Background/Purpose
Giant cell arteritis (GCA) represents the most common primary vasculitis among adults aged 50 years or above. Recently, the national annual incidence rate in this population was determined at 10.5 per 105. GCA may lead to ischemic complications, which among others include permanent visual loss in up to 20% of patients and ischemic stroke in 2–4%. Early diagnosis and initiation of treatment is thus of paramount importance. At our secondary/tertiary level department of rheumatology we examine majority of patients with referral diagnosis of GCA within 24 hours from referral, and those referred during the week-end in up to 72 hours. Also, rheumatologists have been performing temporal artery biopsies (TAB) ourselves for decades with an excellent safety record. Snap frozen TAB specimens are processed and analyzed at the attached university institute of pathology. Results are obtained within three hours from TAB. Since September 2011 Color Doppler ultrasonography of temporal arteries (CDS-TA) is routinely performed in every potential case of GCA to aid diagnosis and guide TAB. Our aim was to analyze the performance of this approach to GCA patient work-up.
Methods
We retrieved and analyzed electronic and paper patient charts of patients diagnosed with GCA form September 1, 2011 to May 31, 2014. Appropriate descriptive statistical methods were used describe our cohort.
Results
During the 32 month observation period, 66 new GCA cases were identified. Their characteristics are presented in Table 1. Median (interquartile range (IQR), range) symptom duration prior to presentation was 30 (14–77, range 2–365) days. Patients were referred to our outpatient clinic by their general practitioners (33/66), infectious disease specialists (13/66), specialists of internal medicine (12/66) ophthalmologists (6/66), and neurologists (2/66). Except for two polymyalgia rheumatica patients, all other patients were glucocorticoid naïve at the time of diagnostic procedures. CDS-TA was performed in 65/66, and TAB in 54/66 cases. Median time to CDS-TA (IQR; range) was 0 (0–1; 0–6) days, and 1 (0–1.75; 0–15) day for TAB. CDS-TA, and TAB were performed on the day of referral to our department in 48/66 (73%), and 20/66 (30%) of patients, respectively. Notably, 24/66 (36.4%) patients reported visual manifestations. Unilateral permanent visual loss developed in 4/66 patients (6.1%)—in one patient despite prompt initiation of glucocorticoid treatment, and in the remaining three cases 13 days, 14 days, and 2 months before diagnosis. One patient had an ischemic stroke 8 days prior to diagnosis.
Conclusion
This fast-track pathway enables us to obtain a definitive diagnosis even before the initiation of treatment, and might contribute to a relatively low incidence of irreversible sight loss in our cohort compared to reported data, as well as avoidance of overtreatment with glucocorticoids.
|
characteristics |
|
|
% female |
69.7 |
|
age (mean ± SD) |
73.2 ± 8.0 |
|
smoking # (%) |
27 (40.9) |
|
new onset/type headache # (%) |
48 (72.7) |
|
scalp tenderness# (%) |
16 (24.2) |
|
jaw claudication # (%) |
21 (31.8) |
|
visual symptoms # (%) |
24 (36.4) |
|
blurred vision # (%) |
15 (22.7) |
|
diplopia # (%) |
8 (12.1) |
|
transient visual loss # (%) |
3 (4.5) |
|
permanent visual loss # (%) |
4 (6.1) |
|
ptosis # (%) |
1 (1.5) |
|
dry cough # (%) |
12 (18.2) |
|
clinically changed TA # (%) |
40 (60.6) |
|
symptoms of large vessel disease # (%) |
7 (10.6) |
|
general symptoms # (%) |
45 (68.2) |
|
fever (≥38°C) # (%) |
14 (21.2) |
|
weight loss # (%) |
36 (54.5) |
|
polymyalgia rheumatica # (%) |
9 (13.6) |
|
ESR (mm/h; ref. <15–32), median (IQR) |
80 (57–95) |
|
CRP (mg/l; ref. <5.0), median (IQR) |
63 (32–122) |
|
SAA (mg/l; N <6.4), median(IQR) |
192 (66.8– 468) |
|
positive TAB #/# all biopsies (%) |
43/54 (79.6) |
|
positive CDS-TA #/# all CDS-TA (%) |
50/65 (76.9) |
|
US signs large vessel disease #/# all CDS (%) |
19/58 (32.7) |
Disclosure:
A. Hočevar,
None;
Z. Rotar,
None;
M. Tomsic,
None.
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