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![Local imaging strategy in patients with suspected cranial or and large-vessel giant cell arteritis at the University Hospital Basel. As highlighted by the European League against Rheumatism recommendations, temporal artery biopsy (TAB) can be replaced by imaging and the modality of imaging of the large-vessels should be chosen based on local expertise and availability [24]. (1) Cranial giant cell arteritis (cGCA) should be suspected if at least one of the following symptoms is present: new headache, vision loss, jaw claudication, suspicious temporal arteries (hard, painful or pulseless). (2) Suspected large-vessel GCA (LV-GCA) includes patients with fever or inflammation of unknown origin, arm/leg claudication (with inflammation or polymyalgia rheumatica [PMR]), and for the algorithm, absence of the symptoms listed in (1), except headache. (3) Vascular status should include auscultation of the large arteries for bruits; palpation of the peripheral pulses; blood pressure measurements on both arms; and lab tests should include at least C-reactive protein (CRP) / erythrocyte sedimentation rate (ESR). (4) If aortic aneurysm or large vessels stenosis is detected during initial or follow-up screen, follow-up imaging frequency has to be decided on an individual basis.CT = computed tomography; MRI = magnetic resonance imaging; PET = positron emission tomography](publication/327204060/figure/fig5/AS:663127838437387@1535113405263/Local-imaging-strategy-in-patients-with-suspected-cranial-or-and-large-vessel-giant-cell.png)
Local imaging strategy in patients with suspected cranial or and large-vessel giant cell arteritis at the University Hospital Basel. As highlighted by the European League against Rheumatism recommendations, temporal artery biopsy (TAB) can be replaced by imaging and the modality of imaging of the large-vessels should be chosen based on local expertise and availability [24]. (1) Cranial giant cell arteritis (cGCA) should be suspected if at least one of the following symptoms is present: new headache, vision loss, jaw claudication, suspicious temporal arteries (hard, painful or pulseless). (2) Suspected large-vessel GCA (LV-GCA) includes patients with fever or inflammation of unknown origin, arm/leg claudication (with inflammation or polymyalgia rheumatica [PMR]), and for the algorithm, absence of the symptoms listed in (1), except headache. (3) Vascular status should include auscultation of the large arteries for bruits; palpation of the peripheral pulses; blood pressure measurements on both arms; and lab tests should include at least C-reactive protein (CRP) / erythrocyte sedimentation rate (ESR). (4) If aortic aneurysm or large vessels stenosis is detected during initial or follow-up screen, follow-up imaging frequency has to be decided on an individual basis.CT = computed tomography; MRI = magnetic resonance imaging; PET = positron emission tomography
Source publication
Historically, giant cell arteritis (GCA) was considered to be synonymous with temporal arteritis. However, the disease spectrum of GCA extends much further, and includes vasculitis of the aorta and its branches with or without involvement of the temporal arteries. Imaging is crucial for the diagnosis and follow-up of GCA patients. Large vessel GCA...
Contexts in source publication
Context 1
... diagnosing cGCA, the best and most extensive data ex- ist on the use of CDS of the temporal arteries. CDS can easily be extended to the larger vessels, thereby increas- ing the diagnostic sensitivity. Therefore, CDS is the pre- ferred imaging method in these patients. If CDS is not available, MRI of the temporal arteries is a good alterna- tive. Large vessel imaging should be performed in all GCA patients to assess potential aortitis, aneurysm or subclavian stenosis. In patients with predominantly LV-GCA having, "B-symptoms" only, large vessel imaging is a reasonable first diagnostic step. Figure 5 shows our local diagnostic workup for patients with suspected GCA. This algorithm must be adapted to local availability and expertise. Since CDS misses isolated vasculitis of the thoracic aorta, this is best combined with a cross-sectional imaging modality. Based on current data, none of the other available methods (PET/CT, MRI or CT) can be preferred over another to di- agnose LV-GCA. Standardised quantitative, and therefore investigator-independent, image analysis has only been es- tablished for PET/CT. Moreover, PET/CT findings link to clinical outcome data: aortitis to an increased risk for fu- ture aortic aneurysm and high FDG uptake during follow- up with subsequent relapses. In patients with FUO or IUO, PET/CT allows the exclusion of various alternative diag- noses, making it a very valuable method in this ...
