA. Although cough may improve, ILD in some patients with GCA may progress despite immunosuppressive therapy.

Giant cell arteritis manifested by chronic dry cough

A 77-year-old man visited the hospital with a chronic cough persisting for 2.5 months accompanied with night sweats, weight loss (3.5 kg) and elevated C-reactive protein level. Chest CT of the lung field was normal, but aortic wall thickening accompanied by a contrast effect was noted. Positron emission tomography-CT (PET-CT) showed that the aorta and subclavian artery were inflamed, suggesting large-vessel vasculitis. Ultrasonography showed thickening of the superficial temporal artery wall (macaroni sign). Biopsy revealed lymphocytic infiltration in the tunica media and foreign-body giant cell reaction with the elastic lamina, resulting in a diagnosis of giant cell arteritis (GCA). The cough was considered a symptom of GCA as it resolved following prednisolone administration. Cough may rarely be an initial GCA symptom. However, for chronic cough accompanied with elevated inflammatory findings but with a normal lung field, imaging studies such as PET-CT are useful for the differential diagnosis.

Pleuroparenchymal fibroelastosis (PPFE) associated with giant cell arteritis: A coincidence or a novel phenotype?

Pleuroparenchymal fibroelastosis (PPFE) is a rare interstitial lung disease characterized by the fibrotic thickening of subpleural and parenchymal areas of the upper lobes. It may be both idiopathic or secondary to infections, interstitial lung diseases and/or drug exposure. Often PPFE patients report recurrent lower respiratory tract infections, suggesting that repeated inflammatory alterations induced by pulmonary infections may contribute to the development/progression of PPFE.

Here, we report for the first time the case of a patient affected by Giant cell Arteritis with histologically proven PPFE. The lung involvement in GCA is rare and interstitial lung diseases are usually reported as an uncommon clinical manifestation of GCA. Our patient is probably the first case presenting PPFE associated with GCA and we wonder if this is a real associative disease or a coincidence perhaps, secondary to drug effects.

Pulmonary nodules in a patient with Giant Cell Arteritis

Giant Cell Arteritis (GCA) is a common systemic vasculitis that involves medium and large arteries, most frequently extracranial branches of the carotid artery. Prompt diagnosis and treatment is essential to prevent devastating complications, such as blindness, stroke and aortic aneurysm or dissection. Typical symptoms include headache, temporal artery tenderness and jaw claudication. On rare occasions patients present with complaints related to pulmonary involvement. These include interstitial infiltration, pulmonary nodules, pleural effusion and pulmonary haemorrhage. The authors report the case of a 74-year-old man who presented with symptoms compatible with GCA confirmed by temporal biopsy, and pulmonary nodules. These lesions were biopsied and histological exam confirmed features compatible with systemic vasculitis. The lesions resolved after two months of steroid treatment. This case shows that we should be aware of atypical GCA manifestations.

Pulmonary manifestations of large, medium, and variable vessel vasculitis

The hallmark of vasculitis is autoimmune inflammation of blood vessels and surrounding tissues, resulting in an array of constitutional symptoms and organ damage. The lung is commonly targeted in the more familiar ANCA-associated small vessel vasculitidies, but large and medium vessel vasculitides, including Takayasu arteritis, giant cell arteritis, polyarteritis nodosa, Behcet's disease, and necrotizing sarcoid granulomatosis, may also feature prominent pulmonary involvement. Pulmonary manifestations of these conditions include pulmonary arterial aneurysms, pulmonary hypertension, diffuse alveolar hemorrhage, pulmonary nodules, and parenchymal infiltrates. An understanding of the diverse manifestations of vasculitis and a high index of clinical suspicion are essential to avoid delays in disease recognition that may result in permanent or life threatening morbidity. In this review, we outline the general clinical manifestations, pulmonary manifestations, diagnostic workup, imaging findings, and treatment of medium, large, and variable vessel vasculitides.

Interstitial Lung Disease as an Initial Manifestation of Giant Cell Arteritis

Interstitial lung disease (ILD) has rarely been reported as a manifestation of giant cell arteritis (GCA). We herein report a unique case of GCA in a 76-year-old woman who presented with ILD as an initial manifestation of GCA. Ten years before admission, she had been diagnosed with granulomatous ILD of unknown etiology. Corticosteroid therapy induced remission. One year after the cessation of corticosteroid therapy, she was admitted with a persistent fever. After admission, she developed left oculomotor paralysis. Positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (¹⁸F-FDG PET/CT) proved extremely useful in establishing the diagnosis. Our case promotes awareness of GCA as a possible diagnosis for granulomatous ILD with unknown etiology.

