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The clinical pictures of giant cell arteritis. Temporal arteritis, polymyalgia rheumatica, and fever of unknown origin.

In a prospective study, 68 hospitalized patients were diagnosed as having giant cell arteritis. Temporal artery biopsy was performed in all patients and showed histologic evidence of arteritis in 42 (62%). Twenty-six patients had a negative biopsy but met the clinical criteria for the diagnosis. Four different clinical pictures were recognized. Thirteen patients (19%) had symptoms of localized temporal arteritis without muscular discomfort. The polymyalgia rheumatica syndrome without signs of localized arteritis was seen in 33 patients (49%). Seventeen (25%) had symptoms of both polymyalgia rheumatica and temporal arteritis. Five patients (7%) had general symptoms only, such as fever, anorexia, and fatigue, without muscular or arteritic symptoms.

Aged↗

Giant cell arteritis (temporal arteritis) affecting the breast: report of two cases and review of published reports.

The breast is an infrequently recognised site of primary giant cell arteritis. Two cases of giant cell arteritis affecting the breast are described and 11 previously described cases are reviewed. All cases presented with single or multiple breast masses, leading to a diagnosis before biopsy of suspected breast carcinoma. Symptoms similar to those of polymyalgia rheumatica occurred in about half of these patients, though the significance of these symptoms was only appreciated in retrospect. Clinical or pathological evidence of giant cell arteritis outside the breast (temporal artery, thyroid artery) was noted in a minority of cases. Seven patients received corticosteroid treatment, and all patients recovered without complications. Two patients had an adenocarcinoma of the breast contiguous with the giant cell arteritis. Giant cell arteritis affecting the breast may be underrecognised and should be considered in older women with polymyalgia rheumatica-like symptoms and tender breast mass(es).

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Thrombocytosis in temporal arteritis rising platelet counts: a red flag for giant cell arteritis.

OBJECTIVES: To determine whether early recognition and detection of thrombocytosis in patients with giant cell arteritis can help secure an earlier diagnosis, and whether it can help differentiate cases of arteritic optic neuropathy from other forms of optic neuropathy. METHODS: Medical and ophthalmologic records from 1993 to 1998 of the authors' patients with biopsy-proven temporal arteritis versus the authors' patients with nonarteritic anterior ischemic optic neuropathy and idiopathic demyelinating optic neuritis were prospectively collected. Past and present blood analyses were collected, and platelet counts were compared between patients with giant cell arteritis and control populations. This was done to determine whether thrombocytosis could help with the diagnosis and differentiation of these different disease states. RESULTS: There was a significant difference in the frequency of thrombocytosis in patients with giant cell arteritis (13 out of 19 patients), with or without arteritic ischemic optic neuropathy, as compared with those with nonarteritic anterior ischemic optic neuropathy (zero out of 30 patients), idiopathic optic neuritis (zero out of 26 patients), and healthy age-matched controls (one out of 22 control subjects). This difference was especially helpful in patients whose sedimentation rates were within the normal range (adjusting for age). Also noted was the finding that the rise in the platelet counts was not acute, but rather it was a slow gradual increase for approximately 12 months before the onset of significant systemic or visual symptoms. CONCLUSION: Thrombocytosis should be considered an important marker in patients being referred for evaluation of ischemic optic neuropathy, diplopia, amaurosis fugax, headache, or even generalized malaise. Westegren sedimentation rates <50 mm/hr are often erroneously viewed as nondiagnostic or equivocal in the elderly and just followed. An over-the-phone review of patients' sedimentation rates, complete blood counts, and platelet counts can lead to expedited evaluation and treatment of patients who may be at high risk of visual loss from temporal arteritis. Thrombocytosis should lower a physician's threshold to acutely treat patients for possible arteritic ischemic optic neuropathy until the disease is definitely ruled out.

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Characterization of the arteritis induced by infusion of rats with UK-61,260, an inodilator, for 24 h. A comparison with the arteritis induced by fenoldopam mesylate.