Context 2
... diagnostic accuracy of different imaging techniques used in LV-GCA has been independently investigated in different settings (various patient populations, treatment durations, etc.). Only a few comparative studies of differ- ent modalities have been published to date [49,51,67,68] and a benchmark is lacking since histological confirma- tion, as the "gold standard", is rarely available [69]. Con- sequently, the 2018 EULAR recommendations for imag- ing in large-vessel vasculitis propose CDS, PET/CT, CT or MRI as equivalent possible methods for the detection of GCA-associated changes in extracranial arteries [24]. Thus, personal preference, local expertise and the reim- bursement situation often drive the decision of what is used. There are some obvious advantages and disadvan- tages to specific modalities (table 2). In the EULAR rec- ommendation, CDS is recommended as the first-line method for screening the supra-aortic arteries in patients with suspected predominantly cGCA ( fig. 5). In the event of negative or inconclusive findings in the temporal arter- ies, this can be complemented with axillary ultrasound in the same session. The advantage of CDS is its availabil- ity and the absence of radiation and nephrotoxic contrast agents. CDS, however, also has several disadvantages that include: (i) the lack of evaluation of the thoracic aorta and the very proximal part of the supra-aortic arteries, (ii) its operator dependency, and (iii) limited information on in- flammatory activity. Therefore, in ambiguous cases, CDS is often complemented with imaging of the large vessels, particularly in patients with arteries that appear normal on CDS ( fig. ...
Context 3
... diagnostic accuracy of different imaging techniques used in LV-GCA has been independently investigated in different settings (various patient populations, treatment durations, etc.). Only a few comparative studies of differ- ent modalities have been published to date [49,51,67,68] and a benchmark is lacking since histological confirma- tion, as the "gold standard", is rarely available [69]. Con- sequently, the 2018 EULAR recommendations for imag- ing in large-vessel vasculitis propose CDS, PET/CT, CT or MRI as equivalent possible methods for the detection of GCA-associated changes in extracranial arteries [24]. Thus, personal preference, local expertise and the reim- bursement situation often drive the decision of what is used. There are some obvious advantages and disadvan- tages to specific modalities (table 2). In the EULAR rec- ommendation, CDS is recommended as the first-line method for screening the supra-aortic arteries in patients with suspected predominantly cGCA ( fig. 5). In the event of negative or inconclusive findings in the temporal arter- ies, this can be complemented with axillary ultrasound in the same session. The advantage of CDS is its availabil- ity and the absence of radiation and nephrotoxic contrast agents. CDS, however, also has several disadvantages that include: (i) the lack of evaluation of the thoracic aorta and the very proximal part of the supra-aortic arteries, (ii) its operator dependency, and (iii) limited information on in- flammatory activity. Therefore, in ambiguous cases, CDS is often complemented with imaging of the large vessels, particularly in patients with arteries that appear normal on CDS ( fig. ...
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Introduction:
Temporal artery biopsy is essential for the diagnosis of giant cell arteritis. It has been shown that 18F-fluorodeoxyglucose positron emission tomography-computed tomography, magnetic resonance angiography, and ultrasonography are useful for the diagnosis of giant cell arteritis. However, there are only a few reports on the usefulnes...
Citations
... Moreover, although we have an increased awareness of the prevalence of subclinical GCA in those with PMR, there are a number of unanswered questions surrounding it. At present, in most centres, routine screening of those with PMR to identify subclinical GCA is not considered a standard of care [19] . Subclinical GCA is typically identified through vessel wall imaging, with both US and FDG-PET computed tomography (CT) offering superior diagnostic accuracy vs. temporal artery biopsy [20][21][22] . ...
... Glucocorticoids have served as the cornerstone of the management of PMR for decades. Characteristically, patients with PMR undergo a rapid resolution in their symptomatology upon commencement of a low to moderate dose of prednisolone (15-25 mg OD) [19] . There is no evidence-based, standardised protocol for steroid taper, with it primarily being physician-led and patient-specific, and indeed, the optimal approach to steroid taper remains controversial, augmented by the paucity of studies addressing it [95] . ...
