Giant cell arteritis. Clinical features and involvement of different organs

A Giant Silence - An atypical association of sensorineural hearing loss with Giant Cell Arteritis

Giant cell arteritis (GCA) is a chronic vasculitic disorder predominantly affecting medium to large sized arteries, prevalent in the 50 plus age group. This case illustrates an atypical presentation of this disease in the form of bilateral sensorineural hearing loss (SNHL). Apart from the presence of constitutional and vertiginous symptoms, there were essentially no classical features of GCA. Differentials were broad including infection, malignancy and medication toxicity as well as brain, eye and ear syndromes such as Cogan's syndrome, all of which were eventually excluded. Her diagnosis was ultimately confirmed on positron emission tomography, which highlights the diagnostic importance of this modality. She was managed with corticosteroids then tocilizumab and is making a gradual recovery. Literature review demonstrates that SNHL is more prevalent than previously suggested in GCA, although this does not have widespread recognition. Mechanisms of SNHL in GCA include vascular occlusion, immunological mechanisms including cross reactivity with viral antigens and direct viral infection. SNHL does appear to improve with corticosteroids. This case emphasizes the importance of considering GCA as an important differential in SNHL.

[Immune-mediated sensorineural hearing loss: prevalence and treatment strategies]

Autoimmune sensorineural hearing loss is a rare clinical entity which accounting for less than 1% in all cases with hearing loss. The prevalence of hearing loss in immune-mediated inner ear diseases, as shown in case reports or single-center statistics, varies widely. We reviewed the current literatures on the association between sensorineural hearing loss and autoimmune diseases, focused on the prevalence of hearing loss in different autoimmune diseases, treatments and challenges.

Role of Thrombocytosis in Diagnosis of Giant Cell Arteritis and Differentiation of arteritic from Non-Arteritic Anterior Ischemic Optic Neuropathy

Purpose

To investigate the role of thrombocytosis in the diagnosis of giant cell arteritis (GCA), and differentiation of arteritic (A-AION) from non-arteritic (NA-AION) anterior ischemic optic neuropathy; and comparison of the sensitivity and specificity of platelet count to that of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and some other hematologic variables in the diagnosis of GCA.

METHODS

This retrospective study is based on 121 temporal artery biopsy confirmed GCA patients and 287 patients with NA-AION seen in our clinic. For inclusion in this study, all GCA patients, at their initial visit, prior to the initiation of corticosteroid therapy, must have had ESR (Westergren), platelet count and complete blood count, and temporal artery biopsy. From 1985 onwards CRP estimation was done. For inclusion in this study, all NA-AION patients at the initial visit must have undergone evaluation similar to that described above for GCA, except for temporal artery biopsy. Wilcoxon rank-sum test and the two-sample t-test were used to compare hematologic variables between GCA patients with and without visual loss, between those with and without systemic symptoms, and also between GCA and NA-AION patients. Pearson correlation coefficient was computed to measure the association of platelet counts and the other hematologic variables with ESR. Receiver operating characteristic (ROC) curves were constructed for ESR, CRP, platelet count, combinations of ESR and platelet count, and CRP and platelet count, hemoglobin, hematocrit, and white blood cell (WBC) count and the area under the curve (AUC) were compared.

Results

Comparison of ESR, CRP, and hematologic variables of GCA patients and of A-AION with the NA-AION group, showed significantly (p <0.0001) higher median levels of ESR, CRP, platelet count, and WBC count and lower levels of hemoglobin and hematocrit in the GCA patients and A-AION than in NA-AION. Comparing AUC of the ROC curve between ESR and platelet count, ESR was a better predictor of GCA compared to platelet count (AUC of 0.946 vs. 0.834). There was a slight improvement in prediction of GCA using the combination of ESR and platelet count (AUC=0.953). The other hematologic variables had an AUC that was smaller than platelet count (0.854 for hemoglobin; 0.841 for hematocrit), with WBC being the least predictive of GCA (AUC=0.666). The AUC of the ROC curve for CRP was 0.978. There was no improvement in prediction of GCA using platelet count in combination with CRP (AUC=0.976).

CONCLUSIONS

Patients with GCA had significantly (p <0.0001) higher values of platelet count, ESR, CRP and WBC but lower values for hemoglobin and hematocrit compared to the NA-AION group. Predictive ability of an elevated platelet count did not surpass elevated ESR or CRP as a diagnostic marker for GCA. Thrombocytosis may complement ESR. Hemoglobin, hematocrit and WBC were much less predictive of GCA. Elevated CRP had a greater predictive ability for GCA compared to ESR or the other hematologic parameters; thrombocytosis in combination with CRP did not yield an improvement in prediction of GCA.