Administration of fenoldopam mesylate (FM), a dopaminergic agonist, or of cyclic cAMP phosphodiesterase inhibitors (PDE III), for example theophylline and caffeine, induces arteritis in the rat. In this study we characterized the arteritis induced by UK-61,260, an investigational inotropic agent with vasodilatory properties which displays an inhibitory action on cyclic AMP phosphodiesterase, in comparison with lesions induced by FM. The compounds were administered to Sprague-Dawley rats by intravenous infusion over 24 h (FM and UK-61,260), orally or subcutaneously (UK-61,260); the rats were killed and necropsied for pathological examination at various times between 0 h and 28 days post-infusion. Infusion of UK-61,260 at doses of 100, 300 or 400 mg/kg produced arteritis mainly in the mesenteric arteries and occasionally in the renal, pancreatic, gastric and coronary arteries. There were no arterial lesions after infusion of 30 mg/kg, or after administration of 30, 100 or 200 mg/kg per day subcutaneously for 7 days, or after acute administration of 100, 300, 400 or 600 mg/kg orally. Infusion of rats with 72 or 144 mg/kg FM produced arteritis over a wider range of tissues than did UK-61,260. However, the arterial lesions produced by infusion of either drug have the same initial aspect and a similar evolution with time. Immediately after the end of the infusion, minimal necrosis and haemorrhage occurred in the media only, without involvement of the endothelium or the perivascular space. This indicates that the media of the artery is the primary site of injury. The lesions seen 1 and 3 days post-infusion were characterized by severe medial necrosis and haemorrhage with perivascular acute inflammation and appeared macroscopically as haemorrhagic spots on the vessels. On days 7, 14 and 28 post-infusion, no medial necrosis or haemorrhage were present, while perivascular chronic inflammation and moderate smooth muscle hyperplasia were seen. It appeared, therefore, that the lesions underwent repair in 28 days, but footprints of the damage were still present 28 days post-infusion. The similarity between arteritis induced in rats by fenoldopam or by UK-61,260, at doses inducing PDE III inhibition, is consistent with the view that they have a similar pathogenesis. In our view it is probable that these pharmacologically and chemically distinct drugs trigger an increase in intracellular levels of cAMP which in turn triggers vascular damage. The arterial changes observed in the current study after acute administration may explain the increased incidence of polyarteritis nodosa occurring in long term toxicity studies with FM or PDE III inhibitors.

Administration, Oral↗

[Liver changes in giant-cell arteritis: temporal arteritis and rheumatic polymyalgia (author's transl)].

Liver changes were demonstrated in six elderly patients with giant-cell arteritis (temporal arteritis, three with polymyalgia). Histologically there was fatty infiltration in four and pericentral congestion in five, star-cell nodules in one and non-specific hepatitis in one. Bromsulphalein test was abnormal in all, but rapidly became normal as the arteritis was successfully treated with corticoids. The pathogenesis of the liver changes is unclear. The authors' observations and published reports suggest that they are typical of giant-cell arteritis; it is of importance in the diagnosis of underlying disease.

Adrenal Cortex Hormones↗

Giant-cell arteritis of the uterus with associated temporal arteritis: a case report.

Giant-cell arteritis involving the uterus was identified incidentally upon hysterectomy and anterior colporrhaphy for uterine prolapse. Subsequently, the patient was found to have giant-cell temporal arteritis presenting with fever of unknown origin. Fourteen previous cases involving the female genital tract have been reported. There appears to be an association between constitutional symptoms of fever, weight loss, malaise, headache, and polymyalgia rheumatica in elderly women with uterine prolapse and giant-cell arteritis of the genital tract. The rare presentation of giant-cell arteritis in the female genital tract does not support invasive costly evaluation in asymptomatic patients. However, a thorough investigation for involvement of other sites, including appropriate treatment for generalized disease, should be undertaken.

Aged↗

[Takayasu arteritis associated with heart valve diseases (pulmonary and aortic) and arteritis (coronary and renal)].