... In order to aid steroid reduction in those with refractory or relapsing disease, a number of different glucocorticoid-sparing agents have been studied. At present, oral or subcutaneous methotrexate is the most widely used steroid-sparing agent [19] . Its clinical efficacy for the initial management of PMR has been assessed in three randomised controlled trials (RCTs), albeit with mixed results [102][103][104] . ...
Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease in those over the age of 50 years. Previously it was considered to be a benign clinical syndrome characterised by subacute onset bilateral shoulder and pelvic girdle pain and stiffness, with a corresponding rise in acute phase reactants, and distinctive rapid resolution of symptoms with the instigation of moderate doses of glucocorticoids. However, over the past decade, with the advancements and, indeed, wider application of imaging modalities in PMR, we have garnered an increased understanding of the anatomic predilection of inflammation and, subsequently, disease pathogenesis. Moreover, our appreciation of the relationship between PMR and giant cell arteritis (GCA) has strengthened. Glucocorticoids have formed the cornerstone of the management of PMR for decades, with often protracted treatment durations and associated high cumulative steroid burden and adverse effects. However, we are now on the cusp of a new era in the management of PMR, with our therapeutic armamentarium expanding with the recent FDA approval of the interleukin -6 antagonist sarilumab for the management of refractory disease. It is an exciting time for PMR, and this review aims to explore the recent advancements in both diagnosis and management, while also providing an updated perspective on the relationship between PMR and GCA.
... The symptoms of GCA can be classified into four subsets: systemic symptoms, cranial arteritis, extracranial arteritis, and polymyalgia rheumatica (PMR). Typically, the disease manifests with a temporal headache as the most common symptom, and jaw claudication as the most specific manifestation [40,41]. Scalp tenderness and visual disturbances can also be present. ...
In the initial assessment of a headache patient, several dangerous secondary etiologies must be considered. A thorough history and physical examination, along with a comprehensive differential diagnosis may alert a physician to the diagnosis of a secondary headache particularly when it is accompanied by certain clinical features. Evaluation and workup include a complete neurological examination, consideration of neuroimaging, and serum/spinal fluid analysis if indicated. Careful attention to the patients' history and physical examination will guide the diagnostic work-up and management. In this review, we summarize the diagnostic workup of various primary and secondary headache etiologies. Although most headaches are primary in nature, it is essential to screen for headache "red flags", as they can suggest life threatening secondary etiologies. When secondary causes are suspected, appropriate neuroimaging can further differentiate the underlying cause. The appropriate imaging is dependent on the most likely secondary etiology, which is deduced from history and physical examination. When no red flags are present, primary headaches are more likely. These can be differentiated by frequency, location, duration, triggers, and presence of aura. The different clinical presentations for secondary headaches, as well as the distinguishing features for primary headaches are outlined in this review.
... Neither imaging findings at diagnosis nor over the disease course were found to predict disease relapse across published studies [18]. However, potential vascular complications, especially in patients with large vessel involvement, favour regular aortal imaging [19]. Research in this field is a critical unmet need that should be investigated with targeted studies. ...
Aims of the study:
To assess current practices in diagnosing, treating, and following-up giant-cell arteritis by specialists in Switzerland and to identify the main barriers to using diagnostic tools.
Methods:
We performed a national survey of specialists potentially caring for patients with giant-cell arteritis. The survey was sent by email to all members of the Swiss Societies of Rheumatology and for Allergy and Immunology. A reminder was sent to nonresponders after 4 and 12 weeks. Its questions covered the following dimensions: respondents' main characteristics, diagnosis, treatment, and imaging's role during follow-up. The main study results were summarized using descriptive statistics.