Prognosis of giant cell arteritis including temporal arteritis and polymyalgia rheumatica. A follow-up study on ninety patients treated with corticosteroids

Ninety patients with giant cell arteritis (GCA) were followed 3-10 years after the diagnosis. The mean observation time was 63 months. Thirteen patients died. Corticosteroids were administered to all but one patient; 35 were still on treatment after a mean observation period of 59 months. In 38 patients, 94 flare-ups of the disease were recorded during corticosteroid treatment, most of them occurring during the first year of treatment and when a low dose of prednisolone had been given. Thirty-three relapses, 76% within 3 months, occurred in 28 patients after withdrawal of treatment. One patient relapsed after more than ten years of disease. Polymyalgia rheumatica was the most common symptom of flare-up or relapse, regardless of the clinical picture at the time of diagnosis. The duration of treatment should be individualized. One year of treatment is enough in a few patients, whereas others need steroid therapy for more than four years. The rate of intercurrent disease and complications of GCA or its treatment was low. No patient developed severe eye damage due to GCA. The mortality rate was in fact lower than expected with regard to age and sex.

Long-term survival in giant cell arteritis including temporal arteritis and polymyalgia rheumatica. A follow-up study of 90 patients treated with corticosteroids

Ninety patients with giant cell arteritis (GCA) were followed for 9-16 years after diagnosis. Corticosteroids were given to all but one patient. Forty-two patients died during the observation period (27 women and 15 men). The survival was compared with that in the general population and found not to be reduced among the GCA patients. In fact, we found a lower mortality than expected after five years from diagnosis (p less than 0.05). We did not see any increase in deaths due to vascular or malignant diseases in our patients.

Acute phase reactants in the initial phase of giant cell arteritis

The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen and haptoglobin were followed weekly during the initial phase of corticosteroid treatment in 18 patients with 19 episodes of giant cell arteritis (GCA). Fibrinogen and CRP decreased most rapidly, with normal values in 67% of the patients after two weeks of treatment. After two weeks 56% of the patients had normal ESR values and 76% after five weeks. Haptoglobin normalised most slowly, no patient having a normal value after one week, 29% after two weeks and 75% after six weeks. For routine clinical use, we found the ESR alone sufficient for monitoring the initial steroid treatment.

An alternate-day corticosteroid regimen in maintenance therapy of giant cell arteritis

It is well established that the side-effects of corticosteroid treatment can be reduced by administering the steroid on alternate days. Twenty-seven patients with giant cell arteritis were given daily treatment initially, followed by a gradual transition to alternate-day treatment. It was possible to maintain 18 (67%) of 27 patients on this regimen. In 9 (33%) the regimen was abandoned because of clinical symptoms on the "day off". These patient, however, could be maintained with a single morning dose of the corticosteroid. Morning plasma cortisol levels on the treatment day were normal in all patients treated with 20 mg prednisolone or less every other day.

The involvement of the peripheral nervous system in biopsy proven active giant cell arteritis

BACKGROUND

Peripheral nervous system (PNS) affection is an uncommon, sometimes life-threatening manifestation of giant cell arteritis (GCA).

OBJECTIVE

To describe characteristics of neurological abnormalities of the PNS in GCA patients.

METHODS

Eighty consecutive cases of biopsy proven GCA were studied.

RESULTS

Three patients presented with subacute sensorimotor deficits abnormalities in the distribution of the arm plexus. In all cases PNS affection was the leading clinical symptom in addition to a typical clinical syndrome of cranial arteriitis. In one case MRI demonstrated diffuse signal abnormalities surrounding the brachial nerve plexus. In another patient, who died from pulmonary embolism 10 weeks after beginning of therapy, autopsy demonstrated residual arteritis in an artery supplying the brachial nerve plexus.

CONCLUSIONS

Involvement of the PNS is more uncommon than cerebral ischemia and neuroophthalmological complications in patients suffering from GCA. Severe PNS involvement has an affinity to the midcervical nerve roots and the brachial nerve plexus.

[Giant cell arteritis (temporal arteritis). Pathophysiology, immunology]

The diagnosis of giant cell arteritis is established by temporal artery biopsy. The findings are those of a panarteritis with mononuclear infiltrates penetrating all layers of the arterial wall. Typically, activated T cells and macrophages are arranged in granulomas. Multinucleated giant cells, when present, are usually close to the fragmented internal elastic lamina. Often, the intimal layer is hyperplastic, leading to concentric occlusion of the lumen. The CD4(+) T cells are the main players in the disease process. T-cell activation in the arterial wall requires the presence of specialized antigen-presenting cells, the dendritic cells. The activation of monocytes and macrophages is responsible for the systemic inflammatory syndrome in giant cell arteritis and polymyalgia rheumatica. The blood vessel wall determines the site specificity of giant cell arteritis and provides the ground for the cell to cell interaction.