The most severe arteritis due to Takayasu's disease are those related to renal and coronary arteries. The first one because it produces severe arterial hypertension and the second one because it puts the patient in high risk of suffering either myocardial ischemia or infarction. These situations worsen when this entity is associated to valvular heart lesions. The authors present the clinical cases of two female patients with Takayasu's disease. One of them in acute phase of the illness, where coronary arteritis, mild coarctation of the aorta, right pulmonary artery stenosis, and pulmonary valve stenosis were present. The second patient was seen during the remission phase of the disease with obstruction of the left subclavicular artery, renal arteritis, severe arterial hypertension and aortic valve insufficiency. The authors discuss the prognosis of patients with Takayasu's disease associated to valvular heart disease and its role in the etiology of pulmonary valvular stenosis. Finally, the authors point out the importance of recognizing the active and non active phases of the Takayasu's disease in relation of the adequate stage for surgical treatment of the lesions caused by this disease.

Adult↗

Laboratory investigations useful in giant cell arteritis and Takayasu's arteritis.

A raised erythrocyte sedimentation rate (ESR) is considered a hallmark for the diagnosis of giant cell arteritis (GCA). The American College of Rheumatology 1990 criteria for GCA include ESR greater than or equal to 50 mm/h as one of the five criteria. Although the presence of a normal ESR made GCA less likely, the results of a population-based study showed that the occurrence of a low/normal value in GCA at diagnosis is not rare. Pre-treatment ESR may be a prognostic indicator for duration of treatment. C-reactive protein (CRP) and interleukin-6 (IL-6) may be more sensitive indicators of disease activity than ESR in GCA patients. However, it is unclear whether the use in clinical practice of CRP and IL-6 has some apparent advantage over ESR. ESR is the most often used tool to assess disease activity in Takayasu's arteritis (TA). However, some studies have found that ESR and CRP are not able to differentiate patients with clinically active and inactive TA. Furthermore, histopathological studies have shown that over 40% of patients thought to be in clinical remission with normal acute phase reactants have active arteritis. IL-6 could be a promising marker of disease activity in TA; however, further studies are required to confirm its usefulness in clinical practice. Other laboratory investigations could be useful in the diagnosis or follow-up of GCA and TA, but more studies are required.

Giant Cell Arteritis↗

Molecular approaches toward pathologic mechanisms in giant cell arteritis and Takayasu's arteritis.

Molecular techniques have provided new tools to define genetic systems involved in disease susceptibility and to dissect molecular events driving inflammatory reactions. Inflammatory infiltrates in the wall of large and medium-sized arteries, sometimes associated with giant cell formation, are pathognomic for Takayasu's arteritis (TA) and giant cell (cranial) arteritis. Molecular techniques have been used successfully to define genetic host factors involved in disease susceptibility and to dissect the nature of inflammatory cells and mediators in the pathologic lesions. Careful analysis of incidence data for TA suggests that TA is a worldwide disease. Genetic comparison of western and eastern TA, however, raises the possibility of disease heterogeneity. Emerging data indicate that HLA-DRB1 genes represent important risk factors in giant cell arteritis. Whether disease association is related to the role of HLA-DR molecules in presenting a disease-inducing antigen remains to be seen. Analysis of the molecular diversity of tissue-infiltrating T cells indicates that a small proportion of CD4+ T cells proliferate in situ, potentially as a result of antigen recognition. Tissue cytokine profiles reveal functional selection of T cells and are compatible with the model that Th1 cells recognize antigen on the surface of activated macrophages. The presence of T cell-derived cytokines in temporal artery tissue of patients with polymyalgia rheumatica who are lacking microscopic inflammation indicates subclinical vasculitis.

Cytokines↗

Giant cell arteritis, temporal arteritis, and polymyalgia rheumatica in a Danish county. A prospective investigation, 1982-1985.

