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Suspected giant cell arteritis: a study of referrals for temporal artery biopsy Tanya N. Moutray,* MRCOphth; Michael A. Williams,*† BMedSci, MRCOphth; Jayne L. Best,* FRCOphth ABSTRACT • RÉSUMÉ
Background: The purpose of this study is to describe the nature of cases undergoing temporal artery biopsy (TAB) for suspected giant cell arteritis (GCA). Methods: A retrospective review of case notes was undertaken for all patients on whom ophthalmologists had performed TAB in 2 teaching hospitals between 1995 and 2001. Presenting symptoms, referring specialty, TAB result, treatment, and discharge diagnosis were recorded. Results: Ophthalmologists performed TAB on 110 patients for suspected GCA. A variety of specialties referred patients to ophthalmology for TAB; presenting symptoms varied with referral source. Of the 110 TABs, 21 (19%) were reported as positive for GCA, 84 (76%) were negative, and 5 (4.5%) were reported as inadequate. The symptoms most commonly associated with a positive TAB were visual disturbance (15/21) and headache (15/21).The odds ratios for having a positive TAB result rather than a negative result were 1.0 for the presence of headache, 4.1 for visual disturbance, and 6.7 for jaw claudication. Interpretation: Physicians were faced with a different population of GCA suspects than ophthalmologists. While physicians should be alert to the significance of visual symptoms or jaw claudication, ophthalmologists should be ready to facilitate prompt TABs when appropriate. TAB should be performed promptly and an adequate length of artery taken for biopsy. An argument can be made that TAB is not needed in cases of suspected GCA. However, a positive result provides firm justification for the use of steroids.We feel that TAB has a useful role and we make reference to methods to maximize its usefulness. Contexte : Cette étude a pour objet de définir la nature des cas de biopsie de l’artère temporale (BAT) pour suspicion d’artérite giganto-cellulaire (AGC). Méthodes : Rétrospective des dossiers de tous les patients qui avaient subi une BAT dans deux hôpitaux universitaires entre 1995 et 2001. On y a relevé les symptômes, la spécialité adressante, le résultat de la BAT, le traitement et le diagnostic à la sortie. Résultats : Les ophtalmologistes avaient pratiqué une BAT chez 110 patients soupçonnés d’AGC, que divers spécialistes avaient adressés en ophtalmologie à cette fin; les symptômes variaient selon les sources d’orientation. Parmi les 110 BAT, 21 (19 %) avaient un diagnostic d’AGC positif, 84 (76 %) négatif et 5 (4,5 %) insuffisant. Les symptômes associés au diagnostic positifs étaient les troubles visuels (15/21) et les maux de tête (15/21). Les rapports de cotes indiquant des résultats BAT positifs plutôt que négatifs étaient de 1,0 pour maux de tête, 4,1 pour troubles visuels et 6,7 pour claudication de la mâchoire. Interprétation : Les médecins se trouvent devant une population sujette à l’AGC différente de celle des ophtalmologistes. Alors que les médecins devraient être vigilants quant à la signification des symptômes visuels ou de la claudication de la mâchoire, les ophtalmologistes devraient être prêts à faciliter la réalisation rapide d’une BAT au besoin. Celle-ci doit être pratiquée rapidement et la parcelle d’artère prélevée doit être adéquate. On peut alléguer que la BAT n’est pas nécessaire pour les cas de soupçon d’AGC. Néanmoins, un résultat positif justifie à coup sûr l’emploi de stéroïdes. Nous estimons que la BAT joue un rôle utile et nous indiquons les moyens d’en maximiser l’utilité.
From *the Department of Ophthalmology, Royal Victoria Hospital, Belfast, U.K.; and †the Department of Geriatric Medicine, Queen’s University of Belfast, U.K.
