Giant cell arteritis

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Giant cell arteritis
Other namesTemporal arteritis, cranial arteritis, [1] Horton disease, [2] senile arteritis, [1] granulomatous arteritis [1]
Gray508.png
The arteries of the face and scalp
Specialty Rheumatology, emergency medicine, Immunology
Symptoms Headache, pain over the temples, flu-like symptoms, double vision, difficulty opening the mouth [3]
Complications Blindness, aortic dissection, aortic aneurysm, polymyalgia rheumatica [4]
Usual onsetAge greater than 50 [4]
CausesInflammation of the small blood vessels within the walls of larger arteries [4]
Diagnostic method Based on symptoms and blood tests, confirmed by biopsy of the temporal artery [4]
Differential diagnosis Takayasu arteritis, [5] stroke, primary amyloidosis [6]
Treatment Steroids, bisphosphonates, proton-pump inhibitor [4]
Prognosis Life expectancy (typically normal) [4]
Frequency~ 1 in 15,000 people a year (> 50 years old) [2]

Giant cell arteritis (GCA), also called temporal arteritis, is an inflammatory autoimmune disease of large blood vessels. [4] [7] Symptoms may include headache, pain over the temples, flu-like symptoms, double vision, and difficulty opening the mouth. [3] Complications can include blockage of the artery to the eye with resulting blindness, as well as aortic dissection, and aortic aneurysm. [4] GCA is frequently associated with polymyalgia rheumatica. [4]

Contents

The cause is unknown. [2] The underlying mechanism involves inflammation of the small blood vessels that supply the walls of larger arteries. [4] This mainly affects arteries around the head and neck, though some in the chest may also be affected. [4] [8] Diagnosis is suspected based on symptoms, blood tests, and medical imaging, and confirmed by biopsy of the temporal artery. [4] However, in about 10% of people the temporal artery is normal. [4]

Treatment is typical with high doses of steroids such as prednisone or prednisolone. [4] Once symptoms have resolved, the dose is decreased by about 15% per month. [4] Once a low dose is reached, the taper is slowed further over the subsequent year. [4] Other medications that may be recommended include bisphosphonates to prevent bone loss and a proton-pump inhibitor to prevent stomach problems. [4]

It affects about 1 in 15,000 people over the age of 50 per year. [2] The condition mostly occurs in those over the age of 50, being most common among those in their 70s. [4] Females are more often affected than males. [4] Those of northern European descent are more commonly affected. [5] Life expectancy is typically normal. [4] The first description of the condition occurred in 1890. [1]

Signs and symptoms

Common symptoms of giant cell arteritis include:

The inflammation may affect blood supply to the eye; blurred vision or sudden blindness may occur. In 76% of cases involving the eye, the ophthalmic artery is involved, causing arteritic anterior ischemic optic neuropathy. [14]

Giant cell arteritis may present with atypical or overlapping features. [15] Early and accurate diagnosis is important to prevent ischemic vision loss. Therefore, this condition is considered a medical emergency. [15]

While studies vary as to the exact relapse rate of giant cell arteritis, relapse of this condition can occur. [16] It most often happens at low doses of prednisone (<20 mg/day), during the first year of treatment, and the most common signs of relapse are headache and polymyalgia rheumatica. [16]

Associated conditions

The varicella-zoster virus (VZV) antigen was found in 74% of temporal artery biopsies that were GCA-positive, suggesting that the VZV infection may trigger the inflammatory cascade. [17]

The disorder may co-exist (in about half of cases) with polymyalgia rheumatica (PMR), [13] which is characterized by sudden onset of pain and stiffness in muscles (pelvis, shoulder) of the body and is seen in the elderly. GCA and PMR are so closely linked that they are often considered to be different manifestations of the same disease process. PMR usually lacks the cranial symptoms, including headache, pain in the jaw while chewing, and vision symptoms, that are present in GCA. [18]

Giant cell arteritis can affect the aorta and lead to aortic aneurysm and aortic dissection. [19] Up to 67% of people with GCA having evidence of an inflamed aorta, which can increase the risk of aortic aneurysm and dissection. [19] There are arguments for the routine screening of each person with GCA for this possible life-threatening complication by imaging the aorta. Screening should be done on a case-by-case basis based on the signs and symptoms of people with GCA. [19]