Giant Cell Arteritis and Polymyalgia Rheumatica

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common and often concurrent diseases in Western countries in individuals aged >50 years. Clinical features of GCA are mainly due to involvement of the cranial arteries. PMR is clinically characterised by pain, aching and morning stiffness involving the neck, shoulder and hip girdles. Both conditions are generally associated with elevation of erythrocyte sedimentation rate and C-reactive protein. A temporal artery biopsy is the gold standard test for the diagnosis of GCA. Some diseases may mimic PMR or present with polymyalgic symptoms. Corticosteroids are the cornerstone of the management of GCA and PMR. An initial dosage of prednisone 10-20 mg/day yields a dramatic improvement of PMR symptoms in most cases. In GCA, the initial prednisone dosage required is higher (40-60 mg/day). However, once established, visual loss, which is the most feared complication of GCA, does not usually improve following corticosteroid therapy. Some patients exhibit a chronic-relapsing course and may need low doses of corticosteroids for several years. Alternative corticosteroid-sparing therapies and some therapeutic agents aimed at restoring balanced bone cell activity in patients taking corticosteroids are potentially useful in the management of GCA and PMR.

Giant cell arteritis: laboratory tests at the time of diagnosis in a series of 240 patients

The outcome of a patient with giant cell arteritis (GCA) is closely related to the development of severe ischemic manifestations. In the current study we analyzed the implications of routine laboratory tests obtained at the time of diagnosis in the clinical spectrum of a series of 240 consecutive patients with biopsy-proven GCA at the single hospital for a defined population. We also examined whether the laboratory markers of inflammation may be predictors of severe ischemic manifestations (visual ischemic events, cerebrovascular accidents, jaw claudication, or large-artery stenosis of the extremities of recent onset), and their potential correlation. Anemia (hemoglobin <12 g/dL) was observed in 131 (54.6%) and thrombocytosis in 117 (48.8%) patients. Sixty-eight (28.3%) patients had leukocytosis. The percentage of patients showing a significant increase of alkaline phosphatase and hypoalbuminemia was similar (25% and 27.8%, respectively). The mean values of erythrocyte sedimentation rate (ESR) and C-reactive protein were 93 +/- 23 mm/h and 94 +/- 63 mg/L, respectively. A strong correlation among most laboratory markers of inflammation was observed. Anemia was more commonly observed in patients without severe ischemic manifestations (61.5% versus 48.9% in those with severe ischemic manifestation; p = 0.05) and in patients with constitutional syndrome or fever (p < 0.001). Patients with ESR greater than 100 mm/h exhibited more commonly constitutional syndrome (p < 0.001) and had a statistically significant reduction in the incidence of visual ischemic events (p < 0.025). Only 7 (22.6%) of the 31 patients who suffered permanent visual loss had an ESR at the time of disease diagnosis greater than 100 mm/h. However, in a multivariate logistic regression analysis, only anemia was found to be a negative predictor for the development of severe ischemic manifestations of GCA (odds ratio, 0.53; 95% confidence intervals, 0.30-0.94; p = 0.03). In conclusion, our results suggest that some laboratory markers of inflammation, in particular the presence of anemia, may negatively predict the risk of severe ischemic complications in GCA patients.

Vertebrobasiläre Ischämie als Komplikation der Arteriitis temporalis

BACKGROUND

Cerebral symptoms in temporal arteritis (TA) may occur if large arteries are affected. To avoid progression of the disease, the immediate administration of adequate doses of steroids is mandatory.

PURPOSE

The prevalence and severity of vertebrobasilar ischemia (VBI) and its relation to structural abnormalities of the vertebral arteries were studied.

METHODS

Clinical and ultrasound data were analyzed in a hospital-based group of 91 patients who received the diagnosis of TA following standard criteria.

RESULTS

In contrast to the occurrence of neuro-ophthalmological complications (27.5%), the rate of VBI was low (4.4%). TIA occurred in three cases and mild stroke in one. Ultrasound demonstrated severe occlusive disease of the extradural parts of the vertebrobasilar arteries consisting of hypoechogenic, concentric, mural thickening. The same was found in the superficial temporal arteries.

CONCLUSIONS

In elderly patients presenting with VBI, TA affecting the vertebral arteries should be considered. In experienced hands, ultrasonography allows the atraumatic preliminary diagnosis of TA.

Ocular manifestations and concepts of systemic vasculitides

Vasculitic disorders are relatively rare. Their etiology and pathophysiology remain enigmatic, leading to confusing nomenclature and multiple classification schemes. Untreated vasculitis can be fatal. Early diagnosis is the key to successful treatment and better prognosis. However, early diagnosis can be difficult; vasculitic conditions usually present with non-specific symptoms for a long period before clinically overt manifestations occur. Ophthalmologists should be familiar with the ocular manifestations of the vasculitic disorders because they may not only be sight-threatening, but more importantly could be the presenting manifestations of active, potentially lethal systemic disease. This review summarizes clinical and ocular manifestations of systemic vasculitic disorders. Furthermore, it discusses general concepts in diagnosis and treatment of these diseases in an effort to provide a practical framework for the ophthalmologist evaluating patients with vasculitis.

