Background: It is known that giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) often occur together. So far, the prevalence of GCA in newly diagnosed PMR patients has not been evaluated in a prospective ultrasound study. Objective: The aim of this study was to assess the prevalence of GCA using vascular ultrasound in patients with newly diagnosed PMR. Design: A consecutive cohort of newly diagnosed PMR patients was prospectively evaluated for the presence of GCA with the use of systematic musculoskeletal and vascular ultrasound examination. Methods: Overall, 60 patients with newly diagnosed PMR were prospectively enrolled. Symptoms and laboratory findings were collected. All patients underwent ultrasound of shoulder and hip joints, and vascular ultrasound evaluating the facial, temporal, carotid, vertebral and axillary arteries. Patients were diagnosed with GCA if they had ultrasound imaging findings of GCA. Patients with PMR (PMR-group) and patients with PMR and GCA (PMR–GCA-group) were compared, and a C-reactive protein (CRP) cut-off value was evaluated. Results: GCA was diagnosed in 28 of 60 PMR patients (46%). The PMR-group consisted of 20 (62.5%) females with a mean age of 69 (±9.9) years, while the PMR–GCA-group consisted of 11 (39.3%) females with a mean age of 74 (±8.4) years. In 13 of 28 patients (46%) in the PMR–GCA-group, GCA was subclinical and only diagnosed by ultrasound. The PMR–GCA-group showed higher values of joint effusion and significantly higher CRP values. A CRP cut-off value of 26.5 mg/litre (reference range 0–5 mg/litre) yielded a sensitivity of 66% with a specificity of 73% for GCA. Conclusion: GCA was found in 46% of newly diagnosed PMR patients; 22% of the patients with PMR had asymptomatic GCA. Joint effusions were higher in the PMR–GCA-group, with significant results for the hip joint. A CRP cut-off value of ⩾26.5 mg/litre in PMR can help in the identification of subclinical GCA.

Background:Giant cell arteritis (GCA) is the most common form of systemic vasculitis affecting people aged 50 years and older.1Although it is known, that GCA often coexists with polymyalgia rheumatica (PMR)2, prevalence of GCA in consecutive patients with PMR has not been investigatedObjectives:To prospectively examine the prevalence of GCA in consecutive patients with PMR by vascular ultrasound (US).Methods:Patients with newly diagnosed PMR fulfilling the ACR /EULAR classification criteria3were included. Vascular US examination of the extracranial arteries typically involved in GCA, such as axillary arteries, vertebral arteries, common carotid arteries, superficial temporal arteries with both frontal and parietal branches, occipital arteries, facial arteries and the central retinal arteries was performed in all PMR patients. Diagnosis of GCA was made, if intima-media thickness (IMT) was above respective cut-off values.4Results:Fifty patients with diagnosis of PMR underwent vascular US. Twenty-three patients (46%) had PMR without GCA (PMR-group). The mean age in this group was 71 years (SD ± 10) with seventeen (73%) females. In twenty-seven PMR patients (54%) GCA was diagnosed (GCA-PMR group); the mean age in this group was 74 years (SD ± 9) with ten (37%) females respectively. Mean C-reactive protein (CRP) values were 29.4 mg/l (SD±24.5) in the PMR-group and 52.2 mg/l (SD±43.2) in the GCA-PMR-group. Although different mean values between the PMR-group and the GCA-PMR-group were observed, CRP values did not differ significantly between the two groups (p = 0.1432). Ten (37%) patients of the GCA-PMR group did not have GCA symptoms and diagnosis of GCA was only determined by ultrasound examination. Symptoms and numbers of patients with respective symptoms are depicted in Table 1 and 2.Table 1.Symptoms and signs in both groupsSymptoms and signsGroupPMR-groupGCA-PMR-groupMorning stiffness22 (95%)23 (85%)≥1 shoulder with synovits or bursitis trochanterica12 (52%)13 (48%)≥1 shoulder or hip with synovitis or bursitis11 (48%)14 (51%)hip pain23 (100%)23 (85%)No other joints affected22 (95%)26 (96%)PMR-group: patients with diagnosis of polymyalgia rheumatica onlyGCA-PMR-group: patients with diagnosis of polymyalgia rheumatic and giant cell arteritisConclusion:Prevalence of GCA in patients with PMR in our cohort was 54%. Ten (37%) patients with GCA and PMR did not have any GCA symptoms. Performing vascular US in patients with PMR can be useful to diagnose a clinical inapparent GCA. Prompt onset of the respective therapy could prevent complications of GCA and improve disease outcome.References:[1]Warrington KJ, Matteson EL. Management guidelines and outcome measures in giant cell arteritis (GCA). Clin Exp Rheumatol 2007;25:137–41[2]Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. The Lancet 2008;372:234–45.