The annual incidence of giant cell arteritis (the term used in this study to encompass the syndromes of temporal arteritis and polymyalgia rheumatica, occurring either together or alone) was prospectively determined in a Danish county that had a population of approximately 200,000. In a single year, 46 new cases of giant cell arteritis were diagnosed, a number which corresponds to an incidence in the overall population of 21.5/10(5), and to an incidence of 76.6/10(5) for individuals age 50 years or older. These rates are higher than those previously reported in retrospective studies. The 3-year followup of all patients showed no onset of other diseases that would require a revision of the original diagnosis. There was no deviation from the age- and sex specific malignancy rate or the mortality rate in the overall population. Women had an incidence rate 4 to 5 times higher than that seen in men. Symptoms, for the most part, were the same as those found in other studies; however, vision loss was not observed during the followup period. Point prevalence at the start of the study was 37.8/10(5), which is below the rates previously reported. This is probably because of failure on the part of participating physicians to record all cases.

Aged↗

Giant cell arteritis (cranial arteritis, polymyalgia rheumatica).

Giant cell arteritis, which is probably due to disturbed immune mechanisms, has a spectrum of clinical symptoms in elderly people. In nearly all cases such general signs as loss of appetite, loss of weight and fever are present. The sedimentation rate is almost without exception about 100 mm in the first hour. The two most frequent and typical clinical syndromes are polymyalgia rheumatica and cranial arteritis. The polymyalgia rheumatica is characterized by periarticular pain which is mostly symmetrical and accentuated in the shoulder girdle. Increasingly severe temporal headache and ocular distrubances are found with cranial arteritis in more than 50% of cases. A combination of both diseases is frequent. Other arterial branches are rarely involved. The course of the disease is over a period of 1 1/2 to 2 years. Treatment with corticosteroids is indicated mainly because of the severe ocular complications with blindness. It should begin immediately, be intensive and last over a long period. Regular followup is necessary over several years in order to avoid relapses.

Age Factors↗

[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.

Antigen Presentation↗

Arteritis of the aged (giant cell arteritis) and fever of unexplained origin.

Arteritis of the aged (giant cell arteritis) masquerades as a degenerative, infectious, neoplastic or even functional disorder in the elderly. In the absence of obliterative vascular changes, the diagnosis is often overlooked when too rigid diagnostic criteria are employed. Four elderly women presented with fever of unexplained origin as the initial manifestation of this disease. The temporal arteries were conspicuously normal in all four, and other traditional clinical clues, such as visual disturbances, headache or manifestations of polymyalgia rheumatica were likewise infrequent of entirely absent. Influenza immunization and uncomplicated rectal surgery preceded the onset of illness in two. Anemia and an increased erythrocyte sedimentation rate are important diagnostic features, particularly in the face of spontaneous clinical improvement accompanied by defervescence and disappearance of nonspecific liver dysfunction. Occult intestinal perforation complicated steroid therapy in one case. Significant and sometimes hectic fever may be a common pattern for this arteritis in its earliest stages, when palpably abnormal temporal arteries, obliterative vascular changes and other traditional diagnostic clues are more likely to be absent.

Aged↗

Long-term survival of patients with giant cell arteritis in the American College of Rheumatology giant cell arteritis classification criteria cohort.

OBJECTIVE: To characterize survivorship among patients with giant cell arteritis in a well-defined, multicenter cohort. PATIENTS AND METHODS: Follow-up was obtained for 205 (95.8%) of the 214 patients enrolled in the 1990 American College of Rheumatology vasculitis classification study. Standardized mortality ratios (SMR) were calculated comparing mortality data from this group of patients with giant cell arteritis versus the general population. RESULTS: There were 49 deaths (33 women and 16 men among the 205 patients available for follow-up. Survivorship was virtually identical to that of the general population (SMR = 1.034 +/- 0.121), and was similar for women (SMR = 1.022 +/- 0.149) and men (SMR = 1.078 +/- 0.206) (SMR = 1 indicates that expected and observed survival are identical). CONCLUSION: The life expectancy of patients with giant cell arteritis is the same as that of the general population.

Female↗

Monozygotic twins with temporal arteritis and ophthalmic arteritis.

Temporal arteritis - ophthalmic arteritis occurring in a pair of monozygotic twins, who were 72 and 77 years of age respectively at the onset of symptoms, is reported. It is pointed out that it is rare to see, as in the first case, an improvement in an already existing severely reduced vision, in relation to corticosteroid treatment. The importance of genetic factors in temporal arteritis is discussed; further it is suggested that a possible association of the disease with tissue type antigens be the object of further study.

