Giant cell (temporal) arteritis and temporal artery biopsy

Giant cell arteritis (GCA) is an uncommon autoimmune inflammatory vasculopathy that can lead to the destruction and occlusion of various arteries that consequently can cause serious complications such as stroke or sight loss. It is seen as a medical emergency. The most commonly affected vessel in GCA is the temporal artery in the side of the head, hence the condition is sometimes also referred to as ‘temporal arteritis’. This article discusses the introduction of an advanced nurse practitioner-led temporal artery biopsy service.

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Polymialgia Rheumatica, Giant Cell Arteritis or Both?

Internal Medicine ◽

10.2478/inmed-2018-0046 ◽

2018 ◽

Vol 15 (6) ◽

pp. 51-58

Author(s):

Adina Cociorvei ◽

Mădălina Ababei

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Temporal Arteritis ◽

Morning Stiffness ◽

Systemic Vasculitis ◽

Diagnostic Algorithm ◽

Signs And Symptoms ◽

Temporal Artery ◽

Clinical Suspicion ◽

Temporal Artery Biopsy

AbstractGiant cell arteritis (GCA), or temporal arteritis, is the most common systemic vasculitis, and the greatest risk factor for developing GCA is aging. The disease almost never occurs before age 50, and its incidence rises steadily thereafter, peaking between ages 70 to 79, the risk of development being two times higher in women.Polymialgia rheumatica (PMR) is an inflammatory rheumatic condition characterized clinically by aching and morning stiffness at the shoulders, hip girdle, and neck. PMR is almost exclusively a disease of adults over the age of 50, with a prevalence that increases progressively with advancing age. The peak incidence of PMR occurs between ages 70 and 80, the same as in the case ofGCA. PMRis 2-3 times more common in women than in men.PMR is two to three times more common than GCA and occurs in about 50% of patients with GCA. The percentage of patients with PMR who experience GCA at some point varies widely in reported series ranging from 5 to 30 percent. PMR can precede, accompany or follow GCA. The diagnostic in the case of PMR is made first of all on clinical features, in the patients in whom another disease to explain the findings is not present. For GCA we must follow the diagnostic algorithm presented below (figure 1) and keep in mind that a negative result for temporal artery biopsy does not exclude the diagnostic if clinical suspicion of GCA is highWe present the case of a 81 year-old male with signs and symptoms from both conditions, PMR and GCA.

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Metaplastic Ossification of the Temporal Artery with Osteoclast-Like Giant Cells: A Mimicker of Giant Cell (Temporal) Arteritis

European Journal of Ophthalmology ◽

10.5301/ejo.5000941 ◽

2017 ◽

Vol 27 (3) ◽

pp. e99-e103 ◽

Cited By ~ 1

Author(s):

Miroslav Sekulic ◽

Alexander M. Truskinovsky

Keyword(s):

Giant Cell ◽

Temporal Arteritis ◽

Temporal Artery ◽

Giant Cells ◽

Temporal Artery Biopsy ◽

Tunica Media ◽

Luminal Narrowing ◽

Stage Renal Disease ◽

Metaplastic Ossification ◽

Medial Calcification

Purpose To describe a patient presenting with suspected giant cell (temporal) arteritis (GCA) in whom subsequent temporal artery biopsy showed luminal narrowing by medial calcification, metaplastic ossification, and fibrointimal proliferation, consistent with calciphylaxis. Methods A 55-year-old man with end-stage renal disease presented with unilateral loss of vision and elevated erythrocyte sedimentation rate and was initially treated as though he had GCA; however, a subsequent temporal artery biopsy showed marked luminal narrowing by medial calcification, metaplastic ossification, and fibrointimal proliferation, consistent with calciphylaxis. In addition, the tunica media of the affected artery contained multinucleate giant cells, but these represented osteoclasts and foreign body giant cells reacting to calcium, rather than a part of GCA. Results This is a rare report of metaplastic ossification and the finding of non-GCA-related giant cells in the tunica media of the temporal artery, thus representing a clinical and histopathologic mimicker of GCA. Conclusions The clinical differential diagnosis of GCA includes other etiologies that can present similarly; however, temporal artery biopsy can discern the underlying pathology. Importantly, the identification of giant cells is not required for the diagnosis of GCA, and likewise, as our case shows, the finding of giant cells in the wall of a temporal artery does not always imply a diagnosis of GCA.