Results:
Ninety-one specialists, primarily aged 46-65 years (n = 53/89; 59%), working in academic or nonacademic hospitals or private practice, and treating a median of 7.5 (interquartile range [IQR]: 3-12) patients with giant-cell arteritis per year participated in this survey. Ultrasound of temporal arteries/large vessels (n = 75/90; 83%) and positron-emission-tomography-computed tomography (n = 52/91; 57%) or magnetic resonance imaging (n = 46/90; 51%) of the aorta/extracranial arteries were the most common techniques used to diagnose giant-cell arteritis with cranial or large vessel involvement, respectively. Most participants reported a short time to obtain imaging tests or arterial biopsy. The glucocorticoid tapering scheme, glucocorticoid-sparing agent, and glucocorticoid-sparing treatment duration varied among the participants. Most physicians did not follow a predefined repeat imaging scheme for follow-up and mainly relied on structural changes (vascular thickening, stenosis, or dilatation) to drive treatment choice.
Conclusions:
This survey indicates that imaging and temporal biopsy are rapidly accessible for diagnosing giant-cell arteritis in Switzerland but highlights heterogeneous practice in many disease management areas.
... Subclinical GCA can be detected by vessel wall imaging [13] or histology obtained by temporal artery biopsy (TAB) [14]. TAB has limited sensitivity for GCA and was the only screening technique for diagnosing GCA before the introduction of temporal artery ultrasound in 1995 [15]. ...
... Today, PET is the most widely used technique for GCA screening, especially for extracranial large vessel GCA with good diagnostic accuracy (sensitivity of 67% to 77% and specificity of 66% to 100%) [17]. It is mostly used in combination with computed tomography (PET/CT) [13,18]. ...
... Due to the high prevalence of subclinical GCA at PMR diagnosis, the role of routine imaging for GCA warrants discussion. Although PET/CT has been most often used, other modalities such as CT, ultrasound, or MRI, each with its specific advantages and disadvantages, are available for this purpose [13]. Carefully designed prospective, longitudinal cohort studies, taking the potential biases in account would be needed to confirm the presented data. ...
Objectives
To determine the prevalence and predictors of subclinical giant cell arteritis (GCA) in patients with newly diagnosed polymyalgia rheumatica (PMR).
Methods
PubMed, Embase, and Web of Science Core Collection were systematically searched (date of last search July 14, 2021) for any published information on any consecutively recruited cohort reporting the prevalence of GCA in steroid-naïve patients with PMR without cranial or ischemic symptoms. We combined prevalences across populations in a random-effect meta-analysis. Potential predictors of subclinical GCA were identified by mixed-effect logistic regression using individual patient data (IPD) from cohorts screened with PET/(CT).
Results
We included 13 cohorts with 566 patients from studies published between 1965 to 2020. Subclinical GCA was diagnosed by temporal artery biopsy in three studies, ultrasound in three studies, and PET/(CT) in seven studies. The pooled prevalence of subclinical GCA across all studies was 23% (95% CI 14%-36%, I²=84%) for any screening method and 29% in the studies using PET/(CT) (95% CI 13%-53%, I²=85%) (n=266 patients). For seven cohorts we obtained IPD for 243 patients screened with PET/(CT). Inflammatory back pain (OR 2.73, 1.32-5.64), absence of lower limb pain (OR 2.35, 1.05-5.26), female sex (OR 2.31, 1.17-4.58), temperature >37° (OR 1.83, 0.90-3.71), weight loss (OR 1.83, 0.96-3.51), thrombocyte count (OR 1.51, 1.05-2.18), and haemoglobin level (OR 0.80, 0.64-1.00) were most strongly associated with subclinical GCA in the univariable analysis but not C-reactive protein (OR 1.00, 1.00-1.01) or erythrocyte sedimentation rate (OR 1.01, 1.00-1.02). A prediction model calculated from these variables had an area under the curve of 0.66 (95% CI 0.55-0.75).
Conclusion
More than a quarter of patients with PMR may have subclinical GCA. The prediction model from the most extensive IPD set has only modest diagnostic accuracy. Hence, a paradigm shift in the assessment of PMR patients in favour of implementing imaging studies should be discussed.
... GCA is categorized as granulomatous vasculitis of large-and medium-sized vessels, especially the temporal artery, and temporal artery biopsy (TAB) is the gold standard for diagnosing GCA [17,18]. However, imaging techniques have revealed a variable prevalence of extracranial involvement in GCA patients [19,20]. With the increasing use of whole-body imaging, more patterns of GCA have been described, including GCA with isolated increased inflammatory parameters and/or fever of unknown origin [8]. ...
