It's Not All in Your Head

Towns, Kathryn; Szmitko, Paul E.; Smith, Chris; Detsky, Allan S.; Mourad, Ophyr

doi:10.1056/nejmcps0900533

Cited by 3 publications

(4 citation statements)

References 15 publications

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Section: Discussionmentioning

confidence: 65%

“…In conclusion, with only a few exceptions reported, including our 2 cases in whom the liver biopsies were performed, liver biopsies were not helpful diagnostically and did not explain the pathogenesis of abnormal ALP (and GGT) levels in a subset of patients with GCA. 40,41 As abnormal isotope scans suggesting reduced hepatic arterial flows were observed by Kyle et al 32 in patients with both PMR and GCA, future studies should focus on the role of hepatic artery-derived peribiliary plexus formed around intrahepatic and extrahepatic cholangiocytes as the primary place of ischemic injury in this subgroup of GCA patients. 40,42 Based on our findings and the previously cited publications, we strongly recommend that a PET/CT-based evaluation precedes the liver biopsy in the age-appropriate group of patients who may be suspected to have atypical GCA/LVV.…”

Section: Findings On Liver Biopsiesmentioning

confidence: 84%

“…In a study by Calamia and Hunder, 22 small noncaseating granulomas were observed in one patient. Cases of intrahepatic granulomas have been infrequently observed by some but not by the others 38–40 …”

Section: Discussionmentioning

confidence: 99%

“…Cases of intrahepatic granulomas have been infrequently observed by some but not by the others. [38][39][40] In the most recently published case of FUO, eventually diagnosed as GCA, liver biopsy was helpful. 40 Liver biopsy revealed a mononuclear cell infiltrate containing a single giant cell, which was disrupting the outer and medial walls of one small arteriole.…”

Section: Findings On Liver Biopsiesmentioning

confidence: 99%

See 3 more Smart Citations

Atypical Large Vessel Vasculitis Presenting With Cholestatic Liver Abnormalities

Sangha¹,

Lenert²,

Dawoud³

et al. 2021

J Clin Rheumatol

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Clinicians usually easily recognize cranial manifestations of giant cell arteritis (GCA) such as new-onset headache, jaw claudication, scalp tenderness, and abrupt changes in visual acuity or blindness; however, when presented with an aberrant clinical course, the diagnosis becomes more elusive. In addition to temporal arteries and other extracranial branches of the carotid arteries, large vessel vasculitis (LVV) can also affect other blood vessels including coronary arteries, aorta with its major branches, intracranial blood vessels, and hepatic arteries.Over time, the scope of the symptoms typically associated with LVV has broadened and includes cases of fever of unknown origin accompanied with other constitutional symptoms that can mimic a range of neoplastic and infectious diseases. In up to half of patients with atypical LVV, liver enzyme level elevations with a cholestatic pattern have been observed. Alkaline phosphatase level and γ-glutamyl transferase level elevations tend to be more prevalent in those LVV patients with vigorous inflammatory responses, particularly in those with fever and other nonspecific constitutional symptoms. These patients also have more profound anemia and thrombocytosis. With the exception of rare instances of vasculitides and granulomas affecting the liver tissue, liver biopsy is generally of little help and primarily shows nonspecific changes of fatty liver.In this article, we review 3 patients who were eventually diagnosed with atypical LVV. The diagnosis was confirmed with temporal artery biopsy in 2 patients and with positron emission tomography/computed tomography in 1 patient. The common hepatic abnormality observed in all patients was the elevation of alkaline phosphatase level, which tended to respond rapidly to initiation of immunosuppressive treatment.

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Section: Discussionmentioning

confidence: 65%

Section: Findings On Liver Biopsiesmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 99%

Section: Findings On Liver Biopsiesmentioning

confidence: 99%

See 2 more Smart Citations

Atypical Large Vessel Vasculitis Presenting With Cholestatic Liver Abnormalities

Sangha¹,

Lenert²,

Dawoud³

et al. 2021

J Clin Rheumatol

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ANA (+) ANCA (+) systemic vasculitis associated with the use of minocycline: case-based review

2013

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Minocycline is a synthetic tetracycline-derived antibiotic with significant anti-inflammatory properties that may benefit patients with rheumatoid arthritis. Surprisingly, chronic exposure to minocycline can also cause a breach in immunologic tolerance resulting in a variety of autoimmune syndromes such as drug-induced lupus or autoimmune hepatitis. Vasculitis, most commonly resembling cutaneous polyarteritis nodosa, has also been seen in patients taking this drug. Herein, we present a case of biopsy-proven systemic vasculitis presenting as an ANA (+) ANCA (+) polyarteritis nodosa-like syndrome in a male patient who was taking minocycline for his acne for approximately 2 years. Patient initially presented with constitutional symptoms such as profound weight loss and fatigue, along with myalgias, oligoarticular arthritis, and livedo reticularis. About 2 months later, he developed a severe left testicular pain. Biopsy showed vasculitis complicated with the infarction of the left testis. Angiography revealed microaneurysms in the renal and splenic circulation. Stopping the offending drug, along with the short course of prednisone and hydroxychloroquine, resulted in prompt resolution of his symptoms. We additionally present a comprehensive review of biopsy-proven cases of vasculitis associated with chronic minocycline treatment focusing on its pathogenesis and clinical manifestations.

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Boundaries of a systemic disease: a protean presentation of giant cell arteritis

Camara

Patrício

et al. 2020

BMJ Case Rep

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A 60-year-old man was hospitalised with persistent fever, arm pain, dry cough and cholestasis. Diagnostic workup was remarkable for elevated inflammatory markers. Infectious diseases and autoimmune screening were negative. Imaging modalities excluded a neoplastic aetiology. Liver biopsy was negative for granulomatous or lymphomatous infiltrations. Giant cell arteritis (GCA) was suspected, but temporal artery Doppler ultrasound and biopsy were non-diagnostic. A positron emission tomography scan showed intense metabolic uptake in large vessels suggesting the diagnosis of GCA. Prednisolone was initiated with clinical and analytical improvement. At 1-year follow-up, there were no relapses and the patient remains symptom free.

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It's Not All in Your Head

Cited by 3 publications

References 15 publications

Atypical Large Vessel Vasculitis Presenting With Cholestatic Liver Abnormalities

Atypical Large Vessel Vasculitis Presenting With Cholestatic Liver Abnormalities

ANA (+) ANCA (+) systemic vasculitis associated with the use of minocycline: case-based review

Boundaries of a systemic disease: a protean presentation of giant cell arteritis

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