Temporal arteritis and polymyalgia rheumatica in north-eastern Spain: clinical spectrum and relationship over a 15 year period

OBJECTIVE

To examine the clinical spectrum of polymyalgia rheumatica (PMR) and temporal arteritis (TA) and their relationship over a period of 15 years in an area of north-eastern Spain.

METHODS

We undertook a descriptive study of an unselected population of 163 patients with PMR and/or TA diagnosed from 1985 to 1999.

RESULTS

Of the 163 patients included, 90 had isolated PMR, 41 had PMR associated with TA, and 32 had isolated TA. The clinical spectrum of both conditions in our area was similar to that reported in other populations, including a marked female predominance. However, in our series, no patient developed permanent blindness or other major ischemic complications. PMR was observed in 56% of patients with TA. Conversely, 7% of patients originally suffering from PMR without clinical evidence of arteritis at presentation developed later symptoms of TA, and there were no predictive features for this. Interestingly, none of these patients suffered visual loss or other ischemic complications. The low risk of major complications in these cases does not support the need for systematic arterial biopsy in all patients with symptoms of PMR alone. On comparing patients with isolated TA with patients with PMR associated with TA, no differences were observed, thus discarding the possibility that the second constitutes a distinct and independent subgroup of TA. In contrast, when comparing patients with isolated PMR with patients with PMR associated with TA, we found significant differences between both the groups, with greater abnormality of clinical and laboratory markers of inflammation in patients with PMR associated with TA. These differences seem to reflect a greater degree of systemic inflammation linked to the presence of TA.

CONCLUSION

In our area, TA appears nowadays as a benign disease which infrequently presents blindness or other major complications. Our experience confirms that even after a good clinical response with normalization of a high ESR in PMR, the patient is at risk for clinical development of TA. Finally, our study also shows that isolated TA and PMR associated with TA seem to be the same condition, different from isolated PMR.

[Risk factors for irreversible cerebral ischemia complications from Horton's disease: prospective study of 178 patients]

PURPOSE

To search for risk factors of developing irreversible cranial ischemic complications (ICIC) in patients with giant cell arteritis (GCA) and to explore whether two subsets of patients (high risk and low risk of developing ICIC) can be defined.

METHODS

One-hundred seventy-eight consecutive patients with temporal arteritis (149 biopsy-proven) were diagnosed and followed up in a department of Internal Medicine between 1976 and 1999. The patients were separated into two groups, according to the presence or absence of ICIC, with comparison of 17 clinical and biological parameters prospectively recorded for each patient using a pre-established comprehensive questionnaire.

RESULTS

ICIC occurred in 25 patients (14%), with amaurosis in 22 cases. Suggestive symptoms and/or signs of temporal arteritis were present in 92% of the patients, lasting 50 days (median) before the onset of ICIC. Forty-three patients (24%) complained of transient visual ischemic symptoms (TVIS), which preceded acute blindness in 11 cases. A multivariate logistic regression, from which 28 cases with upper limb artery involvement were excluded for technical reasons (no CCII in any case, thus predicting perfectly the lack of ischemic risk, P = 0.02), indicated that the only independent variables associated with the ischemic risk were: a history of TVIS (P = 0.05), the lack of signs of polymyalgia rheumatica (PMR; P = 0.02), lower blood levels of fibrinogen (P = 0.024) and higher mean blood platelets levels (P = 0.006). However, these five variables predicted only 30% of the variability of the model. Sensitivity, specificity, positive and negative predictive values of the model reached respectively 36, 96, 64 and 88%. Overall, 86% of the cases were correctly classified with respect to the ischemic risk.

CONCLUSION

The rate of ICIC should be reduced by an earlier recognition of the usual signs of temporal arteritis. Several independent risk factors of ICIC have been identified. However, the logistic model failed to predict accurately the ischemic risk in 14% of the cases, indicating that as yet unrecognised factors probably exist that play a role in the occurrence of ICIC. Nevertheless, regarding the strong association between platelet levels and ICIC, patients with thrombocytosis should receive initially both corticosteroids and antiplatelet agents.

Temporal arteritis and sensorineural hearing loss

OBJECTIVES

The association of temporal arteritis and sensorineural hearing loss is a rare occurrence. We present four cases with both these disorders.

METHODS

A 10-year retrospective review of all cases seen at the Geisinger Medical Center showed 271 cases of temporal arteritis and four cases with concomitant sensorineural hearing loss. The four cases were identified, obtained, and extensively reviewed. Patients ranged in age from 59 to 76 years and presented with sensorineural hearing loss and signs, symptoms, and biopsy evidence of temporal arteritis. The response to therapy and clinical course of each case are discussed.

RESULTS

In three patients, the hearing loss preceded the diagnosis of giant cell arteritis by 2 days to 2 months. In one case, the hearing loss was noted concurrently with systemic features of giant cell arteritis. All cases were treated with corticosteroids and had full or partial return of hearing.

CONCLUSIONS

Sensorineural hearing loss can be a preceding or concurrent symptom of temporal arteritis. Recognition and treatment may lead to partial or full recovery. It is not certain whether the time from onset of hearing loss to diagnosis to institution of therapy influences recovery.