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P040 An unusual case of giant cell arteritis

Rheumatology ◽

10.1093/rheumatology/keab247.037 ◽

2021 ◽

Vol 60 (Supplement_1) ◽

Author(s):

Jessica Ellis ◽

Keziah Austin ◽

Sarah Emerson

Keyword(s):

Inflammatory Markers ◽

Illicit Drugs ◽

Unusual Case ◽

Temporal Arteritis ◽

White Cell Count ◽

Healthcare Providers ◽

Temporal Artery ◽

Low Grade ◽

Temporal Artery Biopsy ◽

The Right

Abstract Background/Aims A 49-year-old female of Nepalese heritage was referred with right-sided headache, scalp tenderness, and a painful swelling overlying the right temple. She denied any visual or claudicant symptoms but felt systemically unwell with a fever. There were no symptoms suggestive of an inflammatory arthritis, underlying connective tissue disease or vasculitis. She was normally fit and well with no past medical history. She did not take any regular medications and denied using over the counter or illicit drugs or recent travel. On review she had a low grade fever. There was a large tender, erythematous swelling overlying the right temple. Bilaterally the temporal arteries were palpable and pulsatile. Peripheral pulses were normal with no bruits. There was no evidence of shingles (HSV) or local infection. Full systemic examination revealed no other abnormalities. Laboratory tests showed: PV 2.56, CRP 101, total white cell count 14.38 (eosinophils 0.4), albumin 33, Hb 115. Urine dip was normal. Renal function, liver function and immunoglobulins were normal. ANCA was negative. Hypoechogenicity surrounding the right frontal branch of the right temporal artery was seen on ultrasound. There were no discrete masses suggestive of cysts, abscess or tumours. Temporal artery biopsy confirmed the presence of vasculitis; histology demonstrated transmural lymphohistiocytic inflammation, disruption of the elastic lamina and intimal proliferation. Prednisolone was started at 40mg daily. Four weeks after initially presenting she was asymptomatic and her inflammatory markers had normalised. Methods The case is discussed below. Results Temporal arteritis, or GCA, is primarily a disease of older adults; with age 50 often used as an inclusion criteria, and is more common in Caucasian populations. Limited reports exist of GCA in younger cohorts, but these are rare. An important differential in younger patients, such as ours, is juvenile temporal arteritis. This rare localised vasculitis affects almost exclusively the temporal artery. It is typically a disease of young males, who present with non-tender temporal swelling. Systemic symptoms are unusual and inflammatory markers are normal. Clinical or laboratory evidence of organ involvement, peripheral eosinophilia or fibrinoid necrosis on histology should prompt consideration of an AAV or PAN. Incidence of GCA increases in correlation with Northern latitude, with highest rates reported in Scandinavian and North American populations. GCA is rare in Asian populations. Higher diagnostic rates in countries where physicians have increased awareness of GCA proposed as an explanation for this difference; however differences in incidence are still observed between Asian and Caucasian populations presenting to the same healthcare providers. Conclusion GCA is an uncommon diagnosis in younger and non-Caucasian patients. Thorough investigation through ultrasound and biopsy helped increase our diagnostic confidence in this unusual case. Rheumatologists must be alert to atypical presentations in order to deliver prompt and potentially sight-saving treatment. Disclosure J. Ellis: None. K. Austin: None. S. Emerson: None.

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OP0150 WHAT IS THE ROLE OF TEMPORAL ARTERY BIOPSY IN GIANT CELL ARTERITIS FAST-TRACK PATHWAYS WHEN TEMPORAL ARTERY ULTRASOUND IS NEGATIVE?

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.6534 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 95.3-95

Author(s):

A. Sachdev ◽

S. Dubey ◽

C. Tiivas ◽

M. George ◽

P. Mehta

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Sensitivity And Specificity ◽

