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van der Geest KSM, Sandovici M, Bley TA, Stone JR, Slart RHJA, Brouwer E. Large vessel giant cell arteritis. THE LANCET. RHEUMATOLOGY 2024; 6:e397-e408. [PMID: 38574745 DOI: 10.1016/s2665-9913(23)00300-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 04/06/2024]
Abstract
Giant cell arteritis is the principal form of systemic vasculitis affecting people over 50. Large-vessel involvement, termed large vessel giant cell arteritis, mainly affects the aorta and its branches, often occurring alongside cranial giant cell arteritis, but large vessel giant cell arteritis without cranial giant cell arteritis can also occur. Patients mostly present with constitutional symptoms, with localising large vessel giant cell arteritis symptoms present in a minority of patients only. Large vessel giant cell arteritis is usually overlooked until clinicians seek to exclude it with imaging by ultrasonography, magnetic resonance angiography (MRA), computed tomography angiography (CTA), or [18F]fluorodeoxyglucose-PET-CT. Although the role of imaging in treatment monitoring remains uncertain, imaging by MRA or CTA is crucial for identifying aortic aneurysm formation during patient follow up. In this Series paper, we define the large vessel subset of giant cell arteritis and summarise its clinical challenges. Furthermore, we identify areas for future research regarding the management of large vessel giant cell arteritis.
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Affiliation(s)
- Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Thorsten A Bley
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - James R Stone
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riemer H J A Slart
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Netherlands; Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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2
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Marvisi C, Bolek EC, Ahlman MA, Alessi H, Redmond C, Muratore F, Galli E, Ricordi C, Kaymaz-Tahra S, Ozguven S, Alibaz-Oner F, Direskeneli H, Salvarani C, Quinn KA, Grayson PC. Development of the Takayasu Arteritis Integrated Disease Activity Index. Arthritis Care Res (Hoboken) 2024; 76:531-540. [PMID: 38059340 PMCID: PMC10963148 DOI: 10.1002/acr.25275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/11/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Accurate clinical assessment of disease activity in Takayasu arteritis (TAK) can be challenging. 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) can directly measure vascular inflammation. This study details the development of a new type of disease activity index called the Takayasu's Arteritis Integrated Disease Activity Index (TAIDAI). METHODS Clinical symptoms for TAIDAI were identified from a literature review. Each symptom was paired with FDG-PET findings in corresponding arterial territories. Constitutional symptoms were paired with acute phase reactant levels. One point was given for each clinical symptom paired with supporting FDG-PET or laboratory abnormalities and summed into the TAIDAI score. A TAIDAI of ≥1 defined active disease. To assess performance of TAIDAI, face validity, content validity, and sensitivity to change were evaluated within a prospective observational cohort study of patients with TAK. RESULTS Seventeen clinical symptoms were paired with imaging or laboratory abnormalities. In a cohort of 96 patients contributing 204 study visits, TAIDAI showed excellent sensitivity (96.3%) and good specificity (79.2%) compared to physician's clinical assessment. TAIDAI significantly correlated with physician global assessment, PET Vascular Activity Score, patient global assessment, and acute phase reactant levels. In patients treated with either tumor necrosis factor inhibitors or tocilizumab, a TAIDAI of 0 was achieved in 21 (91%) of 23 patients who met a predefined definition of clinical response. CONCLUSION TAIDAI is new type of disease activity index in TAK in which clinical symptoms are integrated with specific laboratory and imaging findings. TAIDAI should be validated in future randomized controlled trials in TAK.
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Affiliation(s)
- Chiara Marvisi
- Azienda USL-IRCCS di Reggio Emilia, Italy, and University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Hugh Alessi
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Christopher Redmond
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Francesco Muratore
- Azienda USL-IRCCS di Reggio Emilia, Italy, and University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Galli
- Azienda USL-IRCCS di Reggio Emilia, Italy, and University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Salih Ozguven
- Marmara University School of Medicine, Istanbul, Turkey
| | | | | | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia, Italy, and University of Modena and Reggio Emilia, Modena, Italy
| | - Kaitlin A Quinn
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland
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Zeng Y, Liu X, Bai R, Zhou Y, Ren L. Case report: GCA like picture-preceding inaugural MOGAD presentation: A patient with a sudden-onset uniocular blindness. Medicine (Baltimore) 2023; 102:e36326. [PMID: 38065923 PMCID: PMC10713180 DOI: 10.1097/md.0000000000036326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
RATIONALE Myelin oligodendrocyte glycoprotein antibody-associated disorders (MOGAD) represents a demyelinating neurological syndrome characterized by the presence of serum IgG antibodies directed against myelin oligodendrocyte glycoprotein (MOG-IgG). Concurrently, giant cell arteritis (GCA) constitutes a systemic autoimmune vasculitis. PATIENT CONCERNS In this case, we describe an elderly female patient who presented with the sudden onset of a severe headache, unilateral blindness, and clinical manifestations resembling those of GCA. DIAGNOSIS Upon conducting a comprehensive analysis of serum antibodies, the diagnosis of MOGAD was established due to the presence of detectable serum MOG-IgG. INTERVENTIONS Subsequently, the patient was administered intravenous methylprednisolone therapy, commencing 27 days after the initial onset of symptoms. OUTCOMES It is noteworthy that patients afflicted by MOGAD typically manifest severe visual impairment, which, in many instances, exhibits significant improvement following immunotherapeutic interventions. However, this particular patient did not experience any amelioration in visual function despite glucocorticoid therapy. LESSONS This unique case illustrates that the clinical presentation resembling GCA may precede the inaugural manifestation of MOGAD. This suggests the possibility of immune-mediated arterial involvement. The significance of glucocorticoid therapy in the context of immune-related diseases warrants further scrutiny, particularly in cases where MOG-IgG screening should be promptly considered.
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Affiliation(s)
- Yixuan Zeng
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Xuan Liu
- Department of Gerontology, Shangrao People’s Hospital, Shangrao, China
| | - Runtao Bai
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Yanxia Zhou
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Lijie Ren
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, China
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Matsumoto K, Suzuki K, Yasuoka H, Hirahashi J, Yoshida H, Magi M, Noguchi-Sasaki M, Kaneko Y, Takeuchi T. Longitudinal monitoring of circulating immune cell phenotypes in anti-neutrophil cytoplasmic antibody-associated vasculitis. Autoimmun Rev 2023; 22:103271. [PMID: 36627064 DOI: 10.1016/j.autrev.2023.103271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a necrotizing multiorgan autoimmune disease that affects small- to medium-sized blood vessels. Despite the improvements in treatments, half of the patients with AAV still experience disease relapses. In this review, we focus on peripheral leukocyte properties and phenotypes in patients with AAV. In particular, we explore longitudinal changes in circulating immune cell phenotypes during the active phase of the disease and treatment. The numbers and phenotypes of leukocytes in peripheral blood were differs between AAV and healthy controls, AAV in active versus inactive phase, AAV in treatment responders versus non-responders, and AAV with and without severe infection. Therefore, biomarkers detected in peripheral blood immune cells may be useful for longitudinal monitoring of disease activity in AAV.