[Horton disease revealed by dyspnea]

Les manifestations pleuro-pulmonaires de la maladie de Horton sont rares et peu connues. Elles peuvent être inaugurales, à l'origine d'un retard à la prise en charge si elles sont méconnues. Il s'agissait d'un patient âgé de 75 ans, admis pour une dyspnée, une toux chronique et une fièvre. Il a reçu une antibiothérapie et a bénéficié d'une fibroscopie bronchique avec lavage broncho-alvéolaire à la recherche d'un germe, qui a révélé plutôt, une alvéolite lymphocytaire. L’évolution était marquée par la persistance des signes cliniques et du syndrome inflammatoire biologique. Un angio-scanner thoracique et une échographie cardiaque étaient sans anomalies. Une origine cardiaque, musculaire, hématologique, néoplasique, vasculaire ou métabolique de la dyspnée a été éliminée. Une maladie de Horton a été évoquée. La biopsie de l'artère temporale a confirmé le diagnostic d'une maladie de Horton. L’évolution sous corticothérapie était marquée par la disparition des signes cliniques et biologiques. Les manifestations pleuro-pulmonaires au cours de la maladie de Horton sont rares, et classiquement, rarement révélatrices de la maladie. La dyspnée peut initialement égarer le diagnostic vers d'autres étiologies notamment infectieuses. Le but de ce travail est d'insister sur le fait que la connaissance de ces différentes manifestations respiratoires au cours de la maladie de Horton (toux persistante, dyspnée, épanchement pleural) est utile au clinicien afin de prescrire une corticothérapie, chez un sujet le plus souvent âgé ayant un état fébrile et inflammatoire prolongé, permettant ainsi d’éviter l'apparition de complications.

Pulmonary affectation of vasculitis

Respiratory tract affectation is frequent in some types of vasculitis, fundamentally in those associated with anti-neutrophil cytoplasmic antibodies (ANCA). The clinical, radiological and histopathological presentation is also heterogeneous and conditions the evolution. It is therefore necessary to establish an early diagnosis based on the symptoms because, thanks to new treatments, and despite them being potentially serious diseases, their prognosis has improved considerably in recent years. The present paper updates the diagnosis and the new therapeutic options for pulmonary vasculitis.

Cough as the presenting symptom of large vessel vasculitis

We report the case of a 57-year-old woman presenting with persistent cough, weight loss, and fever. An extensive work-up revealed laboratory signs of inflammation and a mild thickening of the aortic wall on computed tomographic scan of the thorax. These findings raised the suspicion of large vessel vasculitis that was elegantly confirmed by fluorodeoxyglucose positron emission tomography. Persistent cough as the inaugural symptom and involvement of large vessels in Horton's disease are also discussed.

Giant cell arteritis presenting as chronic cough and prolonged fever

A 62-year-old man presented with a 3-month history of chronic non-productive cough and unexplained fever. Further questioning revealed that he had headaches and myalgia. Bilateral thickened temporal arteries were noted on physical examination. The erythrocyte sedimentation rate was 96 mm in 1 h. A biopsy specimen of the left temporal artery showed inflammatory changes consistent with the diagnosis of giant cell arteritis. Commencement of prednisolone resulted in rapid and dramatic resolution of his symptoms. Physicians should be aware of respiratory symptoms in patients with giant cell arteritis in order to avoid delay in diagnosis and therapy of this condition.

Pulmonary vasculitis

Pulmonary vascular inflammation may be seen in a variety of primary lung diseases and in the setting of numerous systemic illnesses. This article reviews those entities in which pulmonary vasculitis represents a central feature of the pathologic process (Wegener's granulomatosis, Churg-Strauss syndrome, and pulmonary capillaritis). In addition, features of pulmonary involvement in other systemic vasculitides (Giant Cell Arteritis, Takayasu's Arteritis, and Behçet's disease) are described. Finally, general principles for the treatment of vasculitis are reviewed.

Peripheral neuropathy associated with temporal arteritis

Peripheral neuropathy is described in a patient with biopsy proven giant cell arteritis. Sural nerve biopsy showed myelin and axonal degeneration. Such an uncommon manifestation was resolved with corticosteroid therapy.