Aged↗

Lower limb giant cell arteritis and temporal arteritis: followup of 8 cases.

Among 8 patients with giant cell arteritis (GCA) (6 women, 2 men) whose clinical presentations were compatible with temporal arteritis (TA), 6 were followed for 37-105 (mean 74.9) months, one died shortly after treatment onset, and the last was asymptomatic (10 mg steroids/day) when lost to followup at 29 months. All 8 patients had bilateral leg claudication of recent onset; for 6 patients, this was the first symptom. All leg angiograms showed multiple, bilateral, long and smooth stenoses, thromboses, or both. Biopsies of diseased leg arteries from 4 patients provided histological proof of GCA; another case was histologically proven post mortem. Among the 5 patients who met at least 3 American College of Rheumatology criteria of GCA or TA, 3 without histologically documented leg GCA also had biopsy proven temporal GCA (n = 1), or headaches and claudication and angiographic inflammatory arteritis of the arms (n = 2). All patients received steroids; 3 had bypasses, one with endarterectomy. Five are asymptomatic after 24-100 months of steroids (mean 50.6). Revascularization was not successful; one amputation was necessary. Large artery involvement in GCA can affect the legs. Bilateral and rapidly progressive intermittent claudication of recent onset is the most common symptom, even in the absence of headaches or the presence of a silent inflammatory syndrome. Early diagnosis allows rapid initiation of steroid therapy, which is usually able to generate a sufficiently good response to avoid vascular surgery.

Adult↗

Comparison between color duplex ultrasonography and histology of the temporal artery in cranial arteritis (giant cell arteritis).

BACKGROUND: Duplex sonography of the temporal artery may be helpful in the diagnosis of cranial arteritis. PATIENTS AND METHODS: The superficial temporal arteries of 36 patients with cranial arteritis or suspected arteritis were examined using both duplex ultrasonography (US) and biopsy. The data of these patients were divided into two groups. Group A consisted of 24 patients (66.7%) with definite positive results using duplex (US) and Group B of 12 patients (33.3%) who showed a suspicious or negative ultrasonographic result. RESULT: In all patients of Group A, the histological findings corresponded with the ultrasonographic changes in the inflamed artery. - The characteristic ultrasonographic sign was a dark halo around the lumen of the temporal arteries. There was a high correlation between a bilateral halo found by US with an ocular involvement. Ten out of 14 patients with a bilateral halo (71.4%) showed a distinct involvement of the optic nerve or retina. - The characteristic histological signs were infiltration of the vessel wall by inflammatory cells, mainly lymphocytes. Group B: The biopsies of the superficial temporal arteries were positive in 8 patients (66.7 %), negative in 4 other patients (33.3%). CONCLUSION: Patients with a distinct halo, demonstrated by US, also showed corresponding pronounced inflammatory cell infiltration of the vessel wall. Patients with no ultrasonographic changes presented histological signs of initial inflammation such as isolated inflammatory cells around the vasa vasorum and/or in the adventitial layer.

Aged↗

Echocardiographic findings in patients with temporal arteritis: apropos of one case of temporal arteritis-associated verrucous (Libman-Sachs) endocarditis.

We report the case of a 70-year-old patient who presented with fever of unknown origin. The initial diagnosis was infective endocarditis as a mitral valve vegetation was found in a transesophageal echocardiogram. Lack of response to empiric antibiotic treatment and further diagnostic work-up established the correct diagnosis of marantic endocarditis due to temporal arteritis. Treatment with steroids and aspirin led to rapid clinical improvement and disappearance of the vegetation. Apropos of this case, we reviewed the records of 25 patients with a new diagnosis of temporal arteritis and analyzed the echocardiographic findings in comparison to those of 40 age- and sex-matched controls. Abnormal echocardiographic findings were present in 13 (52%) out of 25 patients with temporal arteritis and in 5 (12.5 %) out of 40 controls (p < 0.001, chi-square test).

Aged↗