Epidemiology of biopsy‐proven giant cell arteritis in <scp>S</scp>outh <scp>A</scp>ustralia

Dunstan, Emma; Lester, Sue; Rischmueller, Maureen; Dodd, Thomas J.; Black, Robert; Ahern, Michael; Cleland, Leslie G.; Roberts‐Thomson, Peter; Hill, Catherine

doi:10.1111/imj.12293

Cited by 59 publications

(46 citation statements)

References 26 publications

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“…Infection as a trigger for GCA is an attractive hypothesis, which is consistent with reports of seasonal variations in GCA incidence [2,15], the proposed pivotal role of TLR activation in disease initiation [9], and the antigen-driven nature of the inflammatory process [11]. Several infectious agents have been implicated in the pathogenesis of GCA, including Mycoplasma pneumoniae, Chlamydia pneumonia, and varicella-zoster (reviewed in Ref.…”

Section: Introductionsupporting

confidence: 61%

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Giant cell arteritis

Ninan

Lester

Hill

2016

Best Practice & Research Clinical Rheumatology

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Section: Introductionsupporting

confidence: 61%

“…Vision loss, one of the most serious complications of GCA, occurs in up to 15e30% of cases [2,23]. An initial visual manifestation of GCA is often amaurosis fugax.…”

Section: Clinical Presentationmentioning

confidence: 99%

Giant cell arteritis

Ninan

Lester

Hill

2016

Best Practice & Research Clinical Rheumatology

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“…A recent study of biopsy-proven GCA disease in South Australia suggested an incidence in people aged > 50 years of only 32 per million per year, 20 although the relatively low incidence may be a result of the inclusion of biopsy-confirmed cases only. Biopsy for the diagnosis of GCA has a relatively low yield.…”

Section: The Role Of Temporal Artery Biopsy In the Diagnosis Of Giantmentioning

confidence: 99%

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

Luqmani

Lee

Singh

et al. 2016

Health Technol Assess

385

404

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Background Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9–61% of true cases. Objective To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. Design Prospective multicentre cohort study. Setting Secondary care. Participants A total of 381 patients referred with newly suspected GCA. Main outcome measures Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. Results We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician’s assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). Limitations There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. Conclusion We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. Future work Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. Funding The National Institute for Health Research Health Technology Assessment programme.

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“…The incidence increases with age, peaking around the age of 80 years. 1,2 High-dose glucocorticoids are the first-line treatment for GCA and their use may be prolonged. Consequently, the majority of patients experience glucocorticoid-related side effects.…”

mentioning

confidence: 99%

“…Consequently, the majority of patients experience glucocorticoid-related side effects. 2 Severe infections and infection-related mortality are increased during the first year after the diagnosis of GCA. 3 Cryptococcosis is a fungal infection caused by Cryptococcus neoformans, and is generally associated with immunodeficiency and immunosuppressive agents.…”

mentioning

confidence: 99%