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Affiliation(s)
- Kotaro Matsumoto
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Katsuya Suzuki
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hidekata Yasuoka
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Rheumatology, Department of Internal Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Junichi Hirahashi
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | | | - Mayu Magi
- Chugai Pharmaceutical Co. Ltd., Kanagawa, Japan
| | | | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Memon T, Shekha TAM, Acharya P, Nishu RI, Akhter N. A Case Report of Takayasu’s Arteritis With Cerebral Infarction As Initial Presentation. Cureus 2022; 14:e30472. [PMID: 36415359 PMCID: PMC9673871 DOI: 10.7759/cureus.30472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
Takayasu’s arteritis is a chronic inflammation of the large arteries such as the aorta and its primary branches, causing progressive arterial occlusion. This leads to reduced blood flow in the limbs and organs, resulting in arm or leg claudication, diminished or absent peripheral pulses, and end-organ ischemia. Stroke is one of the common complications; however, it is rarely the initial presentation. We describe one such case of a 16-year-old female, who presented with right-sided hemiparesis and non-fluent aphasia, without any significant past history. On examination, her right arm was cold and pulseless. She was extensively investigated for the cause of her presentation. Only non-specific inflammatory markers such as erythrocyte sedimentation rate (ESR) were elevated. Imaging studies revealed left middle cerebral artery territory infarct with occlusion of common carotid arteries, bilateral bifurcation, most parts of the left internal carotid artery, and the proximal part of the right internal carotid artery. She was diagnosed with Takayasu's arteritis and was prescribed steroids, on which she gradually recovered and was discharged. In conclusion, young patients, who present with stroke, should be investigated for Takayasu’s arteritis, which leads to earlier treatment and prevention of further life-threatening end-organ damage.
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Michailidou D, Duvvuri B, Kuley R, Cuthbertson D, Grayson PC, Khalidi NA, Koening CL, Langford CA, McAlear CA, Moreland LW, Pagnoux C, Seo P, Specks U, Sreih AG, Warrington KJ, Mustelin T, Monach PA, Merkel PA, Lood C. Neutrophil activation in patients with anti-neutrophil cytoplasmic autoantibody-associated vasculitis and large-vessel vasculitis. Arthritis Res Ther 2022; 24:160. [PMID: 35768848 PMCID: PMC9241246 DOI: 10.1186/s13075-022-02849-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To assess markers of neutrophil activation such as calprotectin and N-formyl methionine (fMET) in anti-neutrophil cytoplasmic autoantibody-associated vasculitis (AAV) and large-vessel vasculitis (LVV). Methods Levels of fMET, and calprotectin, were measured in the plasma of healthy controls (n=30) and patients with AAV (granulomatosis with polyangiitis (GPA, n=123), microscopic polyangiitis (MPA, n=61)), and LVV (Takayasu’s arteritis (TAK, n=58), giant cell arteritis (GCA, n=68)), at times of remission or flare. Disease activity was assessed by physician global assessment. In vitro neutrophil activation assays were performed in the presence or absence of formyl peptide receptor 1 (FPR1) inhibitor cyclosporine H. Results Levels of calprotectin, and fMET were elevated in patients with vasculitis as compared to healthy individuals. Levels of fMET correlated with markers of systemic inflammation: C-reactive protein (r=0.82, p<0.0001), and erythrocyte sedimentation rate (r=0.235, p<0.0001). The neutrophil activation marker, calprotectin was not associated with disease activity. Circulating levels of fMET were associated with neutrophil activation (p<0.01) and were able to induce de novo neutrophil activation via FPR1-mediated signaling. Conclusion Circulating fMET appears to propagate neutrophil activation in AAV and LVV. Inhibition of fMET-mediated FPR1 signaling could be a novel therapeutic intervention for systemic vasculitides.
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Affiliation(s)
- Despina Michailidou
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA
| | - Bhargavi Duvvuri
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA
| | - Runa Kuley
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, South Florida, Tampa, FL, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Nader A Khalidi
- Division of Rheumatology, Mc Master University, Hamilton, Ontario, Canada
| | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | | | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Larry W Moreland
- Division of Rheumatology and Clinical Immunology, University of Colorado, Denver, CO, USA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Tomas Mustelin
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA
| | - Paul A Monach
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter A Merkel
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Lood
- Division of Rheumatology, Department of Medicine, University of Washington, 750 Republican Street, Seattle, WA, 98109, USA.
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El Chami S, Springer JM. Update on the Treatment of Giant Cell Arteritis and Polymyalgia Rheumatica. Rheum Dis Clin North Am 2022; 48:493-506. [PMID: 35400374 DOI: 10.1016/j.rdc.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are considered 2 diseases on the same spectrum due to their many underlying similarities. In recent years, both diseases have witnessed both diagnostic and treatment advances, which shaped the way we manage them. In this article, the authors focus on different diagnostic modalities in GCA as well as the presence of different clinical phenotypes and the role of screening for aortic involvement. The authors also discuss traditional treatments and the role of evolving steroid-sparing agents in the management of both GCA and PMR.
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Affiliation(s)
- Sarah El Chami
- The University of Kansas Health System, 4000 Cambridge Street, MS 2026, Kansas City, KS 66160, USA
| | - Jason M Springer
- Vanderbilt University Medical Center 1161 21st Avenue South, T-3113 Medical Center North Nashville, TN 37232-2681, USA.
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Intracranial Involvement in Takayasu's Arteritis. Diagnostics (Basel) 2021; 11:diagnostics11111997. [PMID: 34829344 PMCID: PMC8624213 DOI: 10.3390/diagnostics11111997] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/25/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022] Open
Abstract
Takayasu’s arteritis (TAK) is a large-vessel vasculitis that targets the aorta and its major branches. Although extracranial vascular involvement is uniformly present in this disease, the frequency of intracranial involvement in TAK has not been well studied. We retrospectively reviewed the clinical and imaging records of patients diagnosed with TAK at a single Canadian university medical centre to determine the prevalence of intracranial vascular involvement. Intracranial vascular and non-vascular findings were described, and a review of the literature was performed. Of 20 patients with TAK, 12 had vascular neuroimaging completed. Intracranial vascular lesions were identified in 4 patients (33.3% of those with imaging available, 20% of all patients). The frequency of intracranial vessel involvement in TAK may be more common than appreciated. Imaging of both the intra- and extra-cranial vessels should be considered in these young patients.
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Maz M, Chung SA, Abril A, Langford CA, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis. Arthritis Rheumatol 2021; 73:1349-1365. [PMID: 34235884 DOI: 10.1002/art.41774] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/24/2021] [Accepted: 04/13/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis (TAK) as exemplars of large vessel vasculitis. METHODS Clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for GCA and TAK (27 for GCA, 27 for TAK). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. Recommendations were developed by the Voting Panel, comprising adult and pediatric rheumatologists and patients. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 22 recommendations and 2 ungraded position statements for GCA, and 20 recommendations and 1 ungraded position statement for TAK. These recommendations and statements address clinical questions relating to the use of diagnostic testing, including imaging, treatments, and surgical interventions in GCA and TAK. Recommendations for GCA include support for the use of glucocorticoid-sparing immunosuppressive agents and the use of imaging to identify large vessel involvement. Recommendations for TAK include the use of nonglucocorticoid immunosuppressive agents with glucocorticoids as initial therapy. There were only 2 strong recommendations; the remaining recommendations were conditional due to the low quality of evidence available for most PICO questions. CONCLUSION These recommendations provide guidance regarding the evaluation and management of patients with GCA and TAK, including diagnostic strategies, use of pharmacologic agents, and surgical interventions.