Mechanism

The pathological mechanism is the result of an inflammatory cascade that is triggered by an as of yet undetermined cause resulting in dendritic cells in the vessel wall recruiting T cells and macrophages to form granulomatous infiltrates. [19] These infiltrates erode the middle and inner layers of the arterial tunica media leading to conditions such as aneurysm and dissection. [19] Activation of T helper 17 (Th17) cells involved with interleukin (IL) 6, IL-17, IL-21 and IL-23 play a critical part; specifically, Th17 activation leads to further activation of Th17 through IL-6 in a continuous, cyclic fashion. [19] This pathway is suppressed with glucocorticoids, [20] and more recently it has been found that IL-6 inhibitors also play a suppressive role. [19]

Diagnosis

Physical exam

Intermediate magnification micrograph showing giant cell arteritis in a temporal artery biopsy. The arterial lumen is seen on the left. A giant cell is seen on the right at the interface between the thickened intima and media. H&E stain Giant cell arteritis -- intermed mag.jpg
Intermediate magnification micrograph showing giant cell arteritis in a temporal artery biopsy. The arterial lumen is seen on the left. A giant cell is seen on the right at the interface between the thickened intima and media.  H&E stain

Laboratory tests

Biopsy

Histopathology of giant cell vasculitis in a cerebral artery. Elastica-stain. Cerebral Giant-Cell Vasculitis.jpg
Histopathology of giant cell vasculitis in a cerebral artery. Elastica-stain.

The gold standard for diagnosing temporal arteritis is biopsy, which involves removing a small part of the vessel under local anesthesia and examining it microscopically for giant cells infiltrating the tissue. [23] However, a negative result does not definitively rule out the diagnosis; since the blood vessels are involved in a patchy pattern, there may be unaffected areas on the vessel and the biopsy might have been taken from these parts. Unilateral biopsy of a 1.5–3 cm length is 85-90% sensitive (1 cm is the minimum). [24] Characterised as intimal hyperplasia and medial granulomatous inflammation with elastic lamina fragmentation with a CD4+ predominant T cell infiltrate, currently biopsy is only considered confirmatory for the clinical diagnosis, or one of the diagnostic criteria. [11]

Medical imaging

Radiological examination of the temporal artery with ultrasound yields a halo sign. Contrast-enhanced brain MRI and CT are generally negative in this disorder. Recent studies have shown that 3T MRI using super high resolution imaging and contrast injection can non-invasively diagnose this disorder with high specificity and sensitivity. [25] Temporal artery thickening on imaging has been demonstrated to have highest positive likelihood ratios for GCA when compared with other non invasive diagnostic tests. [26]

Early recognition

Women and men approximately 45 years old and who suffer from several complaints (at least 5 of the 16 symptoms) [27] listed below could have giant cell arteritis.

Treatment

GCA is considered a medical emergency due to the potential of irreversible vision loss. [15] Corticosteroids, typically high-dose prednisone (1 mg/kg/day), should be started as soon as the diagnosis is suspected (even before the diagnosis is confirmed by biopsy) to prevent irreversible blindness secondary to ophthalmic artery occlusion. Steroids do not prevent the diagnosis from later being confirmed by biopsy, although certain changes in the histology may be observed towards the end of the first week of treatment and are more difficult to identify after a couple of months. [28] The dose of corticosteroids is generally slowly tapered over 12–18 months. [22] Oral steroids are at least as effective as intravenous steroids, [29] except in the treatment of acute visual loss where intravenous steroids appear to offer significant benefit over oral steroids. [30] Short-term side effects of prednisone are uncommon but can include mood changes, avascular necrosis, and an increased risk of infection. [31] Some of the side effects associated with long-term use include weight gain, diabetes mellitus, osteoporosis, avascular necrosis, glaucoma, cataracts, cardiovascular disease, and an increased risk of infection. [32] [33] It is unclear whether adding a small amount of aspirin is beneficial or not as it has not been studied. [34] Injections of tocilizumab may also be used. [35] Tocilizumab is a humanized antibody that targets the interleukin-6 receptor, which is a key cytokine involved in the progression of GCA. [36] Tocilizumab has been found to be effective at minimizing both recurrence, and flares of GCA when used both on its own and with corticosteroids. [36] Long term use of tocilizumab requires further investigation. [36] [37] Tocilizumab may increase the risk of gastrointestinal perforation and infections, however it does not appear that there are more risks than using corticosteroids. [36] [37]

Epidemiology

Giant cell arteritis typically only occurs in those over the age of 50; [4] particularly those in their 70s. [22] It affects about 1 in 15,000 people over the age of 50 per year. [2] It is more common in women than in men, by a ratio of 2:1, [4] and more common in those of Northern European descent, as well as in those residing further from the Equator. [5] Roughly 1 in 5 people with polymyalgia rheumatica also have giant cell arteritis. [38]