Occult giant cell arteritis: ocular manifestations

PURPOSE

To report the incidence, visual symptoms, and ocular signs of occult giant cell arteritis in patients who initially presented with visual symptoms and ocular signs of giant cell arteritis. Occult giant cell arteritis was defined as ocular involvement by giant cell arteritis without any systemic symptoms and signs of giant cell arteritis.

METHODS

In a prospective study from 1973 to 1995, we investigated 85 patients who had ocular involvement caused by giant cell arteritis and whose diagnosis of giant cell arteritis was confirmed on temporal artery biopsy. At the initial visit, patients were questioned specifically on systemic and ocular symptoms and signs of giant cell arteritis at or before the onset of visual disturbance. Erythrocyte sedimentation rate (Westergren) and C-reactive protein level were evaluated before the start of systemic corticosteroid therapy.

RESULTS

Eighteen (21.2%) of 85 patients had occult giant cell arteritis. There was no significant difference in age and sex distribution between patients with and without systemic symptoms of giant cell arteritis. Although both groups of patients had abnormal erythrocyte sedimentation rate and C-reactive protein level, there was a significant difference in erythrocyte sedimentation rate (P < .0001) and C-reactive protein level (P=.0133), these being relatively lower in patients with occult giant cell arteritis. The ocular symptoms in the 18 patients with occult giant cell arteritis were visual loss of varying severity in 18 (100%), amaurosis fugax in six (33.3%), diplopia in two (11.1%), and eye pain in one (5.6%). Ocular ischemic lesions consisted of anterior ischemic optic neuropathy in 17 (94.4%), central retinal artery occlusion in two (11.1%), and cilioretinal artery occlusion in two (of 11 patients with satisfactory fluorescein angiography [18.2%]). The ocular symptoms and ischemic lesions were seen in a variety of combinations.

CONCLUSIONS

Because occult giant cell arteritis is a potential cause of blindness, its early diagnosis is the key to preventing blindness; it is important to recognize that 21.2% of patients with giant cell arteritis and visual loss do not have any systemic symptoms of giant cell arteritis. Thus, in persons older than 55 years, amaurosis fugax or visual loss, development of an acute ocular ischemic lesion (particularly arteritic anterior ischemic optic neuropathy), and abnormal C-reactive protein level, with or without elevated erythrocyte sedimentation rate and systemic symptoms, should raise a high index of suspicion for giant cell arteritis.

Current concepts in giant cell (temporal) arteritis

Giant cell (temporal) arteritis continues to be a sight-threatening, systemic vasculitis with a poorly understood pathogenesis. The characteristic granulomatous inflammation of the vessel wall commonly leads to local ischemia. Recent advances in immunological investigations have characterized the cellular components of the disease process, but the etiology has so far remained unresolved. A reappraisal of the clinical features of giant cell (temporal) arteritis demonstrates the heterogeneity of the manifestations of the disease, including ischemic optic neuropathy. A range of new laboratory investigations and blood flow studies with color Doppler imaging have demonstrated promising roles, with respect to diagnosis and long-term follow-up. Prompt diagnosis and expeditious treatment require a high index of clinical suspicion, particularly for atypical cases. Corticosteroids remain the treatment of choice, other immuno-suppressive agents being used as second line steroid-sparing agents. Giant cell (temporal) arteritis leads to increased vascular and visual morbidity and, if untreated, may prove fatal. To maintain high standards of management of this enigmatic disorder, ophthalmologists need to be aware of the clinical spectrum of giant cell (temporal) arteritis and currently available diagnostic tests and treatment strategies.

Temporal arteritis associated with acute Q fever. A case report

The authors describe the case of a sixty-four-year-old man who presented with clinical and histopathologic evidence of temporal arteritis associated with acute Q fever. This association, which has not been previously reported, supports the possible infectious etiology in temporal arteritis.

Occult subacute thyroiditis mimicking classic giant cell arteritis

We report the case of a 60-year-old man who presented with fever, weight loss, generalized aching, left temporal and ear pain, and an erythrocyte sedimentation rate of 125 mm/hour. Due to the presumed diagnosis of giant cell arteritis (GCA), the patient was treated with prednisone (60 mg daily), with immediate improvement in his symptoms. Biopsy of the temporal arteries revealed no significant inflammatory infiltrate. Further evaluation included assessments of thyroid function, which revealed an elevated T4 level, low thyroid-stimulating hormone level, and suppressed radioactive iodine uptake on thyroid scintigraphy. A diagnosis of subacute thyroiditis was made, prednisone therapy was tapered over 3 weeks, and treatment with beta blockers was instituted. The patient remained asymptomatic and returned to a euthyroid state. This case illustrates that subacute thyroiditis should be considered in the differential diagnosis of GCA.

[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.

Simultaneous onset of giant cell arteritis and subacute thyroiditis

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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.