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Affiliation(s)
- Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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10
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Maz M, Chung SA, Abril A, Langford CA, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis. Arthritis Care Res (Hoboken) 2021; 73:1071-1087. [PMID: 34235871 DOI: 10.1002/acr.24632] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/24/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis (TAK) as exemplars of large vessel vasculitis. METHODS Clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for GCA and TAK (27 for GCA, 27 for TAK). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. Recommendations were developed by the Voting Panel, comprising adult and pediatric rheumatologists and patients. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 22 recommendations and 2 ungraded position statements for GCA, and 20 recommendations and 1 ungraded position statement for TAK. These recommendations and statements address clinical questions relating to the use of diagnostic testing, including imaging, treatments, and surgical interventions in GCA and TAK. Recommendations for GCA include support for the use of glucocorticoid-sparing immunosuppressive agents and the use of imaging to identify large vessel involvement. Recommendations for TAK include the use of nonglucocorticoid immunosuppressive agents with glucocorticoids as initial therapy. There were only 2 strong recommendations; the remaining recommendations were conditional due to the low quality of evidence available for most PICO questions. CONCLUSION These recommendations provide guidance regarding the evaluation and management of patients with GCA and TAK, including diagnostic strategies, use of pharmacologic agents, and surgical interventions.
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Affiliation(s)
- Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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11
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Dashora HR, Rosenblum JS, Quinn KA, Alessi H, Novakovich E, Saboury B, Ahlman MA, Grayson P. Comparing Semi-quantitative and Qualitative Methods of Vascular FDG-PET Activity Measurement in Large-Vessel Vasculitis. J Nucl Med 2021; 63:280-286. [PMID: 34088771 DOI: 10.2967/jnumed.121.262326] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/05/2021] [Indexed: 11/16/2022] Open
Abstract
The study rationale was to assess the performance of qualitative and semi-quantitative scoring methods for 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) assessment in large-vessel vasculitis (LVV). Methods: Patients with giant cell arteritis (GCA) or Takayasu's arteritis (TAK) underwent clinical and imaging assessment, blinded to each other, within a prospective observational cohort. FDG-PET-CT scans were interpreted for active vasculitis by central reader assessment. Arterial FDG uptake was scored by qualitative visual assessment using the PET vascular activity score (PETVAS) and by semi-quantitative assessment using standardized uptake values (SUV) and target-to-background ratios (TBR) relative to liver/blood activity. Performance of each scoring method was assessed by intra-rater reliability using the intra-class coefficient (ICC) and area under receiver-operator characteristic curves (AUC), using physician assessment of clinical disease activity and reader interpretation of vascular PET activity as independent reference standards. Wilcoxon signed-rank test was used to analyze change in arterial FDG uptake over time. Results: Ninety-five patients (GCA=52; TAK=43) contributed 212 FDG-PET studies. The ICC for semi-quantitative evaluation [0.99 (range 0.98-1.00)] was greater than the ICC for qualitative evaluation [0.82 (range 0.56-0.93)]. PETVAS and TBR metrics were more strongly associated with reader interpretation of PET activity than SUV metrics. All assessment methods were significantly associated with physician assessment of clinical disease activity, but the semi-quantitative metric TBRLiver¬ achieved the highest AUC (0.66). Significant but weak correlations with C-reactive protein were observed for SUV metrics (r = 0.19, p<0.01) and TBRLiver (r = 0.20, p<0.01) but not for PETVAS. In response to increased treatment in 56 patients, arterial FDG uptake was significantly reduced when measured by semi-quantitative (TBRLiver 1.31 to 1.23, 6.1% ∆, p<0.0001) or qualitative (PETVAS 22 to 18, p<0.0001) methods. Semi-quantitative metrics provided complementary information to qualitative evaluation in cases of severe vascular inflammation. Conclusion: Both qualitative and semi-quantitative methods to measure arterial FDG uptake are useful to assess and monitor vascular inflammation in LVV. Compared to qualitative metrics, semi-quantitative methods have superior reliability and better discriminate treatment response in cases of severe inflammation.
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Affiliation(s)
- Himanshu R Dashora
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, United States
| | - Joel S Rosenblum
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, United States
| | - Kaitlin A Quinn
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, United States
| | - Hugh Alessi
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, United States
| | - Elaine Novakovich
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, United States
| | - Babak Saboury
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health
| | - Mark A Ahlman
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health
| | - Peter Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, United States
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Dua AB, Husainat NM, Kalot MA, Byram K, Springer JM, James KE, Chang Lin Y, Turgunbaev M, Villa-Forte A, Abril A, Langford C, Maz M, Chung SA, Mustafa RA. Giant Cell Arteritis: A Systematic Review and Meta-Analysis of Test Accuracy and Benefits and Harms of Common Treatments. ACR Open Rheumatol 2021; 3:429-441. [PMID: 33811481 PMCID: PMC8280815 DOI: 10.1002/acr2.11226] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/25/2020] [Indexed: 01/31/2023] Open
Abstract
This systematic review compares treatment options for patients with giant cell arteritis (GCA) and evaluates the test accuracy of studies used in diagnosing and monitoring GCA. These studies were used to inform evidence-based recommendations for the American College of Rheumatology (ACR)/Vasculitis Foundation (VF) vasculitis management guidelines. A systematic review and search of articles in English in Ovid Medline, PubMed, Embase, and the Cochrane Library was conducted. Articles were screened for suitability, and studies presenting the highest level of evidence were given preference. Three hundred ninety-nine full-text articles addressing GCA questions were reviewed to inform 27 Population, Intervention, Comparison, and Outcome questions. No benefit was found with intravenous glucocorticoids (GCs) compared with high-dose oral GCs in patients with cranial ischemic symptoms (27.4% vs 12.3%; odds ratio [OR] 2.39 [95% confidence interval (CI) 0.75-7.62], [very low certainty of evidence]). Weekly tocilizumab with a 26-week GC taper was superior to a 52-week GC taper in patients achieving remission (risk ratio 4.00 [95% CI 1.97-8.12], [low certainty of evidence]). Non-GC immunosuppressive therapies with GCs compared with GCs alone showed no statistically significant in relapse at 1 year (OR 0.87 [95% CI 0.73-1.04], [moderate certainty of evidence]) or serious adverse events (OR 0.81 [95% CI 0.54-1.20]; [moderate certainty of evidence]). Temporal artery biopsy has a sensitivity of 61% (95% CI 38%-79%) and a specificity of 98% (95% CI 95%-99%) in patients with a clinical diagnosis of suspected GCA. This comprehensive systematic review synthesizes and evaluates the benefits and harms of different treatment options and the accuracy of commonly used tests for the diagnosis and monitoring of GCA.
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Affiliation(s)
- Anisha B Dua
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Kevin Byram
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | | | | | | | | | - Mehrdad Maz
- University of Kansas Medical Center, Kansas City
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El Chami S, Springer JM. Update on the Treatment of Giant Cell Arteritis and Polymyalgia Rheumatica. Med Clin North Am 2021; 105:311-324. [PMID: 33589105 DOI: 10.1016/j.mcna.2020.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are considered 2 diseases on the same spectrum due to their many underlying similarities. In recent years, both diseases have witnessed both diagnostic and treatment advances, which shaped the way we manage them. In this article, the authors focus on different diagnostic modalities in GCA as well as the presence of different clinical phenotypes and the role of screening for aortic involvement. The authors also discuss traditional treatments and the role of evolving steroid-sparing agents in the management of both GCA and PMR.