Background:
Musculoskeletal involvement in primary large vessel vasculitis (LVV), including giant cell arteritis and Takayasu's arteritis (TAK), tends to be subacute. With the progression of arterial disease, patients may develop polyarthralgia and myalgias, mainly involving muscle stiffness, limb/jaw claudication, cold/swelling extremities, etc. Acute development of rhabdomyolysis in addition to aortic aneurysm is uncommon in LVV. Herein, we report a rare case of LVV with the first presentation of acute rhabdomyolysis.
Case summary:
A 70-year-old Asian woman suffering from long-term low back pain was hospitalized due to limb claudication, dark urine and an elevated creatine kinase (CK) level. After treatment with fluid resuscitation and antibiotics, the patient remained febrile. Her workup showed persistent elevated levels of inflammatory markers, and imaging studies revealed an aortic aneurysm. A decreasing CK was evidently combined with elevated inflammatory markers and negativity for anti-neutrophilic cytoplasmic antibodies. LVV was suspected and confirmed by magnetic resonance angiography and positron emission tomography with 18F-fluorodeoxyglucose/computed tomography. With a favourable response to immunosuppressive treatment, her symptoms resolved, and clinical remission was achieved one month later. However, after failing to follow the tapering schedule, the patient was readministered 25 mg/d prednisolone due to disease relapse. Follow-up examinations showed decreased inflammatory markers and substantial improvement in artery lesions after 6 mo of treatment. At the twelve-month follow-up, she was clinically stable and maintained on corticosteroid therapy.
Conclusion:
An exceptional presentation of LVV with acute rhabdomyolysis is described in this case, which exhibited a good response to immunosuppressive therapy, suggesting consideration for a differential diagnosis when evaluating febrile patients with myalgia and elevated CK. Timely use of high-dose steroids until a diagnosis is established may yield a favourable outcome.
... For these cases, and also for patients lacking cranial symptoms, PET/CT has a potentially higher diagnostic accuracy than ultrasound. Moreover, both techniques may be used complementary, enhancing sensitivity for the diagnosis of GCA [1]. [ 18 F] Fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) is well established and has been integrated in the current guidelines for diagnosing LV-GCA [2]. ...
We previously proposed standard uptake value (SUV) ratio-based cut-off values for [18F] fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) for diagnosing giant cell arteritis (GCA) with high diagnostic accuracy. Here we confirm our findings in an independent cohort and report a simplified procedure for using a SUV ratio to diagnose LV-GCA. Patients with suspected GCA were consecutively included. The ‘peak SUV ratio’ was defined in a two-step approach. First, the vessel with the visually brightest radiotracer uptake in the supra-aortic (SA) and in the aorto-iliofemoral (AIF) region was identified. Here, the maximum SUV of the vessel was measured and divided by the mean SUV of the liver (SUVratio). A ratio >1.0 in the SA or >1.3 in the AIF region was scored as vasculitis. The diagnostic accuracy, sensitivity, and specificity of the ‘peak SUV ratio’ in the SA and AIF region was assessed. From 2015 to 2019, 50 patients (24 female, median age 71 years) with suspicion of GCA were included, 28 patients with GCA and 22 patients with exclusion of GCA. Peak SUV had an AUC of 0.91, a sensitivity of 0.89, and a specificity of 0.73 for diagnosing GCA. Peak SUV accuracy of the AIF arteries was lower (AUC 0.81) than of the SA arteries (AUC 0.95). Our SUV ratio cut-off values for diagnosing GCA are consistently valid, also when applied in a time-efficient clinical procedure focusing on the peak SUV ratio. The diagnostic performance of PET/CT in this validation cohort was even higher, compared to the inception cohort (AUC of 0.83).
... 11 Berger et al emphasised the role of imaging in the one third of the GCA patients with no involvement of the temporal arteries. 12 The subclavian arteries were involved in 42% of 187 patients with GCA in a recent prospective longitudinal study. 5 The role of imaging proved to be of great importance in our patient who did not have symptoms or signs of cranial involvement. ...