Fast Track ◽

Temporal Artery ◽

Clinical Findings ◽

Specimen Size ◽

Temporal Artery Biopsy ◽

Duration Of Treatment ◽

Relevant Role

Background:A number of centres are now running fast track pathways for diagnosis and management of Giant cell arteritis with ultrasound as the first port of call for diagnosis1. Temporal artery biopsies (TABs) have become the second line of investigation, and it is unclear how useful TAB is in this setting.Objectives:This study looked at accuracy of Temporal artery biopsy (TAB) in patients with suspected Giant Cell arteritis (GCA) with negative/inconclusive ultrasound (U/S) and how duration of treatment on steroids prior to these investigations and arterial specimen size affected it.Methods:Prospective study of all patients with suspected GCA referred for TAB when U/S was negative or inconclusive, as part of the local fast-track pathway (Coventry). Database included clinical findings, serological work up, U/S and TAB results and treatment. Sensitivity and specificity of U/S and TAB was calculated and compared based on duration of treatment with steroids.Results:One hundred and nine patients were referred for TAB via Coventry fast-track-pathway. The sensitivity of U/S in this cohort of patients was 9.08% and specificity was 93.33%. After 3 days of steroid this was 0% and 100% respectively. For TAB when done within 10 days of starting steroids, this was 65% and 87.5% respectively. After 20 days of steroids this was 0 % and 100%. The sensitivity and specificity was 20% and 85% when arterial specimen size was 11-15mm and 47% and 100% when specimen size was 16 mm or more. Sensitivity and specificity of U/S of 644 suspected GCA patients was 48% and 98%.Conclusion:Our study demonstrates that TAB plays a relevant role in GCA fast-track-pathways, when U/S is negative/inconclusive. TAB was more sensitive than U/S in this cohort of patients, but overall sensitivity of U/S was higher when calculated for all patients suspected with GCA. Both remain useful tests if performed early. TAB specimen size should ideally be 16mm or more and done within 10 days of starting steroids.References:[1]Jonathan Pinnell, Carl Tiivas, Kaushik Chaudhuri, Purnima Mehta, Shirish Dubey, O38 The diagnostic performance of ultrasound Doppler in a fast-track pathway for giant cell arteritis,Rheumatology, Volume 58, Issue Supplement_3, April 2019, kez105.036,https://doi.org/10.1093/rheumatology/kez105.036Disclosure of Interests:None declared

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Evaluating the Usefulness and Timing of the Temporal Artery Biopsy for the Diagnosis of Giant Cell Arteritis

The Laryngoscope ◽

10.1002/lary.22215 ◽

2011 ◽

Vol 121 (S5) ◽

pp. S264-S264

Author(s):

Stephen V. Tornabene ◽

Raymond Hilsinger ◽

Raul M. Cruz

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Temporal Artery ◽

Temporal Artery Biopsy

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AB0551 The impact of temporal artery biopsy on diagnosis of giant cell arteritis in clinical practice

10.1136/annrheumdis-2017-eular.4749 ◽

2017 ◽

Author(s):

E Kaltsonoudis ◽

D Kirochristos ◽

A Bai-Papoudou ◽

P Voulgari ◽

AA Drosos

Keyword(s):

Clinical Practice ◽

Giant Cell Arteritis ◽

Giant Cell ◽

Temporal Artery ◽

Temporal Artery Biopsy ◽

The Impact

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The sensitivity of temporal artery biopsy in the detection of giant cell arteritis is independent of tissue length

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqab191.055 ◽

2021 ◽

Vol 156 (Supplement_1) ◽

pp. S28-S29

Author(s):

H J Hurley ◽

P Q Deb

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Average Length ◽

Statistical Significance ◽

Temporal Artery ◽

Temporal Artery Biopsy ◽

Temporal Arteries ◽

Biopsy Specimens ◽

Two Samples ◽

Left And Right

Abstract Introduction/Objective Giant cell arteritis (GCA) is the most common vasculitis of the elderly, and the most common primary systemic vasculitis overall, with an annual incidence of 200/million. The long term sequelae, namely vision loss and stroke, are permanent and devastating. While GCA is often treated empirically based on clinical presentation, panarteritis on temporal artery biopsy is required for diagnosis. However, these biopsies have the tendency to be falsely negative due to skip lesions, a common feature of GCA. Therefore, we set out to determine whether longer biopsy specimens were more sensitive in the detection of GCA. Methods/Case Report A census of temporal artery biopsies performed with the indication of clinical symptoms of GCA was taken at our institution. The patient age, sex, biopsy laterality, biopsy length, and pathological diagnosis were recorded for each cataloged sample. Statistical significance of difference in biopsy length was tested using an unpaired t-test in R 4.1.0. Results (if a Case Study enter NA) A total of 114 temporal artery specimens were biopsied from 94 different patients with the indication of GCA and assigned a definitive positive or negative diagnosis. Of the 94 patients, 54 were female and 40 were male. Of the total pathological specimens, 11 were positive and 103 were negative. The overall average length of biopsy specimens was 2.13 cm with a standard deviation of 0.65 cm. The average positive biopsy was 2.26 cm long, and the average negative was 2.12 cm, an insignificant difference (0.14 cm, t = 0.7, p = 0.43). In 25 patients, biopsies were taken from both the left and right temporal arteries. Of those patients, 2 were positive for GCA and the remaining 23 were negative. Interestingly, the biopsy result in every case was identical between the left and right samples; we found no instances of pathological evidence of GCA in only one of the two samples from the same patient. Conclusion According to data taken at our institution, there is no indication to lengthen the biopsy requirements from the existing 1.5 cm. However, we have demonstrated evidence that it may be unnecessary to biopsy both temporal arteries in a single patient. Larger studies would be required to confirm our findings.

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