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Affiliation(s)
- Sarah El Chami
- The University of Kansas Health System, 4000 Cambridge Street, MS 2026, Kansas City, KS 66160, USA
| | - Jason M Springer
- Vanderbilt University Medical Center 1161 21st Avenue South, T-3113 Medical Center North Nashville, TN 37232-2681, USA.
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Kaymaz-Tahra S, Alibaz-Oner F, Direskeneli H. Assessment of damage in Takayasu's arteritis. Semin Arthritis Rheum 2020; 50:586-591. [PMID: 32470706 DOI: 10.1016/j.semarthrit.2020.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 03/11/2020] [Accepted: 04/13/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To assess the progression and the factors associated with damage in Takayasu's arteritis (TAK) patients during routine follow-up. METHODS Patients diagnosed with TAK and had >6 months follow-up were enrolled in this study retrospectively. Takayasu's arteritis damage score (TADS) and vasculitis damage index (VDI) were determined at diagnosis and at the end of the follow-up and variables associated with damage scores were assessed. RESULTS One-hundred fourteen patients (F/M: 101/13) were included in the study. The mean age at diagnosis, median symptom duration at baseline visit and mean follow-up duration were 35.3±13.3 years, 12 (0-360) months and 76.9±51.4 months, respectively. Median VDI score was 4.0 (1-8) and median TADS score was 7.0 (1-15) at baseline assessment. At the end of the follow-up, median VDI score increased to 5.0 (1-17) and TADS score to 8.0 (1-19). The median number of disease-related items were higher in TADS (8 items vs 4 items). At least one new corticosteroid (CS)-related damage item occurred in 35 patients (31%). Age at symptom-onset and cumulative CS doses were predictor factors for higher VDI score (≥5), whereas age at symptom-onset and disease duration were associated with increase in TADS (≥8). Gender and number of relapses were not associated with damage scores. CONCLUSION Damage assessment with VDI seems to capture treatment-related damage better, whereas TADS provides some additional information on disease-related damage in Takayasu's arteritis. Older age at symptom onset, disease duration and cumulative CS dose were associated with higher damage scores. The relapse frequency did not influence the damage level in our routine-follow-up of TAK patients.
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Affiliation(s)
- Sema Kaymaz-Tahra
- Division of Rheumatology, Department of Internal Medicine, Marmara University, Turkey.
| | - Fatma Alibaz-Oner
- Division of Rheumatology, Department of Internal Medicine, Marmara University, Turkey
| | - Haner Direskeneli
- Division of Rheumatology, Department of Internal Medicine, Marmara University, Turkey
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Abstract
Isolated noninfectious ascending aortitis (I-NIAA) is increasingly diagnosed at histopathologic review after resection of an ascending aortic aneurysm. PubMed was searched using the term aortitis; publications addressing the issue were reviewed, and reference lists of selected articles were also reviewed. Eleven major studies investigated the causes of an ascending aortic aneurysm or dissection requiring surgical repair: the prevalence of noninfectious aortitis ranged from 2% to 12%. Among 4 studies of lesions limited to the ascending aorta, 47% to 81% of cases with noninfectious aortitis were I-NIAA, more frequent than Takayasu arteritis or giant cell arteritis. Because of its subclinical nature and the lack of "syndromal signs" as in Takayasu arteritis or giant cell arteritis, I-NIAA is difficult to diagnose before complications occur, such as an aortic aneurysm or dissection. Therefore, surgical specimens of dissected aortic tissue should always be submitted for pathologic review. Diagnostic certainty requires the combination of a standardized histopathologic and clinical investigation. This review summarizes the current knowledge on I-NIAA, followed by a suggested approach to diagnosis, management, and follow-up. An illustrative case of an uncommon presentation is also presented. More follow-up studies on I-NIAA are needed, and diagnosis and follow-up of I-NIAA may benefit from the development of diagnostic biomarkers.
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Marinelli KC, Ahlman MA, Quinn KA, Malayeri AA, Evers R, Grayson PC. Stenosis and Pseudostenosis of the Upper Extremity Arteries in Large-Vessel Vasculitis. ACR Open Rheumatol 2019; 1:156-163. [PMID: 31750423 PMCID: PMC6858046 DOI: 10.1002/acr2.1018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective Pseudostenosis is a magnetic resonance angiography (MRA) artifact that mimics arterial stenosis. The study objective was to compare imaging and clinical aspects of stenosis and pseudostenosis in a cohort of large‐vessel vasculitis (LVV), including giant‐cell arteritis (GCA) and Takayasu's arteritis (TAK). Methods Patients with LVV and comparator conditions (healthy or vasculopathies) underwent MRA of the aortic arch vessels. The subclavian and axillary arteries were systematically assessed for presence of stenosis and pseudostenosis by two independent readers. Serial and delayed imaging and clinical assessments were used to confirm suspected pseudostenoses. Multivariable regression analyses were used to identify associations between angiographic pathology and clinical findings. Results One hundred eighty‐four MRA scans were analyzed from patients with GCA (n = 36), TAK (n = 47), and comparators (n = 25). Pseudostenoses were frequently observed (48 of 184 scans, 26%) in the distal subclavian artery only on the side of injection and were shorter in length compared with true stenoses (25 mm vs 78 mm, P < 0.01). There was no difference in prevalence of pseudostenosis by diagnosis (GCA = 33%, TAK = 23%, comparator = 20%, P = 0.44), disease activity status (P = 0.31), or treatment status (P = 1.00). Percent and length of true stenosis were independently associated with pulse and blood pressure abnormalities in the upper extremity. Adjusting for length and stenosis degree, absence of collateral arteries was associated with arm claudication (odds ratio = 2.37, P = 0.03). Conclusion Although a pseudostenosis could be falsely interpreted as an arterial stenosis, radiographic and associated clinical features can help distinguish true disease from arterial susceptibility artifacts. In addition, the peripheral vascular examination can help to confirm a suspected true stenosis, as specific aspects of angiographic pathology are associated with vascular examination abnormalities in LVV.
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Affiliation(s)
- Kathleen C Marinelli
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Mark A Ahlman
- National Institutes of Health, Clinical Center, Radiology and Imaging Sciences, Bethesda, MD, USA
| | - Kaitlin A Quinn
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
| | - Ashkan A Malayeri
- National Institutes of Health, Clinical Center, Radiology and Imaging Sciences, Bethesda, MD, USA
| | - Robert Evers
- National Institutes of Health, Clinical Center, Radiology and Imaging Sciences, Bethesda, MD, USA
| | - Peter C Grayson
- Systemic Autoimmunity Branch, National Institutes of Health, NIAMS, Bethesda, MD, USA
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Advantages in diagnosis of giant cell arteritis by ultrasound. Postepy Dermatol Alergol 2019; 36:25-28. [PMID: 30858775 PMCID: PMC6409876 DOI: 10.5114/ada.2019.82823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/13/2017] [Indexed: 12/30/2022] Open
Abstract
Giant cell arteritis is the most common systemic vasculitis. It selectively affects large- and medium-sized arteries. Arterial wall inflammation leads to luminal occlusion and tissue ischemia, which cause the clinical manifestations of this vasculitis. Susceptible sites include the vascular bed of the cranial nerves and scalp including the temporal arteries, optic nerve, masseter muscles, and the posterior circulation of the central nervous system. Involvement can extend to the aorta and its primary and secondary branches, including the subclavian and axillary arteries, which leads to upper-extremity ischemia. The article presents a review of epidemiology, clinical presentation and especially ultrasound diagnostics of giant cell arteritis.