Giant cell arteritis can involve both cranial and extracranial arteries. Isolated extracranial large vessel vasculitis more often manifests with non-specific constitutional symptoms, causing a diagnostic delay. We report the case of a 57-year-old Caucasian female patient presenting with persistently elevated resting heart rate, as revealed by a smartwatch healthcare application, and non-specific constitutional symptoms. Imaging revealed inflammation of the aorta, bilateral subclavian and axillary arteries, compatible with large vessel vasculitis. Treatment with glucocorticoids and tocilizumab led to a significant improvement of her symptoms and decrease in inflammatory parameters. In sum, an unexplained elevated resting heart rate may lead to an earlier diagnosis and treatment of large vessel vasculitis, especially when other manifestations are non-specific. The use of healthcare smartwatch applications may prove useful in the future and lead to an earlier referral of patients to a physician.
... The first line imaging modality, especially for cranial GCA is color duplex sonography (CDS). [4,8,9] CDS assesses vascular wall anatomy and luminal lining and diameter. A characteristic finding of GCA on CDS is the (halo) sign, which is homogenous, hypoechogenic circumferential vessel wall thickening. ...
... Another finding is the lack of compressibility of the artery manifested by the application of transducer-imposed pressure on the temporal arteries (compression sign). [4,8] The (halo) sign has a sensitivity ranging from 55 to 100% and specificity of 78 to 100% in the diagnosis of temporal arteritis. [8] The wide range of sensitivity may be attributed to operator experience and arterial involvement. ...
... [4,8] The (halo) sign has a sensitivity ranging from 55 to 100% and specificity of 78 to 100% in the diagnosis of temporal arteritis. [8] The wide range of sensitivity may be attributed to operator experience and arterial involvement. A systematic review published in 2016 discussed the use of the different imaging modalities in the diagnosis and follow-up of GCA. ...
Medical image segmentation and classification algorithms are commonly used in clinical applications. Several automatic and semiautomatic segmentation methods were used for extracting veins and arteries on transverse and longitudinal medical images. Recently, the use of medical image processing and analysis tools improved giant cell arteries (GCA) detection and diagnosis using patient specific medical imaging. In this chapter, we proposed several image processing and analysis algorithms for detecting and quantifying the GCA from patient medical images. The chapter introduced the connected threshold and region growing segmentation approaches on two case studies with temporal arteritis using ultrasound (US) and magnetic resonance imaging (MRI) imaging modalities extracted from the Radiopedia Dataset. The GCA detection procedure was developed using the 3D Slicer Medical Imaging Interaction software as a fast prototyping open-source framework. GCA detection passes through two main procedures: The pre-processing phase, in which we improve and enhances the quality of an image after removing the noise, irrelevant and unwanted parts of the scanned image by the use of filtering techniques, and contrast enhancement methods; and the processing phase which includes all the steps of processing, which are used for identification, segmentation, measurement, and quantification of GCA. The semi-automatic interaction is involved in the entire segmentation process for finding the segmentation parameters. The results of the two case studies show that the proposed approach managed to detect and quantify the GCA region of interest. Hence, the proposed algorithm is efficient to perform complete, and accurate extraction of temporal arteries. The proposed semi-automatic segmentation method can be used for studies focusing on three-dimensional visualization and volumetric quantification of Giant Cell Arteritis.
... In addition, since TAB involves sampling of arterial tissue, it is not always reliable [7] . Imaging studies provide a less intrusive, and potentially more reliable method of detecting signs of GCA and other forms of vasculitis, which could lead to early treatment with corticosteroids [7][8][9][10] . This course of early diagnosis and treatment, if effective, might not only confirm the role of aortic inflammation and diagnosis of GCA, but also prevent the more serious, potentially disabling and fatal consequences of untreated GCA. ...
... Similarly, Berger et al. emphasized the clinical benefits of imaging in the diagnosis and treatment of GCA [8] . Their 2018 review of the literature concluded that color duplex sonography (CDS) is particularly sensitive to assess the vascular wall anatomy as well as the lumen and blood flow. ...