[3]Dasgupta B, Cimmino MA, Kremers HM, et al. 2012 Provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheum 2012;64:943–54.[4]Schäfer VS, Juche A, Ramiro S, Krause A, Schmidt WA. Ultrasound cut-off values for intima-media thickness of temporal, facial and axillary arteries in giant cell arteritis. Rheumatology (Oxford) 2017;56:1479–83.Table 2.Number of patients in each group with symptoms of giant cell arteritisSymptomsGroupPMR-groupGCA-PMR-groupVisual symptoms2 (9%)8(30%)Headache2 (9%)9 (33%)Jaw claudication4 (18%)10 (38%)Scalp tenderness0 (0%)5 (19%)No GCA symptoms15 (65%)10 (37%)PMR-group: patients with diagnosis of polymyalgia rheumatica onlyGCA-PMR-group: patients with diagnosis of polymyalgia rheumatic and giant cell arteritisDisclosure of Interests:None declared

Background Giant cell arteritis (GCA) is the most common form of systemic vasculitis in persons aged 50 years and older. Medium and large vessels, like the temporal and axillary arteries, are commonly affected. Typical symptoms are headache, scalp tenderness, jaw claudication and ophthalmological symptoms as loss of visual field, diplopia or amaurosis due to optic nerve ischemia. Tongue pain due to vasculitic affection of the deep lingual artery can occur and has so far not been visualized and followed up by modern ultrasound. Case presentation We report the case of a 78-year-old woman with typical symptoms of GCA, such as scalp tenderness, jaw claudication and loss of visual field, as well as severe tongue pain. Broad vasculitic affection of the extracranial arteries, vasculitis of the central retinal artery and the deep lingual artery could be visualized by ultrasound. Further did we observe a relevant decrease of intima-media thickness (IMT) values of all arteries assessed by ultrasound during follow-up. Especially the left common superficial temporal artery showed a relevant decrease of IMT from 0.49 mm at time of diagnosis to 0.23 mm on 6-months follow-up. This is the first GCA case described in literature, in which vasculitis of the central retinal artery and the lingual artery could be visualized at diagnosis and during follow-up using high-resolution ultrasound. Conclusion High-resolution ultrasound can be a useful diagnostic imaging modality in diagnosis and follow-up of GCA, even in small arteries like the lingual artery or central retinal artery. Ultrasound of the central retinal artery could be an important imaging tool in identifying suspected vasculitic affection of the central retinal artery.

BackgroundGiant cell arteritis (GCA) is an immune-mediated, granulomatous vasculitis that primarily affects the elderly and results in local vascular changes of middle-sized and large arteries. A protracted diagnosis delaying high-dose corticosteroid therapy may result in permanent visual loss. Therefore, invasive and time-consuming biopsy of the superficial temporal artery has been replaced by high-resolution vascular ultrasound of the temporal and axillary artery to evaluate extracranial inflammation. Intracranial involvement of the ophthalmic vessels can be visualized by magnetic resonance imaging. Transorbital Ultrasound (TOS), as a simple and inexpensive diagnostic method, could be an option for assessing the optic nerve and the central retinal artery (CRA) and might improve diagnostic sensitivity in GCA, especially in anterior optic neuropathy (AION).ObjectivesThe purpose of this study was to assess the utility of TOS in patients with untreated and newly diagnosed GCA.MethodsPatients with new GCA diagnosed by a board-certified rheumatologist who also met the expanded ACR-EULAR classification criteria were enrolled in the study between October 1, 2018, and May 31, 2022. Each participant underwent TOS to assess the CRA and optic nerve diameter (OND). The eyes of the patients with GCA were categorized as eyes with or without visual impairment (VI), which was defined as transient or persistent visual field loss, diplopia, amaurosis, and blurred vision. Peak systolic velocity (PS), end diastolic velocity (ED), resistance index (RI) of the CRA and OND were recorded.ResultsA total of 54 GCA patients were prospectively enrolled in the study, 27 of whom had VI in at least one eye. To account for repeated measures within a patient, associations between TOS and VI were evaluated using linear mixed-effect models (LME). PS and ED values of the CRA were statistically significant lower in