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The Role of Vascular Imaging to Advance Clinical Care and Research in Large-Vessel Vasculitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019; 5:20-35. [PMID: 31598465 DOI: 10.1007/s40674-019-00114-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose of the Review The two main forms of large-vessel vasculitis (LVV) are giant cell arteritis (GCA) and Takayasu's arteritis (TAK). Vascular imaging can characterize disease activity and disease extent in LVV. This review critically analyzes the clinical utility of vascular imaging in LVV and highlights how imaging may be incorporated into the management and study of these conditions. Recent Findings There are multiple imaging modalities available to assess LVV including ultrasonography, CT angiography (CTA), magnetic resonance angiography (MRA), and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET). As these techniques are refined, imaging may be increasingly useful to evaluate the cranial arteries and the aorta and its primary branches. In addition, vascular imaging may be useful to monitor disease activity and may have prognostic value to predict future clinical events. Summary There are strengths and weaknesses associated with vascular imaging that should be considered when evaluating patients with LVV. Vascular imaging will likely play an increasingly important role in the clinical management of patients and the conduct of research in LVV and may ultimately be incorporated as outcome measures in clinical trials in these conditions.
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Affiliation(s)
- Maria Josefina Sanchez
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Medical Center, Children's Health, Dallas, TX, USA
| | - Benjamin C Lee
- 1 University of Texas Southwestern Medical Center, Dallas, TX, USA.,2 Children's Medical Center, Children's Health, Dallas, TX, USA
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20
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Kermani TA, Diab S, Sreih AG, Cuthbertson D, Borchin R, Carette S, Forbess L, Koening CL, McAlear CA, Monach PA, Moreland L, Pagnoux C, Seo P, Spiera RF, Warrington KJ, Ytterberg SR, Langford CA, Merkel PA, Khalidi NA. Arterial lesions in giant cell arteritis: A longitudinal study. Semin Arthritis Rheum 2018; 48:707-713. [PMID: 29880442 DOI: 10.1016/j.semarthrit.2018.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/25/2018] [Accepted: 05/07/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate large-vessel (LV) abnormalities on serial imaging in patients with giant cell arteritis (GCA) and discern predictors of new lesions. METHODS Clinical and imaging data from patients with GCA (including subjects diagnosed by LV imaging) enrolled in a prospective, multicenter, longitudinal study and/or a randomized clinical trial were included. New arterial lesions were defined as a lesion in a previously unaffected artery. RESULTS The study included 187 patients with GCA, 146 (78%) female, mean (±SD) age at diagnosis 68.5 ± 8.5 years; 39% diagnosed by LV imaging. At least one arterial lesion was present in 123 (66%) on the first study. The most frequently affected arteries were subclavian (42%), axillary (32%), and thoracic aorta (20%). In 106 patients (57%) with serial imaging, new arterial lesions were noted in 41 patients (39%), all of whom had a baseline abnormality, over a mean (±SD) follow-up of 4.39 (2.22) years. New abnormalities were observed in 33% patients by year 2; clinical features of active disease were present at only 50% of these cases. There were no differences in age, sex, temporal artery biopsy positivity, or disease activity in patients with or without new lesions. CONCLUSIONS In this cohort of patients with GCA, LV abnormalities on first imaging were common. Development of new arterial lesions occurred in patients with arterial abnormalities at first imaging, often in the absence of symptoms of active disease. Arterial imaging should be considered in all patients with GCA at diagnosis and serial imaging at least in patients with baseline abnormalities.
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Affiliation(s)
- Tanaz A Kermani
- Division of Rheumatology, University of California Los Angeles, 2020 Santa Monica Boulevard, Suite 540 Santa Monica, CA 90404.
| | - Sehriban Diab
- Division of Rheumatology, St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
| | - Antoine G Sreih
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA
| | - David Cuthbertson
- Department of Biostatistics and Informatics, Department of Pediatrics, University of South Florida, Tampa, FL
| | - Renée Borchin
- Department of Biostatistics and Informatics, Department of Pediatrics, University of South Florida, Tampa, FL
| | - Simon Carette
- Division of Rheumatology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Lindsy Forbess
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Curry L Koening
- Division of Rheumatology, University of Utah, Salt Lake City, UT
| | - Carol A McAlear
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA
| | - Paul A Monach
- Section of Rheumatology, Boston University School of Medicine, Boston, MA
| | - Larry Moreland
- Division of Rheumatology, University of Pittsburgh, Pittsburgh, PA
| | | | - Philip Seo
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD
| | - Robert F Spiera
- Division of Rheumatology, Hospital for Special Surgery, New York, NY
| | | | - Steven R Ytterberg
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Lerner College of Medicine, Cleveland, OH
| | - Peter A Merkel
- Division of Rheumatology and the Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Nader A Khalidi
- Division of Rheumatology, St. Joseph's Healthcare, McMaster University, Hamilton, ON, Canada
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Kermani TA, Warrington KJ. Prognosis and monitoring of giant cell arteritis and associated complications. Expert Rev Clin Immunol 2018; 14:379-388. [DOI: 10.1080/1744666x.2018.1467758] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Tanaz A. Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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22
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Kermani TA. Takayasu arteritis and giant cell arteritis: are they a spectrum of the same disease? Int J Rheum Dis 2018; 22 Suppl 1:41-48. [PMID: 29624864 DOI: 10.1111/1756-185x.13288] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Giant cell arteritis (GCA) and Takayasu arteritis (TAK) are forms of large-vessel vasculitides that affect the aorta and its branches. There is ongoing debate about whether they are within a spectrum of the same disease or different diseases. Shared commonalities include clinical features, evidence of systemic inflammation, granulomatous inflammation on biopsy, role of T-helper (Th)-1 and Th17 in the pathogenesis, and, abnormalities of the aorta and its branches on imaging. However, there are also several differences in the geographic distribution, genetics, inflammatory cells and responses to treatment. This review highlights the similarities and differences in the epidemiology, pathogenesis, clinical manifestations, imaging findings and treatment responses in these conditions. Current data supports that they are two distinct conditions despite the numerous similarities.
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Affiliation(s)
- Tanaz A Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent updates and distill practical points from the literature which can be applied to the care of patients with suspected and confirmed giant cell arteritis (GCA). RECENT FINDINGS Contemporary thinking implicates a fundamental failure of T regulatory cell function in GCA pathophysiology, representing opportunity for novel therapeutic avenues. Tocilizumab has become the first Food and Drug Administration-approved treatment for GCA following demonstration of efficacy and safety in a phase 3 clinical trial. There have been significant parallel advances in both our understanding of GCA pathophysiology and treatment. Tocilizumab, and other agents currently under investigation in phase 2 and 3 clinical trials, presents a new horizon of hope for both disease remission and avoidance of glucocorticoid-related complications.
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Affiliation(s)
- Swati Pradeep
- Department of Neurology, University of Kentucky, 740 S. Limestone, L445, Lexington, KY, 40536, USA
| | - Jonathan H Smith
- Department of Neurology, University of Kentucky, 740 S. Limestone, L445, Lexington, KY, 40536, USA.