Giant cell arteritis manifesting as chronic cough and fever of unknown origin

A 57-year-old white man sought medical attention because of chronic cough and fever of unknown origin. An extensive work-up over 4 weeks, including repeated blood cultures, chest roentgenograms, a gallium scan, and computed tomographic scans of the sinuses, chest, and abdomen, was nondiagnostic. The patient was referred to our institution for bronchoscopy. Further analysis of his history revealed that he had a headache in conjunction with the cough and an episode of a flashing color design in his left eye 1 week before assessment. The erythrocyte sedimentation rate was 115 mm in 1 hour. A biopsy of the temporal artery showed granulomatous inflammation of the vessel wall with multinucleated giant cells, histiocytes, lymphocytes, plasma cells, and few eosinophils. The multinucleated giant cells were closely related to the fragmented elastic lamina. Corticosteroid therapy resulted in prompt resolution of the chronic cough and fever. Giant cell arteritis should be considered in the differential diagnosis of chronic cough.

Vasculitis by organ systems

Systemic vasculitides, hitherto thought to be a rare clinical entity, are now rarely considered to be an uncommon disorder and patients are often seen between several departments, suffering from a non-infectious systemic disease with multi-organ involvement. Systemic vasculitis not only poses a major management problem but also has a significant impact on healthcare resources. The clinical outcome of a vasculitic illness depends on a number of factors, such as aetiology of the vasculitic process, site, size and number of blood vessels affected, duration and severity of the disease and also the complications associated with the disease or its therapy.

[Pleuropulmonary manifestations of systemic vasculitis]

Pleuropulmonary manifestations of systemic vasculitis are common, polymorphic and of ambiguous significance: the same pulmonary lesion may reveal a specific manifestation of vasculitis as well as a therapy-induced complication, especially infection which may favor per se a flare-up. Two questions will be successively studied: what are the pleuropulmonary characteristics of Wegener's granulomatosis, Churg-Strauss syndrome, periarteritis nodosa, Behçet's disease, Takayasu's disease and temporal arteritis? What are the major adverse effects that may occur in the course of a treated systemic vasculitis?

Pleural effusion as a presenting manifestation of giant cell arteritis

Pulmonary involvement is rare in giant cell arteritis (GCA). Only a few cases have been reported, manifested by interstitial infiltration, pulmonary nodules, pulmonary artery vasculitis, and granuloma formation. Moreover, only 3 previous cases of pleural effusion associated with GCA have been described. Herein we report a 67-year-old woman with biopsy-proven temporal arteritis, presented with prolonged fever, weight loss, cough and pleural effusion. ELISA test for the presence of anti- proteinase-3 antibodies was negative. The importance of the anti-neutrophil cytoplasmic-antibodies (ANCA) examination in the differential diagnosis from other vasculitides with pulmonary involvement is discussed.

Isolated pulmonary giant cell vasculitis

An autopsy case of granulomatous vasculitis confined to the pulmonary vasculature in a 40-year-old woman with widespread ovarian carcinoma is reported. Although gross lesions were not identified in the lungs other than a few metastatic tumor nodules, vascular lesions were demonstrated microscopically throughout both lungs. Histopathologically, granulomatous vasculitis was present only in the large and medium-calibered pulmonary arteries of elastic type and in pulmonary veins. Granulomas were distributed mainly in the media and adventitia. The lumina of arteries and veins were free from any occlusion or dilatation. In the granulomas, multinucleated giant cells of both foreign body and Langhans' types containing asteroid body often appeared with slight infiltration by T-lymphocytes. Fibrinoid necrosis was absent in the granulomatous lesions, and neutrophils and eosinophils were also not present. The pulmonary granulomatous vasculitis in this case is distinctly different from the other pulmonary necrotizing and granulomatous vasculitides previously reported.

[Specific respiratory manifestations of Horton disease]

Several respiratory manifestations have been described in patients with temporal arteritis. These complications may develop at the onset of the disease or later. Cough is the most frequent of them. Other complications include pleural effusions, interstitial pneumonitis, pulmonary vasculitis. Hyperreactive airways, hoarseness, diaphragm paralysis have been noted. Generally, corticosteroids cause a prompt improvement. Physicians should be aware of respiratory symptoms in patients with temporal arteritis in order to avoid delays in diagnosis and therapy.

Liver involvement in giant cell arteritis

Giant cell arteritis is a vasculitis which usually affects large and medium-sized vessels in patients over 50 years old. The liver is one of the internal organs which can be involved in this systemic disease. During the last 15 years, 56 patients with giant cell arteritis were seen in our hospital. In 12 patients disturbed liver function test were found. In the majority of cases the disturbance was of cholestatic type and resolved completely with steroid treatment. The association of temporal arteritis with disturbed liver function tests is discussed, with a review of the recent literature.