[Death in Horton disease. Prognostic factors]

The authors reported causes of death and searched for prognosis factors in Giant Cell Arteritis (GCA). The diagnosis was confirmed by temporal biopsy in all cases. Fourteen patients died during treatment; thirty-six patients had completely recovered (follow up > 6 months after withdrawal of steroid therapy). The commonest causes of death were cardiovascular (n = 7) and digestive (n = 4); they occurred after an average of 195 days of treatment, half of them during the first three months. One death was due to GCA (autopsy) and five deaths were attributed to the treatment with corticosteroids. The prognosis factors were searched for by comparing age, sex, clinical signs, laboratory data before treatment, past medical history in the both series; further more initial dose of Prednisone and the dose after 180 days of steroid therapy were compared in the two groups. The adverse prognosis factors revealed by this study were: advanced age (p < 0.01), previous ischaemic heart disease (p < 0.05) and higher dose of corticosteroids administered at 6 months of treatment (< 0.01).

Clinical features of giant cell arteritis

The clinical features of GCA can be classified into: (1) the systemic manifestations of malaise, weight loss, fever, night sweats and depression; (2) the proximal muscle pain and stiffness of polymyalgia rheumatica; (3) arteritic manifestations of pain or tenderness due to local inflammation; and (4) arteritic manifestations of ischaemia due to narrowing or occlusion of vessels. These may occur singly or in any combination and may come and go with the passage of time. Thus GCA can result in many different clinical signs and symptoms. The feared ocular and cerebrovascular complications of the condition can be prevented by the early institution of corticosteroid treatment. Early diagnosis is therefore vital. This is a simple matter when GCA presents in the classical textbook manner, but in atypical cases diagnosis can be exceedingly difficult. The absence of a reliable way of excluding the disease means that diagnosis is often a clinical exercise. A sound knowledge of the many and varied clinical manifestations of GCA is therefore required if the physician is going to prevent the ocular and cerebrovascular complications of GCA by early diagnosis and treatment.

Laboratory investigations including liver in polymyalgia rheumatica/giant cell arteritis

The most useful investigation in supporting the clinical diagnosis of PMR/GCA is elevation of the ESR or viscosity. Acute phase proteins, particularly C-reactive protein, are also elevated but in most cases are not more helpful than the ESR in either diagnosis or follow-up. The definitive investigation is the demonstration of giant cell arteritis histologically, usually from temporal artery biopsy. The classical changes are internal elastic lamina fragmentation and destruction, with marked intimal thickening and an inflammatory infiltrate in the vessel wall with giant cells. Changes of healed arteritis can be distinguished from ageing changes and can therefore confirm the diagnosis. Positive biopsies are found in about 70% of patients with clinical GCA but are unlikely to be helpful in pure PMR. Elevation of alkaline phosphatase of liver origin is seen in one-third to half of patients with both PMR and GCA. Abnormal tracer uptake has been reported in radionuclide scans with a variety of non-specific abnormalities on liver biopsy. Promising developments include measurement of CD8+ lymphocytes and interleukins.

Liver scan abnormalities in polymyalgia rheumatica/giant cell arteritis

Liver involvement in polymyalgia rheumatica/giant cell arteritis (PMR/GCA) before treatment and during follow-up of up to 3 1/2 years was assessed in 74 patients clinically, with liver function tests, isotope scans and blood flow studies. Twenty-seven patients had elevated alkaline phosphatase levels which fell to normal after 2.6 weeks treatment. Both PMR and GCA patients were affected, the latter more commonly. Isotope scans were abnormal in 7 of 29 patients and remained abnormal on follow-up. The arterial fraction of hepatic flow was significantly reduced in GCA patients in comparison with those having PMR only; values became normal after treatment. These abnormalities may be due to hepatic arteritis.

Neurologic manifestations of giant cell arteritis

Giant cell arteritis (GCA) is a common vasculitic disease in the elderly, with a multitude of neurologic manifestations including, but not limited to, stroke and blindness. Many uncommon manifestations are often unrecognized and proper diagnosis and treatment delayed. This review focuses on the pathophysiology and neurologic symptoms of GCA, with special emphasis on the diversity of ocular involvement.

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.

Erythrocyte sedimentation rate and C reactive protein in the assessment of polymyalgia rheumatica/giant cell arteritis on presentation and during follow up

The erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) were measured in 74 patients with polymyalgia rheumatica (PMR)/giant cell arteritis (GCA) on presentation, in the first month of treatment, and at long term follow up (up to 177 weeks). Before treatment the ESR was raised (greater than 30 mm/h) in all cases and the CRP was raised (greater than 6 mg/l) in 49/55 cases. The ESR was a better indicator of clinical disease activity except in patients who felt completely well at week 1. 'False positive' increases of ESR or CRP were rare. During relapses ESR was normal in 37/77 (48%) of cases and CRP in 41/73 (56%). It is suggested that ESR is the most useful laboratory parameter in assessing PMR/GCA.