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24
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Gomez L, Chaumet-Riffaud P, Noel N, Lambotte O, Goujard C, Durand E, Besson FL. Effect of CRP value on 18F-FDG PET vascular positivity in Takayasu arteritis: a systematic review and per-patient based meta-analysis. Eur J Nucl Med Mol Imaging 2017; 45:575-581. [PMID: 28856429 DOI: 10.1007/s00259-017-3798-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/03/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to quantify the association between the CRP value and 18F-FDG PET vascular positivity in Takayasu arteritis (TAK) through a structured dedicated systematic review and meta-analysis. METHODS From January 2000 to December 2016, the PubMed/MEDLINE database was searched for articles specifically dealing with the assessment of vascular inflammation using 18F-FDG PET and CRP biomarkers in TAK. Inclusion criteria for the qualitative analysis were (1) 18F-FDG PET used to assess the disease activity, (2) The use of the ACR criteria for the diagnosis of TAK, (3) No case mixed vasculitis (i.e., no giant cell arteritis), and (4) CRP concentration and clinical disease activity available. For the meta-analysis, PET-positive and PET-negative subgroups with the corresponding CRP concentrations were generated based on per patient data. The standard mean difference, which represents the effect of the CRP concentrations on the 18F-FDG PET vascular uptake, was computed for all studies, and then the results were pooled together. RESULTS Among the 33 initial citations, nine complete articles including 210 patients fulfilled the inclusion criteria. Five studies found a significant correlation between the 18F-FDG PET and CRP concentration, one provided a trend towards association and three did not find any association between the two biomarkers. Six studies found a significant association between 18F-FDG PET and clinical disease activity, one found a trend towards association and the last two studies did not evaluate this correlation. The meta-analysis (121 patients) provided the following results: Standard Mean Deviation = 0.54 [0.15;0.92]; Chi2 = 3.35; I2 = 0%; Test for overall effect: Z = 2.70 (P = 0.007). CONCLUSION The CRP concentration only moderately reflects the 18F-FDG PET vascular positivity in TAK, suggesting dissociated information. Standardized longitudinal prospective studies are necessary to assess the value of 18F-FDG PET as an independent biomarker for subtle vascular wall inflammation detection.
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Affiliation(s)
- Léa Gomez
- Department of Biophysics and Nuclear Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, 94275, Le Kremlin-Bicêtre, France
| | - Philippe Chaumet-Riffaud
- Department of Biophysics and Nuclear Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, 94275, Le Kremlin-Bicêtre, France
| | - Nicolas Noel
- Department of Internal Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, 94275, Le Kremlin-Bicêtre, France
- Université Paris Sud, Le Kremlin Bicêtre, France
- INSERM UMR 1184, Immunologie des Maladies Virales et Autoimmunes (IMVA), Université Paris Sud, Le Kremlin Bicêtre, France
- CEA, DSV/iMETI, Division of Immuno-Virology IDMIT, Paris, France
| | - Olivier Lambotte
- Department of Internal Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, 94275, Le Kremlin-Bicêtre, France
- Université Paris Sud, Le Kremlin Bicêtre, France
- INSERM UMR 1184, Immunologie des Maladies Virales et Autoimmunes (IMVA), Université Paris Sud, Le Kremlin Bicêtre, France
- CEA, DSV/iMETI, Division of Immuno-Virology IDMIT, Paris, France
| | - Cécile Goujard
- Department of Internal Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, 94275, Le Kremlin-Bicêtre, France
- Université Paris Sud, Le Kremlin Bicêtre, France
- CEA, DSV/iMETI, Division of Immuno-Virology IDMIT, Paris, France
- INSERM U1018, CESP, Le Kremlin Bicêtre, France
| | - Emmanuel Durand
- Department of Biophysics and Nuclear Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, 94275, Le Kremlin-Bicêtre, France
- Université Paris Sud, Le Kremlin Bicêtre, France
- IR4M - UMR8081, Université Paris Sud, Université Paris Saclay, CNRS, 91404, Orsay, France
| | - Florent L Besson
- Department of Biophysics and Nuclear Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, 94275, Le Kremlin-Bicêtre, France.
- Université Paris Sud, Le Kremlin Bicêtre, France.
- IR4M - UMR8081, Université Paris Sud, Université Paris Saclay, CNRS, 91404, Orsay, France.
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Kvickström P, Lindblom B, Bergström G, Zetterberg M. Amaurosis fugax: risk factors and prevalence of significant carotid stenosis. Clin Ophthalmol 2016; 10:2165-2170. [PMID: 27826182 PMCID: PMC5096748 DOI: 10.2147/opth.s115656] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this study was to describe clinical characteristics and prevalence of carotid stenosis in patients with amaurosis fugax (AF). Method Patients diagnosed with AF and subjected to carotid ultrasound in 2004–2010 in Sahlgrenska University Hospital, Gothenburg (n=302), were included, and data were retrospectively collected from medical records. Results The prevalence of significant carotid stenosis was 18.9%, and 14.2% of the subjects were subjected to carotid endarterectomy. Significant associations with risk of having ≥70% stenosis were male sex (adjusted odds ratio [aOR]: 2.62; 95% confidence interval [CI]: 1.26–5.46), current smoking (aOR: 6.26; 95% CI: 2.62–14.93), diabetes (aOR: 3.68; 95% CI: 1.37–9.90) and previous vasculitis (aOR: 10.78; 95% CI: 1.36–85.5). A majority of the patients (81.4%) was seen by an ophthalmologist prior to the first ultrasound. Only 1.7% of the patients exhibited retinal artery emboli at examination. Conclusion The prevalence of carotid stenosis among patients with AF is higher than has previously been demonstrated in stroke patients. An association with previously reported vascular risk factors and with vasculitis is seen in this patient group. Ocular findings are scarce.
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Affiliation(s)
| | - Bertil Lindblom
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at University of Gothenburg; Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Madeleine Zetterberg
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal
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26
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Abstract
Giant cell arteritis (GCA) is the most common vasculitis of the elderly. The diagnosis can be challenging at times because of the limitation of the American Rheumatology Association (ARA) classification criteria and the significant proportion of biopsy-negative patients with GCA. We discuss the role of advanced imaging techniques, including positron emission tomography (PET) scanning, in establishing diagnosis and improved histopathology techniques to improve the sensitivity of temporal artery biopsy. There have been significant advances in the understanding of the pathogenesis of GCA, particularly the role of cytokine pathways such as the interleukins, IL-6-IL-17 axis, and the IL-12-interferon-γ axis and their implication for new therapies. We highlight that glucocorticoids remain the primary treatment for GCA, but recognize the risk of steroid-induced side effects. A number of pharmacotherapies to enable glucocorticoid dose reduction and prevent relapse have been studied. Early diagnosis and fast-track pathways have improved outcomes by encouraging adherence to evidence-based practice.
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Affiliation(s)
- Jem Ninan
- Rheumatology Unit, Modbury Hospital, Modbury, South Australia, Australia
| | - Susan Lester
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia; Department of Medicine, University of Adelaide, Adelaide, Australia
| | - Catherine Hill
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia; Department of Medicine, University of Adelaide, Adelaide, Australia; Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia.
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27
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Abstract
The prevalence of headache decreases in elderly age groups; however, headache remains a significant issue with unique diagnostic and therapeutic considerations in this population. While primary headache disorders such as migraine and tension-type headache still occur in the majority of cases, secondary headaches are more common with advancing age. Additionally, several rare primary headache disorders, such as hypnic headache and primary cough headache, occur more frequently in an elderly population and have distinct treatments. In this review, we provide an updated overview of the common, concerning, and unique headache disorders affecting the elderly.