Wegener's granulomatosis associated with vasculitis of the temporal artery: report of five cases

Between January 1973 and October 1991 at the Mayo Clinic, 5 of 345 patients with Wegener's granulomatosis initially had features suggestive of giant cell arteritis and subsequently were found to have biopsy-proven vasculitis of the temporal artery. All five patients were older than 60 years of age and had jaw claudication, sudden loss of vision, severe headache with or without diplopia, or polymyalgia rheumatica at the time of initial examination. The erythrocyte sedimentation rate was high at the time of onset of symptoms in four patients (and unavailable in one patient). A temporal artery biopsy specimen revealed giant cell arteritis in one patient and non-giant cell arteritis in four patients. All five patients subsequently had pulmonary and renal lesions characteristic of Wegener's granulomatosis, with typical histopathologic features on biopsy or positive cytoplasmic staining antineutrophil cytoplasmic antibodies. Thus, overlapping features of giant cell arteritis and Wegener's granulomatosis do occur in some patients.

[Genital sites of giant-cell arteritis]

Temporal arteritis is one of the localisation of the giant cell arteritis. The involvement of the female genital tract had been rarely reported with only 16 cases in the literature. We report 3 cases revealed by a tumor of the genital tract. Histologic features are found in the vessels of ovaries, fallopian tubes and myometrium. Only one patient had symptoms suggestive of temporal arteritis.

Temporal arteritis: the silent presentation and delay in diagnosis

To determine the frequency of the so-called silent or occult presentation of temporal arteritis (presentation with mere constitutional symptoms) and the resulting delay in diagnosis in this particular group, the medical records of all patients (n = 82) with temporal arteritis or polymyalgia rheumatica, presenting between 1982 and 1988 at the Department of General Internal Medicine of the University Hospital, were retrospectively analysed. Only biopsy-proven cases (n = 34) were studied further. Of the 34 patients with temporal arteritis, 13 (38%) presented with the silent or occult form. In this group the mean delay in diagnosis was 21.5 d (range 2-105) in contrast to a delay of 8.5 d (range 1-40) in the other group (P less than 0.05). Increased awareness of this presentation should lead to earlier diagnosis and treatment of this potentially life-threatening disease, resulting in a shorter hospital stay and fewer technical investigations, with a considerable financial saving.

Pulmonary function of nonsmoking patients with giant cell arteritis and/or polymyalgia rheumatica; a controlled study

The pulmonary function of 26 nonsmoking patients with giant cell arteritis (GCA) and/or polymyalgia rheumatica (PMR) was evaluated and the results were compared with those of 28 age and sex matched nonsmoking controls. Normal function was observed in 30.8% of the patients and 50% of the controls (p = non significant). Isolated small airways disease (SAD) was detected in a high percentage of the patients (46.2%), but not significantly different from that of the controls (50%). Its clinical significance remains to be answered. Obstructive, restrictive and diffuse interstitial lung disease (DILD) was seen in one, three and two patients respectively, but was absent in the control population. All the patients had a normal chest radiograph and were asymptomatic, except for three. Two of them had normal respiratory function and one DILD. It is speculated that DILD and restrictive disease, seen only in patients with biopsy proven GCA, may be related to the underlying process.

Giant cell arteritis with pulmonary involvement

Giant cell arteritis (GCA) may present as pyrexia of unknown origin with profuse night sweats, pain on mastication, headache, pain in the region of the temporal arteries, polymyalgia rheumatica, myocardial infarction or dissecting aortic aneurysm. Few cases with pulmonary involvement have been described. We report a patient with temporal arteritis preceded by pulmonary vascular disease.

Giant cell arteritis of the legs. Clinical isolation of severe disease with gangrene and amputations

Giant cell arteritis rarely presents as clinically advanced extra-ocular ischemia or gangrene. Clinically isolated leg involvement with amputation is even more unusual. A 69-year-old woman is described who had giant cell arteritis necessitating bilateral leg amputations. No other clinical sequelae have ensued during a four-year follow-up period. Temporal artery biopsy subsequent to the amputations revealed no arteritis. Disparities between the usual patterns of clinical and anatomic involvement in giant cell arteritis underlie the potential diagnostic difficulties in this disease. Although typically diagnostic, temporal artery biopsy does not always bridge the clinical and anatomic disparities.