Postprandial transient painful amaurosis fugax

A case of recurrent postprandial amaurosis fugax (AF) associated with periorbital pain is described. Clinical and angiographic examination revealed moderate atherosclerosis of the cerebral vessels and narrow-angle glaucoma. Cerebral postprandial hypoperfusion combined with increased intraocular pressure probably precipitated the painful monocular blindness. The attacks of AF subsided partially after treatment of the glaucoma.

Polymyalgia rheumatica and temporal arteritis

Polymyalgia rheumatica and temporal arteritis are a clinical syndrome and clinicopathologic entity, respectively. Polymyalgia rheumatica occurs more commonly than temporal arteritis, with approximately half of all patients with temporal arteritis having the polymyalgia rheumatica syndrome. Both conditions are found in the population over 50 years of age and are associated with an elevated ESR. The etiology of both is unclear, although genetic, and potentially, environmental factors may play significant roles. Both conditions respond to corticosteroid therapy, but patients with temporal arteritis require significantly higher doses to control symptoms and to prevent blindness.

Serum C-reactive protein in polymyalgia rheumatica. A prospective serial study

A prospective serial study of 13 well-documented, previously untreated cases of polymyalgia rheumatica was undertaken in order to assess the behavior of the nonspecific indices of disease activity, erythrocyte sedimentation rate and serum C-reactive protein (CRP) concentration, during induction of disease remission by prednisolone therapy. The clinical manifestations of all patients responded rapidly and completely to steroids, and the serum CRP value, which was raised in all patients at presentation, fell to normal at a rate which precisely reflected the clinical improvement. The erythrocyte sedimentation rate also fell, but did so much more slowly than the CRP concentration and, in half the patients, was still not normal after 14 days. These results indicate that assay of serum CRP provides a precise means of objectively assessing the course of polymyalgia rheumatica during initial therapy with steroids, and suggest that routine measurements of CRP may make a useful contribution to the management of the disease.

Abnormal radionuclide liver scans in giant cell arteritis

In the investigation of six patients with giant cell arteritis and abnormal liver function radionuclide liver scans were found to be abnormal in all. The abnormality may be due to arteritis of hepatic vessels. It is important to recognise that giant cell arteritis may cause liver scan abnormalities. If other pathology is suspected and corticosteroid treatment delayed while further investigations are carried out, patients are at risk of complications such as blindness.

Acute hearing loss in giant cell arteritis

A case of giant cell arteritis presenting with acute hearing loss which was reversed by corticosteroid therapy is described

Giant cell arteritis (temporal arteritis) presenting as fever of undetermined origin

A retrospective study of the histories of 100 patients with biopsy-proven giant cell arteritis was performed. Fifteen of these patients had "fever of unknown origin" as the initial manifestation of this disease. All 15 had normal leukocyte counts; however, they had significantly lower hemoglobulin and albumin levels (P greater than 0.01) and significantly higher platelet counts, erythrocyte sedimentation rates, and alkaline phosphatase values (P congruent to 0.05) compared to the other 85 patients. In 4 patients, random temporal artery biopsies were performed despite persistently negative results from diagnostic evaluations and in the absence of any symptoms or findings suggestive of arteritis.

Relationship of the erythrocyte sedimentation rate to acute phase proteins in polymyalgia rheumatica and giant cell arteritis

We have compared the erythrocyte sedimentation rate (ESR) with other acute phase proteins (C-reactive protein (CRP), alpha(1) antitrypsin, orosomucoid, and haptoglobin) in 108 patients with polymyalgia rheumatica and/or giant cell arteritis. There was good correlation between CRP and ESR, but the ESR was also found to have the highest correlation with disease activity. The additional measurement of CRP or other acute phase proteins may be of value in a minority of cases.

The epidemiology of giant cell arteritis including temporal arteritis and polymyalgia rheumatica. Incidences of different clinical presentations and eye complications

During a period of three years in Göteborg, Sweden, 126 cases of giant cell arteritis (GCA) were diagnosed. Histologic evidence of arteritis was found on temporal artery biopsy in 74 (59%). The total annual incidence of GCA was calculated to be 9.3 per 100,000 inhabitants. In the age group over 50, incidence was 28.6 per 100,000. For histologically proven GCA, the incidence was 5.5 per 100,000 of the total population. The corresponding figure in the age group over 50 was 16.8 per 100,000. Twenty-six patients (21%) had a clinical presentation of temporal arteritis, and 23 (18%) had a combined picture of temporal arteritis and polymyalgia rheumatica (PMR). Sixty-seven (53%) had the PMR syndrome without any temporal symptoms, and 10 patients (8%) had a "silent" presentation with only general symptoms. The PMR syndrome was more common among women with GCA (79%) than among men (56%). The group of patients without muscular symptoms contained an equal number of men and women. Eye complications were seen in 15 patients (12%). In 6, the ocular symptoms were transient, while 9 suffered from permanent loss of vision. In 3 of these patients, temporal artery biopsy revealed no evidence of arteritis, and 5 had no clinical signs of localized temporal arteritis.