Correspondence to Michael Williams, MRCOphth, Department of Geriatric Medicine, Queen’s University of Belfast, Whitla Medical Building, 97 Lisburn Rd., Belfast, U.K., BT9 7BL;
[email protected]
Poster presentation at the Irish College of Ophthalmologists Meeting in Killarney, U.K., April 27–29, 2005, and at the Third International Conference on Giant Cell Arteritis and Polymyalgia Rheumatica in Cambridge, U.K., July 2005
This article has been peer-reviewed. Cet article a été évalué par les pairs. Can J Ophthalmol 2008;43:445–8 doi:10.3129/i08-070
Originally received Nov. 7, 2007. Revised Feb. 24, 2008 Accepted for publication Mar. 17, 2008 Published online July 2, 2008 CAN J OPHTHALMOL—VOL. 43, NO. 4, 2008
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G
iant cell arteritis (GCA) is a systemic vasculitis that characteristically affects the blood vessels of the head and neck. GCA can present in a variety of ways to a variety of specialties. Most patients with GCA are said to be treated by rheumatologists.1 However, GCA is regarded as “the prime medical emergency in ophthalmology,” there being few other diseases in which the prevention of blindness depends so much on prompt recognition and early treatment.1 Diagnosis is often made on purely clinical grounds, but a temporal artery biopsy (TAB) provides a definitive diagnosis. The purpose of the present study was to describe cases referred to ophthalmologists for TAB. METHODS
A retrospective review of case notes was performed for all patients on whom ophthalmologists had performed TAB in 2 teaching hospitals between 1995 and 2001. This was originally carried out as an audit, and approval was given by the audit departments of both hospitals. A record was made of the source of referral to the ophthalmologists for TAB, presenting symptoms, and treatment commenced. The eventual discharge diagnosis was ascertained from the discharge letter. Odds ratios and χ2 tests were performed as appropriate. RESULTS
According to data obtained from the 2 hospitals, ophthalmologists performed TAB on 110 patients for suspected GCA between 1995 and 2001. Of these, 78% (86/110) were female and 93% (102/110) were over 60 years of age. Most biopsies (74%) were performed within 1 week of presentation. Of the 110 patients, 1.8% (2 patients) had complications, both hematomas, 1 requiring surgery for ligation of the bleeding vessel. Overall, 19% of TABs (21/110) were reported as positive for GCA, 76% (84/110) were negative, and 4.5% (5/110) were reported as inadequate because of insufficient size or quality of the specimen. The most common presenting symptoms were headache (68%, 75/110), visual symptoms (43%, 47/110), malaise (31%, 34/110), and jaw claudication (18%, 20/110). The odds ratios (ORs) for having a positive TAB result rather than a negative result were 1.0 for the presence of headache, 4.1 for visual disturbance, 0.8 for malaise, and 6.7 for jaw claudication. Referral specialties to the ophthalmology department for TAB were medical (most commonly rheumatology and neurology) (52%, 57/110), from within ophthalmology (45%, 50/110), and other surgical specialties, specifically otorhinolaryngology and vascular surgery (2.7%, 3/110). Of those referred from ophthalmology 34% (17/50) had positive TAB results, while only 7.0% (4/57) referred by physicians had positive results. Patients referred for TAB from medical or surgical specialties other than ophthalmology were significantly less likely to have presented with
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visual disturbance and significantly more likely to have presented with myalgia than patients referred from within ophthalmology (p < 0.05) (Table 1). Of cases referred for TAB from the ophthalmology department 68% (34/50) had visual symptoms, and for these cases, a variety of signs was recorded (Table 2). For headache, malaise, or jaw claudication there was no significant difference in the proportion referred for TAB from ophthalmology versus other specialties (Table 1). According to their discharge letters, 50% of patients (55/110) had a diagnosis of GCA. The TAB result significantly influenced the probability of a discharge letter diagnosis of GCA (p < 0.001). All the patients with a positive TAB result (21/21) had a discharge letter diagnosis of GCA, and 40% of cases (34/84) with a negative TAB result had a discharge diagnosis of GCA. Those not given a diagnosis of GCA had a variety of other diagnoses: “non-specific headache” (16/110), polymyalgia rheumatica (11/110), nonarteritic ophthalmic conditions (11/110), and “others” (17/110), including infection and malignancy. For all patients the erythrocyte sedimentation rate (ESR) was measured, and 87% (96/110) had a result of >50 mm/h, including all 21 patients with a positive biopsy. In only 37% of cases (41/110) was C-reactive protein (CRP) measured. This level was recorded as elevated in 21 patients, 4 of whom had a positive biopsy result. Overall, 70% of patients referred for TAB (77/110) began treatment with steroids. Of these 77 patients, 97% (75/77) started taking steroids before the results of TAB were available, and 2.6% (2/77) did not commence steroids until the results of biopsy were available. The TAB result was positive in these 2 cases. Steroids were stopped before discharge in 24 patients, within 6 months in 19 patients, and within 2 years in 10 patients. Of 24 patients still receiving mainteTable 1—Presenting symptoms of suspected giant cell arteritis for each referring specialty Ophthalmology (n = 50)
Medical (n = 57)
Surgical (n = 3)
Headache, n (%)
33 (66)
39 (68)
3 (100)
Jaw claudication, n (%)
12 (24)
8 (14)
Malaise, n (%)
13 (26)
19 (33)
2 (67)
34 (31)
0.418
Myalgia, n (%)
9 (18)
22 (39)
2 (67)
33 (30)
0.022
34 (68)
13 (23)
47 (43)