... Berger et al. argued that, since invasive TAB is diag-nostic in only 50% of patients, "imaging is essential for diagnosing GCA." They recommended the development of "fasttrack clinics with diagnostic algorithms adopted to local expertise" for imaging studies that are readily available [8] . ...
Giant cell arteritis, the most common form of vasculitis in the elderly, is characterized by granulomatous inflammation of arteries, which can lead to serious, life-threatening conditions including aortic aneurysms, ruptures, and dissections as well as blindness. Since GCA can be treated by immunosuppressant therapy, such as corticosteroids, early diagnosis and treatment may reduce the risk of serious disability and morbidity. While temporal artery biopsy is considered the gold standard to diagnosis giant cell arteritis, it is intrusive with inherent risks as well as unreliable due to tissue sampling. Imaging studies, such as computerized tomography, are nonintrusive and have been shown to identify vasculitis including giant cell arteritis. We present a case of a 72-year-old male patient who was diagnosed with giant cell arteritis by temporal artery biopsy during surgery for aortic aneurysm and coronary artery bypass graft. Computerized tomography imaging studies, prior to the surgery and biopsy, were suggestive of vasculitis. This case serves to emphasize the beneficial role of imaging studies to assess vasculitis, including giant cell arteritis, that can be done prior to the progressive development of more serious debilitating and potentially fatal pathology.
... GCA is typically diagnosed based on clinical features combined with histopathological evidence from a temporal artery biopsy [7,8]. However, patients with primarily large vessel GCA (eg, aorta and central vessels) often lack classic symptoms such as headache and jaw pain because the vascular inflammation does not involve the smaller, peripheral vessels that supply these areas. ...
... As a result, such patients are more likely to have a negative temporal artery biopsy. In fact, in approximately one-third of patients, the temporal arteries are not involved; therefore, imaging of larger arteries can be helpful in diagnosis [7]. Appropriate imaging modalities include Doppler ultrasonography, CT with angiography (CTA), magnetic resonance imaging with angiography (MRA), and PET scan [7]. ...
... In fact, in approximately one-third of patients, the temporal arteries are not involved; therefore, imaging of larger arteries can be helpful in diagnosis [7]. Appropriate imaging modalities include Doppler ultrasonography, CT with angiography (CTA), magnetic resonance imaging with angiography (MRA), and PET scan [7]. Doppler ultrasound of axillary and subclavian arteries typically shows circumferential vessel wall thickening or incompressibility of the arterial lumen [9]. ...
Patient: Female, 27-year-old
Final Diagnosis: Giant cell arteritis
Symptoms: Cough
Medication:—
Clinical Procedure: —
Specialty: Pulmonology
Objective
Unknown etiology
Background
Chronic cough is a common medical concern. Giant cell arteritis (GCA) is an uncommon cause of chronic cough and is not usually suspected since symptoms can be non-specific. We present a case of chronic cough due to GCA in which symptoms were subtle but imaging was remarkable and clearly disclosed the diagnosis.
Case Report
A 71-year-old woman presented to the pulmonary clinic with a concern of worsening cough for 4 months. She had been treated with proton pump inhibitor, intranasal steroids, and antibiotics, without improvement. Other symptoms were an occasional headache for the prior 5 months, but this had resolved. She had a history of early-stage breast and thyroid cancers, both of which were treated surgically several years earlier and were in remission. Results of a physical examination including flexible video laryngoscopy of the upper airway were completely normal. Laboratory investigations showed normal blood chemistries and blood cell counts. Her C-reactive protein level was 1 mg/L (upper limit of normal <10) but her erythrocyte sedimentation level was 121 mm/hr (upper limit of normal <30). A positron emission tomography (PET) scan was performed as surveillance for her prior cancers. This showed diffuse tracer uptake in the aorta as well as bilateral common carotid, subclavian, and common iliac arteries, revealing GCA as the underlying diagnosis.
Conclusions
Giant cell arteritis is a rare cause of chronic cough. Other symptoms can be subtle or non-specific as in our case, and a high index of suspicion is needed to obtain a temporal artery biopsy. In these cases, imaging adjuncts can provide a non-invasive diagnosis.