Immune complexes, rheumatoid factors, and cellular immunological parameters in patients with giant cell arteritis

Circulating immune complexes were found in 2 of 15 patients with giant cell arteritis (GCA) by using a solid phase Clq enzyme linked immunoabsorbent assay (ELISA). The prevalence in controls was 5%. Rheumatoid factor could be demonstrated in 2 out of 27 patients and in 11% of the controls by using a similar ELISA technique. The prevalence of T cells in blood was similar in 25 patients with GCA and in controls. The blood lymphocyte blastogenic response to the mitogens, phytohaemagglutinin, concanavalin-A, and pokeweed mitogen did not differ in 25 untreated patients compared with controls. Stimulation of lymphocytes by arterial homogenates was tested in 8 patients. In no case could a significant simulation by obtained. We conclude that immune complexes and rheumatoid factors are present in the same low frequency in GCA patients as in the normal population, and that the studied parameters of cellular immunity appear to be normal.

Hepatocellular disease in the giant-cell arteritis/polymyalgia rheumatica syndrome

An elderly man developed temporal arteritis and polymyalgia rheumatica with coexisting biochemical abnormalities of liver function. Biopsy revealed hepatic changes which have not been previously reported. There was hepatocellular necrosis and inflammation together with a prominent hyperplasia of perisinusoidal lipocytes of Ito. Temporal artery biopsy confirmed the presence of granulomatous panarteritis. Corticosteroid therapy produced rapid resolution of symptoms and reversion of liver function tests to normal.

Prognosis and management of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is considered to be a benign disease by some, while others think it is a more serious illness which required similar treatment to giant cell arteritis (GCA). The progress of 85 patients with PMR who presented to a district general hospital has been studied in an attempt to study this relationship. Thirty-eight patients had PMR alone, and 14 developed PMR and GCA within 1 month. Five patients presented with GCA and then developed PMR, and 28 patients developed symptoms of GCA after presenting with PMR (PMR leads to GCA). Arteritis and complications developed up to 9 years after the onset of PMR (mean 1 year). Twenty-two patients (26%) developed some cerebral or visual complication. Fifteen of these patients were in the PMR leads to GCA group. All 6 patients with permanent loss of vision were in this group. Seven patients developed complications while on corticosteroids. 97% of patients required corticosteroids for at least 1 year; 32% of patients still required 10 mg of prednisone or more after 1 year. PMR is not a benign disease.

Hepatitis B virus and polymyalgia rheumatica: a search for HBsAg, HBsAb, HBcAb, HBeAg, and HBeAb

Forty-three consecutive patients with polymyalgia rheumatica were studied for serological markers of actual or previous hepatitis B virus infection. Signs of active virus replication, which include HBsAg supported by the presence of HBeAg and anti-HBc in high titres, were not found in any cases. Anti-HBs, a serological sign of previous hepatitis B virus exposure, was present in 16.8%. The prevalence of anti-HBs is strongly age-dependent in the normal population, and its prevalence in polymyalgia rheumatica was not significantly different from the incidence found in other hospital patients. No significantly raised incidence was found in any subgroups, including patients without liver dysfunction. These results do not support the concept that current or previous hepatitis B virus infection plays any role in the pathogenesis of the majority of cases of polymyalgia rheumatica.

HLA antigens in patients with giant cell arteritis, compared with two control groups of different ages

The prevalence of 39 HLA antigens of series A, B and C was determined in 63 patients with Giant cell arteritis. In 44 patients the diagnosis was established by means of temporal artery biopsy and in 19 it was based on clinical criteria. The prevalence of the antigens was compared with that in two control groups of different ages. No significantly increased antigen prevalence was seen in our patients, as compared with controls. There were no differences in the prevalence of HLA antigens between groups of patients with different clinical forms of GCA. Nor was any difference in the prevalence of HLA antigens found between younger and older healthy individuals.

Thrombokinetics in giant cell arteritis, with special reference to corticosteroid therapy

Duplicate platelet survival studies were carried out on 8 patients with giant cell arteritis (GCA), once before the institution of any therapy, and the second time when they were in a completely asymptomatic phase after having received corticosteroid treatment. The time interval between the studies ranged between 5 and 14 months. In the first study the mean peripheral platelet count was 486 +/- 25 X 10(9)/l and in the second 326 +/- 25 X 10(9)/l. The difference between the means was highly significant (P less than 0.001). The mean life-span of the platelets was normal in the duplicate experiments (6.7 +/- 0.3 and 7.3 +/- 0.4 days, respectively). Platelet production rate was significantly (P less than 0.001) raised in the first experiment but became normal in response to corticosteroid therapy. It is concluded that the thrombocytosis seen in GCA is reactive to the inflammation present in this disease, and it seems reasonable to assume that the reduction in the peripheral platelet count which occurs in response to corticosteroid therapy accurately reflects the clinical improvement of the patient.