Disease impact

Giant cell arteritis and its treatment impact on people's lives because of symptoms, adverse effects of GCs and disruption to normal life. [39] People with GCA have previously ranked ‘losing sight in both eyes permanently’, ‘having intense or severe pain’ and ‘feeling weak, tired or exhausted’ as important quality of life domains. [40]

Terminology

The terms "giant cell arteritis" and "temporal arteritis" are sometimes used interchangeably, because of the frequent involvement of the temporal artery. However, other large vessels such as the aorta can be involved. [41] Giant-cell arteritis is also known as "cranial arteritis" and "Horton's disease". [42] The name (giant cell arteritis) reflects the type of inflammatory cell involved. [43]

Related Research Articles

Rheumatology is a branch of medicine devoted to the diagnosis and management of disorders whose common feature is inflammation in the bones, muscles, joints, and internal organs. Rheumatology covers more than 100 different complex diseases, collectively known as rheumatic diseases, which includes many forms of arthritis as well as lupus and Sjögren's syndrome. Doctors who have undergone formal training in rheumatology are called rheumatologists.

<span class="mw-page-title-main">Erythrocyte sedimentation rate</span> Physiological quantity

The erythrocyte sedimentation rate is the rate at which red blood cells in anticoagulated whole blood descend in a standardized tube over a period of one hour. It is a common hematology test, and is a non-specific measure of inflammation. To perform the test, anticoagulated blood is traditionally placed in an upright tube, known as a Westergren tube, and the distance which the red blood cells fall is measured and reported in millimetres at the end of one hour.

<span class="mw-page-title-main">Prednisone</span> Steroid medication

Prednisone is a glucocorticoid medication mostly used to suppress the immune system and decrease inflammation in conditions such as asthma, COPD, and rheumatologic diseases. It is also used to treat high blood calcium due to cancer and adrenal insufficiency along with other steroids. It is taken by mouth.

<span class="mw-page-title-main">Vasculitis</span> Medical disorders that destroy blood vessels by inflammation

Vasculitis is a group of disorders that destroy blood vessels by inflammation. Both arteries and veins are affected. Lymphangitis is sometimes considered a type of vasculitis. Vasculitis is primarily caused by leukocyte migration and resultant damage. Although both occur in vasculitis, inflammation of veins (phlebitis) or arteries (arteritis) on their own are separate entities.

<span class="mw-page-title-main">Aortoiliac occlusive disease</span> Medical condition

In medicine, aortoiliac occlusive disease is a form of central artery disease involving the blockage of the abdominal aorta as it transitions into the common iliac arteries.

<span class="mw-page-title-main">Takayasu's arteritis</span> Medical condition

Takayasu's arteritis (TA), also known as aortic arch syndrome, nonspecific aortoarteritis, and pulseless disease, is a form of large vessel granulomatous vasculitis with massive intimal fibrosis and vascular narrowing, most commonly affecting young or middle-aged women of Asian descent, though anyone can be affected. It mainly affects the aorta and its branches, as well as the pulmonary arteries. Females are about 8–9 times more likely to be affected than males.

<span class="mw-page-title-main">Arteritis</span> Medical condition

Arteritis is a vascular disorder characterized by inflammation of the walls of arteries, usually as a result of infection or autoimmune responses. Arteritis, a complex disorder, is still not entirely understood. Arteritis may be distinguished by its different types, based on the organ systems affected by the disease. A complication of arteritis is thrombosis, which can be fatal. Arteritis and phlebitis are forms of vasculitis.

Claudication is a medical term usually referring to impairment in walking, or pain, discomfort, numbness, or tiredness in the legs that occurs during walking or standing and is relieved by rest. The perceived level of pain from claudication can be mild to extremely severe. Claudication is most common in the calves but it can also affect the feet, thighs, hips, buttocks, or arms. The word claudication comes from Latin claudicare 'to limp'.

<span class="mw-page-title-main">Polymyalgia rheumatica</span> Inflammatory disease featuring pain and stiffness

Polymyalgia rheumatica (PMR) is a systemic inflammatory disease characterized by pain or stiffness, usually in the neck, shoulders, upper arms, and hips, but which may occur all over the body. Almost all cases occur in people age 50 or older. Pain and stiffness of PMR is worst in the morning and improves throughout the day, but these symptoms frequently persist to some extent throughout the day and into the evening.