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Affiliation(s)
- Thomas P Bravo
- Department of Neurology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA,
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Spira D, Xenitidis T, Henes J, Horger M. MRI parametric monitoring of biological therapies in primary large vessel vasculitides: a pilot study. Br J Radiol 2015; 89:20150892. [PMID: 26649990 DOI: 10.1259/bjr.20150892] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To evaluate the development of characteristic MRI changes in patients with primary large-vessel vasculitis (LVV) when treated with biological therapies. METHODS 12 patients with primary LVV (8 patients with Takayasu arteritis and 4 patients with giant-cell arteritis) received biological therapy with tumour necrosis factor-α blockers (n = 9) or an interleukin-6 inhibitor (n = 3). MRI investigations were performed at baseline (pre-treatment) and follow-up. All patients underwent the same MRI/MR angiography (MRA) protocol. Laboratory parameters (C-reactive protein and erythrocyte sedimentation rate) and clinical response (Birmingham Vasculitis Activity Score) were assessed. RESULTS Wall thickness was 4.2 ± 0.3 mm pre-treatment and significantly decreased to 3.2 ± 0.3 mm post treatment in 9/12 patients. Mural enhancement was increased in all 12/12 patients with LVV, and subsided with therapy in 5/12 patients. Mural oedema or ill-defined contour were less prevalent but also improved with biological treatment. C-reactive protein and erythrocyte sedimentation rate levels decreased, and clinical assessment revealed a significant improvement from pre-treatment to post-treatment. However, the course of imaging characteristics often did not parallel that of laboratory or clinical parameters. In all three patients receiving interleukin-6 blockade, laboratory markers and clinical scores normalized despite persistent vascular inflammation in one patient which was disclosed by MRI. CONCLUSION Contrast-enhanced MRI/MRA may be useful when evaluating the development of disease activity in primary LVV under biological therapies. A high degree of suspicion and regular imaging follow-up is needed to detect persistent inflammation. ADVANCES IN KNOWLEDGE This is the first study investigating the applicability of different MRI/MRA parameters for monitoring biological therapy in patients with primary LVV.
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Affiliation(s)
- Daniel Spira
- 1 Department of Diagnostic and Interventional Radiology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Theodoros Xenitidis
- 2 Department of Internal Medicine II, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Jörg Henes
- 2 Department of Internal Medicine II, Eberhard-Karls-University Tübingen, Tübingen, Germany
| | - Marius Horger
- 3 Department of Diagnostic and Interventional Radiology, Eberhard-Karls-University Tübingen, Tübingen, Germany
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Misra DP, Misra R. Assessment of disease activity in Takayasu's arteritis. INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Nakagomi D, Jayne D. Outcome assessment in Takayasu arteritis. Rheumatology (Oxford) 2015; 55:1159-71. [PMID: 26472566 DOI: 10.1093/rheumatology/kev366] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Indexed: 01/24/2023] Open
Abstract
Takayasu arteritis (TAK) is a systemic granulomatous large-vessel vasculitis with a phenotype that overlaps with GCA and defined by the 1993 and 2012 Chapel Hill Consensus Conference statements. However, the diagnosis of TAK is often delayed since TAK patients may be asymptomatic or have non-specific symptoms. Once a diagnosis is made, it is difficult to judge remission or recurrence since there are no reliable assessment tools. With the availability of newer agents, such as cytokine blockade, which are being evaluated in GCA, there is the potential for real advances in TAK patient management. Without reliable assessment tools it will be difficult to introduce newer agents in an organized way or to optimally benefit patients in the future. In this article we review the use and performance of disease indicators in TAK clinical trials as a basis for the further development of assessment tools for this disease.
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Affiliation(s)
- Daiki Nakagomi
- Lupus and Vasculitis Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - David Jayne
- Lupus and Vasculitis Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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Abstract
PURPOSE OF REVIEW Takayasu's arteritis (TAK) is a large-vessel vasculitis with a chronic, indolent course affecting the aorta and its main branches. This review will describe the recent studies to develop validated outcome measures to assess TAK. RECENT FINDINGS TAK is traditionally assessed with a physician's global assessment including symptoms and signs of inflammation and vascular insufficiency, acute-phase reactants (APRs), and imaging including conventional digital subtraction angiography, computerized tomographic, and magnetic resonance angiography, and recently 18-FDG-PET. Recent attempts to develop a validated tool for disease assessment include the Indian Takayasu Clinical Activity Score (ITAS2010), which incorporates clinical signs and symptoms with APRs in a simplified and weighted adoption of the Birmingham Vasculitis Activity Score. Among biomarkers to assess clinical activity, pentraxin-3 is perhaps the most promising, but its validity and superiority against APRs in clinical practice need to be demonstrated. Patient-reported outcomes (PROs) are increasingly recognized as of substantial importance to measure in clinical trials; in addition to so-called 'generic' tools such as the SF-36 or measures of fatigue, disease-specific instruments would likely help capture aspects of TAK not measured by generic quality-of-life assessments or physician-based tools. SUMMARY Although outcome measures for TAK are not sufficiently validated, progress in the assessment of TAK is reflected in recent studies with new tools such as ITAS2010, new biomarkers, and a variety of PROs.
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Espígol-Frigolé G, Prieto-González S, Alba MA, Tavera-Bahillo I, García-Martínez A, Gilabert R, Hernández-Rodríguez J, Cid MC. Advances in the diagnosis of large vessel vasculitis. Rheum Dis Clin North Am 2015; 41:125-40, ix. [PMID: 25399944 DOI: 10.1016/j.rdc.2014.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The diagnosis of large-vessel vasculitis has experienced substantial improvement in recent years. While Takayasu arteritis diagnosis relies on imaging, the involvement of epicranial arteries by giant-cell arteritis facilitates histopathological confirmation. When appropriately performed temporal artery biopsy has high sensitivity and specificity. However, an optimal biopsy is not always achievable and, occasionally, the superficial temporal artery may not be involved. Imaging in its various modalities including colour-duplex ultrasonography, computed tomography angiography, magnetic resonance angiography and positron emission tomography, are emerging as important procedures for the diagnosis and assessment of disease extent in large-vessel vasculitis. Recent contributions to the better performance and interpretation of temporal artery biopsies as well as advances in imaging are the focus of the present review.
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Affiliation(s)
- Georgina Espígol-Frigolé
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Marco A Alba
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Itziar Tavera-Bahillo
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Ana García-Martínez
- Vasculitis Research Unit, Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Villarroel 170, Barcelona 08036, Spain
| | - Rosa Gilabert
- Center for Diagnostic Imaging, Hospital Clínic, Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Maria C Cid
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain.
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Alibaz-Oner F, Aydin SZ, Akar S, Aksu K, Kamali S, Yucel E, Karadag O, Ozer H, Kiraz S, Onen F, Inanc M, Keser G, Akkoc N, Direskeneli H. Assessment of Patients with Takayasu Arteritis in Routine Practice with Indian Takayasu Clinical Activity Score. J Rheumatol 2015; 42:1443-7. [DOI: 10.3899/jrheum.140817] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2015] [Indexed: 11/22/2022]
Abstract
Objective.To assess the Indian Takayasu Clinical Activity Score (ITAS2010) in followup of Takayasu arteritis (TA).Methods.ITAS2010 forms were filled in prospectively (n = 144). Clinical activity was assessed with physician’s global assessment (PGA) and criteria defined by Kerr,et al.Results.ITAS2010 was significantly higher in patients with active disease. Total agreement between ITAS2010 and PGA was 66.4%, and between ITAS2010 and Kerr,et alwas 82.8%. During followup, 14 of 15 patients showing vascular progression with imaging were categorized as having inactive disease according to ITAS2010.Conclusion.ITAS2010 was discriminatory for activity during the followup, but the agreement between PGA and ITAS2010 was moderate. Future work should include the incorporation of advanced vascular imaging and demonstration of ITAS2010 as a scalable measure and not simply a dichotomous measure of activity/flare versus remission.