the eyes with GCA manifestation (ß=-1.93; p<0.001 for PS; ß=-0.61; p=0.003 for ED). The RI of the CRA was statistically significant reduced in the eyes with GCA associated VI (ß=-0.04; p=0.007). OND was lower in the eyes with VI, too (ß=-0.36; p=0.06) (Table 1, Figure 1).ConclusionIn TOS, eyes affected by VI exhibited significantly reduced PS, ED, and RI indicating an inflammatory process of the intracranial vessels leading to impaired blood flow to the optic nerve and contributing to ischemia-associated optic neuropathy. The shown decrease in OND is probably due to reduced blood flow and the resulting lessened vessel diameter and, in the case of a persistent depletion of blood flow, due to atrophic alterations of the optic nerve suggestive of irreversible damage. Therefore, VI in combination with decreased PS, ED, RI and OND may constitute a specific finding in the diagnosis of optic affection in GCA. Our study was the first to prospectively demonstrate the diagnostic value of TOS in untreated and new diagnosed GCA patients as a complementary diagnostic tool to assess GCA associated intracranial inflammation.Table 1.Mean values of central retinal artery flow velocity, resistance index, optic nerve diameter in patients with/ without visual impairmentGCA without VIGCA with VILME (ß)p-valuePeak systolic velocity (SD); cm/s12.95 (± 3.84)10.16 (± 4.10)- 1.93<0.001End diastolic velocity (SD); cm/s3.91 (± 0.12)3.18 (± 1.27)-0.610.003Resistance Index (SD)0.69 (± 0.10)0.64 (± 0.17)-0.040.007Optic nerve diameter (SD); mm5.3 (± 0.99)4.93 (± 1.1)-0.360.06Eyes affected by VI exhibited reduced flow velocity and resistance index of the central retinal artery and decreased optic nerve diameter. Abbrev.: GCA: Giant Cell Arteritis, VI: Visual impairment, LME: Linear mixed-effects model, SD: standard deviationFigure 1.Assessment of central retinal artery/ optic nerve diametera, b: Measurement of central retinal artery flow velocity/ optic nerve diameter; c, d: Central retinal artery flow velocity (cm/s), e: Resistance Index, f: Optic nerve diameter (mm). Abbrev.: GCA: Giant Cell Arteritis, VI: Visual impairment, PS: Peak systolic velocity, ED: End diastolic velocityREFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Background:Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) often coexist.1The role of modern ultrasound in diagnosis of GCA as well as PMR is well known.2To date it is unknown, whether patients with GCA and PMR have a different vasculitis pattern in ultrasound (US) examination than patients with GCA only.Objectives:To prospectively identify differences in vasculitis patterns in consecutive patients with newly diagnosed GCA and PMR compared to newly diagnosed GCA patients without PMR.Methods:US examination of the arteries typically affected in GCA, such as axillary arteries, vertebral arteries, superficial temporal arteries with both frontal and parietal branches and facial arteries was performed in patients with GCA and PMR (GCA-PMR-group) as well as in patients with GCA only (GCA-group) at time of first diagnosis. Arteries were defined as pathological, if measured intima-media-thickness by US was above respective cut-off values.3Results:The GCA-PMR-group consisted of 27 patients, the GCA-group of 18 patients. In the GCA-PMR-group, a total of 206 arteries were affected, while in the GCA-group 131 arteries were affected. Mean age and gender distribution was 74 years (SD± 9) with 10 (37%) females in the GCA-PMR-group and 76 years (SD± 9) with 10 (55%) females in the GCA-group. Median values of C-reactive protein (CRP) were 57.2 (IQR 31.7-75.7) in the GCA-group and 48.3 (IQR 17.5- 79.9) in the GCA-PMR-group, no significance was observed (p= 0.3577). Mean number of affected arteries per patient was 7.63 and 7.28 in the GCA-PMR-group and GCA-group, respectively. Altogether, no significant difference in vascular pattern between the two groups was observed. Exact numbers, distribution and IMT-values for all measured arteries are depicted in table 1.Conclusion:In our cohort, we did not observe a significant difference in vascular patterns between patients with GCA and PMR and GCA only patients.References:[1]Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. The Lancet 2008;372:234–45.[2]Dejaco C, Ramiro S, Duftner C, et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis 2018;77:636–43.[3]Schäfer VS, Juche A, Ramiro S, Krause A, Schmidt WA. Ultrasound cut-off values for intima-media thickness of temporal, facial and axillary arteries in giant cell arteritis. Rheumatology (Oxford) 2017;56:1479–83.Disclosure of Interests:None declared