Posterior ischemic optic neuropathy (PION) is a medical condition characterized by damage to the retrobulbar portion of the optic nerve due to inadequate blood flow (ischemia) to the optic nerve. Despite the term posterior, this form of damage to the eye's optic nerve due to poor blood flow also includes cases where the cause of inadequate blood flow to the nerve is anterior, as the condition describes a particular mechanism of visual loss as much as the location of damage in the optic nerve. In contrast, anterior ischemic optic neuropathy (AION) is distinguished from PION by the fact that AION occurs spontaneously and on one side in affected individuals with predisposing anatomic or cardiovascular risk factors.

Bruit, also called vascular murmur, is the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery.

<span class="mw-page-title-main">Giant cell</span> Mass resulting from the fusion of many cells

A giant cell is a mass formed by the union of several distinct cells, often forming a granuloma.

Retroperitoneal fibrosis or Ormond's disease is a disease featuring the proliferation of fibrous tissue (fibrosis) in the retroperitoneum, the compartment of the body containing the kidneys, aorta, renal tract, and various other structures. It may present with lower back pain, kidney failure, hypertension, deep vein thrombosis, and other obstructive symptoms. It is named after John Kelso Ormond, who rediscovered the condition in 1948.

Arteritic anterior ischemic optic neuropathy is vision loss that occurs in giant cell arteritis. Temporal arteritis is an inflammatory disease of medium-sized blood vessels that happens especially with advancing age. AAION occurs in about 15-20 percent of patients with temporal arteritis. Damage to the blood vessels supplying the optic nerves leads to insufficient blood supply (ischemia) to the nerve and subsequent optic nerve fiber death. Most cases of AAION result in nearly complete vision loss first to one eye. If the temporal arteritis is left untreated, the affected eye will likely suffer vision loss as well within 1–2 weeks. Arteritic AION (AAION) falls under the general category of anterior ischemic optic neuropathy (AION), which also includes non-arteritic AION (NAION). AAION is considered an eye emergency, immediate treatment is essential to rescue remaining vision.

Aortitis is the inflammation of the aortic wall. The disorder is potentially life-threatening and rare. It is reported that there are only 1–3 new cases of aortitis per year per million people in the United States and Europe. Aortitis is most common in people 10 to 40 years of age.

<span class="mw-page-title-main">Inflammatory myopathy</span> Muscular inflammatory disease of unknown origin

Inflammatory myopathy, also known as idiopathic inflammatory myopathy (IIM), is disease featuring muscle weakness, inflammation of muscles (myositis), and in some types, muscle pain (myalgia). The cause of much inflammatory myopathy is unknown (idiopathic), and such cases are classified according to their symptoms and signs, electromyography, MRI, and laboratory findings. It can also be associated with underlying cancer. The main classes of idiopathic inflammatory myopathy are polymyositis (PM), dermatomyositis (DM), inclusion-body myositis (IBM), immune-mediated necrotising myopathy (IMNM), and focal autoimmune myositis.

<span class="mw-page-title-main">Systemic vasculitis</span> Medical condition

Necrotizing vasculitis, also called systemic necrotizing vasculitis, is a general term for the inflammation of veins and arteries that develops into necrosis and narrows the vessels.

Jaw claudication is pain in the jaw associated with chewing. It is a classic symptom of giant-cell arteritis, but can be confused with symptoms of temporomandibular joint disease, rheumatoid arthritis of the temporomandibular joint, myasthenia gravis, tumors of the parotid gland, or occlusion or stenosis of the external carotid artery.

<span class="mw-page-title-main">Inflammatory aortic aneurysm</span> Medical condition

Inflammatory aortic aneurysm (IAA), also known as Inflammatory abdominal aortic aneurysm (IAAA), is a type of abdominal aortic aneurysm (AAA) where the walls of the aneurysm become thick and inflamed. Similar to AAA, IAA occurs in the abdominal region. IAA is closely associated and believed to be a response to and extensive peri-aneurysmal fibrosis, which is the formation of excess fibrous connective tissue in an organ or tissue in a reparative or reactive process IAA accounts for 5-10% of aortic aneurysms. IAA occurs mainly in a population that is on average younger by 10 years than most AAA patients. Some common symptoms of IAA may include back pain, abdominal tenderness, fevers, weight loss or elevated Erythrocyte sedimentation rate (ESR) levels. Corticosteroids and other immunosuppressive drugs have been found to decrease symptoms and the degree of peri-aortic inflammation and fibrosis

<span class="mw-page-title-main">Acute visual loss</span> Loss of visual acuity associated with illness or aging

Acute visual loss is a rapid loss of the ability to see. It is caused by many ocular conditions like retinal detachment, glaucoma, macular degeneration, and giant cell arteritis, etc.

References

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  43. ↑ "giant cell arteritis" at Dorland's Medical Dictionary
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