Temporal artery biopsy: A diagnostic tool for systemic necrotizing vasculitis

Abstract

Objective. To describe the clinical, biologic, and histologic features of temporal artery biopsy (TAB)-localized systemic necrotizing vasculitides (SNV), and to assess their frequency among elderly patients undergoing TAB for suspected giant cell (temporal) arteritis (GCA).Methods. The frequency of a TAB localization of SNV was prospectively assessed in a multicenter study of elderly patients undergoing TAB for suspected GCA. All patients with SNV fulfilling the American College of Rheumatology criteria for a specific vasculitic syndrome and with evidence of vasculitis on TAB were included in a retrospective, descriptive study.Results. SNV was diagnosed based on the TAB in 1.4% of the patients with suspected GCA and in 4.5% of the positive (inflamed) TAB specimens. We retrospectively selected 27 patients (18 female, 9 male; mean ؎ SD age 62 ؎ 15 years, range 22-79 years) with SNV and TAB-localized vasculitis. Only 2 of these patients were known to have SNV before TAB localization. Twenty-two patients (81%) had cephalic symptoms, including jaw claudication in 33%, clinically abnormal temporal arteries in 33%, and neuro-ophthalmologic symptoms in 11%. All patients had systemic symptoms suggestive of SNV and histologically proven NV in the TAB specimens (70%) or elsewhere in other biopsy sites (74%). Abnormal biologic results suggestive of SNV were present in 17 patients (63%). For 4 patients, the TAB-documented involvement led to initial misdiagnoses of GCA, and systemic manifestations that developed under steroid therapy revealed the correct diagnosis. The final diagnoses of the patients were polyarteritis nodosa (PAN) (n ‫؍‬ 11), Churg-Strauss syndrome (n ‫؍‬ 6), micropolyangiitis (n ‫؍‬ 3), Wegener's granulomatosis (n ‫؍‬ 3), hepatitis B virus-related PAN (n ‫؍‬ 2), hepatitis C virus-related cryoglobulinemic vasculitis (n ‫؍‬ 1), and rheumatoid vasculitis (n ‫؍‬ 1).Conclusion. TAB-localized SNV presents a major diagnostic dilemma because it can mimic GCA. Careful analysis of clinical, biologic, and histologic data should lead to the correct diagnosis and help guide the clinician's choice of appropriate therapy.

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

“…[55][56][57][58] It has been suggested that TAB may be a useful test to diagnose other forms of vasculitis, which could mimic GCA. 59 There is an inevitable tension between obtaining enough material to make a diagnosis and initiating therapy before disease-related complications set in. In practice, it is common for patients to start on treatment as soon as a physician suspects the diagnosis, typically based on symptoms suggesting the diagnosis of GCA and possible laboratory investigations such as an elevated C-reactive protein (CRP) level or ESR.…”

“…11,115 Patients who had a positive biopsy but who did not have GCA were reported to have other forms of vasculitis. 59 We wanted to compare the performance of ultrasound, which we predicted would provide 87% sensitivity and 83% specificity or higher. Among 381 patients who had ultrasound and TAB for suspected GCA, 101 (27%) had a TAB consistent with GCA and 162 (43%) had an ultrasound result compatible with GCA.…”

New insights into the pathogenesis of giant cell arteritis

“…The classic histologic picture of GCA is characterized by panarteritis with a predominantly lymphomononuclear inflammatory cell infiltrate, with or without giant cells [5]. Recently, however, it has been demonstrated that together with transmural involvement, the inflammation may be restricted to the vasa vasorum (vasa vasorum vasculitis, VVV), to the periadventitial small vessels (small vessel vasculitis, SVV), or both [12].…”

“…In many patients a systemic inflammatory response may also occur with fever, weight loss and fatigue [2]. To date no specific circulating biomarkers have been identified and the gold standard for the diagnosis of GCA remains the biopsy of temporal artery (TAB) [3][4][5]. Histologically, arteries show inflammation and necrosis of the arterial media wall, infiltrating CD4 + T lymphocytes, macrophages multinucleated giant cells and/or epithelioid macrophages with the production of various cytokines and arterial remodelling [6,7].…”

A 56‐Year‐Old Man With Visual Changes and Arthralgias

“…However, his relatively young age and months of ocular symptoms without progression to blindness make GCA less likely. Antineutrophil cytoplasmic antibody-associated vasculitis and other primary forms of vasculitis can also affect the temporal arteries and mimic GCA and PMR (3,4). However, the patient lacks any features of a systemic small-or medium-vessel vasculitis.…”