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Alibaz-Oner F, Dede F, Ones T, Turoglu HT, Direskeneli H. Patients with Takayasu's arteritis having persistent acute-phase response usually have an increased major vessel uptake by 18F-FDG-PET/CT. Mod Rheumatol 2015; 25:752-5. [PMID: 25671403 DOI: 10.3109/14397595.2015.1012798] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Although not uniformly accepted, an increased uptake by 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) in large vessels is accepted to be a sign of active disease in Takayasu's arteritis (TAK). We aimed to investigate the value of 18F-FDG-PET/CT for clinical assessment in a subset of TAK patients having a persistent acute-phase response (APR) without any signs or symptoms of clinical disease activity. METHOD We studied 14 patients (mean age: 38.6 ± 13.9 years, Female/Male: 11/3, and disease duration: 5.7 ± 5 years). Patients were clinically inactive (according to the definition of activity by Kerr et al.), while categorized as having "persistent" disease activity by physician's global assessment due only to APR. 18F-FDG uptake was graded using a four-point scale from grade 0 (no uptake present) to grade 3 (high grade: uptake higher than that of liver). Any uptake in major vessels with a grade ≥ 2 was accepted to be "active." RESULTS Mean erythrocyte sedimentation rate was 50.8 ± 13.2 mm/hour and mean C-reactive protein level was 28.5 ± 22.1 mg/L. Active vasculitic lesions were observed by 18F-FDG-PET/CT in 9 of 14 (64.3%) patients. The median number of active vascular lesions was 2 (range: 1-5). A step-up treatment change was decided in 8 patients according to 18F-FDG-PET/CT results. CONCLUSION We observed increased 18F-FDG uptake in the majority of TAK patients with an increased APR, but clinically silent disease. 18F-FDG-PET/CT showed the presence and localization of active inflammation in the aorta and its branches. Although specificity for observed lesions is not clear, 18F-FDG-PET/CT imaging may influence physician's assessment of clinical activity and treatment choices in TAK.
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Affiliation(s)
- Fatma Alibaz-Oner
- a Department of Rheumatology , Marmara University, School of Medicine , Pendik, Istanbul , Turkey
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Alibaz-Oner F, Direskeneli H. Update on Takayasu's arteritis. Presse Med 2015; 44:e259-65. [DOI: 10.1016/j.lpm.2015.01.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 01/02/2015] [Indexed: 01/17/2023] Open
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Affiliation(s)
- Jonathan H. Smith
- Kentucky Neuroscience Institute; University of Kentucky; Lexington KY USA
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Chatterjee S, Flamm SD, Tan CD, Rodriguez ER. Clinical Diagnosis and Management of Large Vessel Vasculitis: Takayasu Arteritis. Curr Cardiol Rep 2014; 16:499. [DOI: 10.1007/s11886-014-0499-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Direskeneli H, Aydın SZ, Merkel PA. Disease assessment in Takayasu’s arteritis. Rheumatology (Oxford) 2013; 52:1735-6. [DOI: 10.1093/rheumatology/ket274] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Gao S, Wang R. Takayasu arteritis presenting with massive cerebral ischemic infarction in a 35-year-old woman: a case report. J Med Case Rep 2013; 7:179. [PMID: 23830048 PMCID: PMC3707746 DOI: 10.1186/1752-1947-7-179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/01/2013] [Indexed: 11/29/2022] Open
Abstract
Introduction Takayasu arteritis is a relatively rare type of large-vessel arteritis that primarily affects the aorta and its major branches, the coronary arteries, and the pulmonary arteries. Depending on the different groups of blood vessels involved in the disease process, the clinical presentation of Takayasu arteritis varies. Here we report a case of a woman presenting with a debilitating massive cerebral ischemic infarct that turned out to be a relatively rare first presentation of Takayasu arteritis. Case presentation A 35-year-old Chinese woman presented to the Emergency Department with left hemiparesis, pain and numbness of her arms and weak radial pulses. Her laboratory results showed an elevated C-reactive protein and erythrocyte sedimentation rate, and subsequent digital subtraction angiography demonstrated narrowing and occlusion of the major branches of her aortic arch. We report the case of a patient with Takayasu arteritis presenting with a massive cerebral ischemic infarct and review the current literature on this topic. Conclusion Takayasu arteritis is a relatively rare disease with various and sometimes devastating clinical manifestations, such as massive cerebral ischemic infarction as in our case. Currently, there are multiple diagnostic tools and treatment options available, and more under investigation. Early, appropriate diagnosis and initiation of proper therapy could avoid further progression and reduce complications of the disease.
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Affiliation(s)
- Shan Gao
- Intensive Care Unit, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, 650 Xinsongjiang Road, Shanghai 201620, China.
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Pipitone N, Versari A, Hunder GG, Salvarani C. Role of imaging in the diagnosis of large and medium-sized vessel vasculitis. Rheum Dis Clin North Am 2013; 39:593-608. [PMID: 23719077 DOI: 10.1016/j.rdc.2013.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In large-vessel vasculitis, imaging studies are useful to document temporal artery involvement and crucial to show large-vessel involvement. Color Doppler sonography, magnetic resonance, and computed tomography show early vasculitic lesions. Angiography delineates later vascular complications well. Color Doppler sonography, magnetic resonance angiography, and computed tomography angiography can also be used to show vascular luminal changes. Positron emission tomography is very sensitive in detecting large-vessel inflammation. Imaging procedures can also be used to monitor the course of large-vessel vasculitis. In medium-vessel vasculitis, imaging studies can be used to show both vascular changes and internal organ changes.
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Affiliation(s)
- Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia 42123, Italy
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Alibaz-Oner F, Aydin SZ, Direskeneli H. Advances in the diagnosis, assessment and outcome of Takayasu's arteritis. Clin Rheumatol 2012; 32:541-6. [PMID: 23271611 DOI: 10.1007/s10067-012-2149-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 12/10/2012] [Indexed: 01/09/2023]
Abstract
Takayasu's arteritis (TAK) is a rare, chronic large-vessel vasculitis (LVV) that predominantly affects aorta, its major branches, and the pulmonary arteries. Segmental stenosis, occlusion, dilatation, or aneurysm formation may occur in the vessel wall during the course of the disease. The vascular involvement can be shown with different imaging modalities to make the diagnosis of TAK. Conventional angiography, the gold standard method for initial diagnosis, seems to be replaced with the new imaging modalities such as magnetic resonance angiography (MRA) and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in recent years. The data coming from the new studies support that MRA and FDG-PET are also promising for the assessment of disease activity. Prognosis is possibly getting better with lower mortality in recent years; however, it is difficult to assess the widely different vascular intervention rates among the clinical series. Leflunomide, TNF-α antagonists, and tocilizumab are new options in patients resistant to conventional therapies. There is a clear need to develop a validated set of outcome measures for use in clinical trials of TAK. The OMERACT Vasculitis Working Group has taken on this task and aims to develop a core set of outcomes for LVV.
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Affiliation(s)
- Fatma Alibaz-Oner
- Rheumatology Department, School of Medicine, Marmara University, Istanbul, Turkey.
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