sign in sign up
<<
Home , Blurred vision, Giant cell arteritis

June 2008 • www.rheumatologynews.com /CT Diseases 23 Vision Loss Is Preventable in

BY NANCY WALSH New York Bureau

L IVERPOOL, ENGLAND — is a critical ischemic process and HASKAR . B R

should be considered a preventable D in the eye, yet vision loss almost always oc- curs before treatment is begun, according to Dr. Bhaskar Dasgupta. Giant cell arteritis (GCA), the most com- ASGUPTA HOTOS COURTESY mon of the vasculitides, has an incidence P D of 7-29/100,000 people aged 50 and older At left: associated with GCA, characterized by a pale disc with diffuse edema, splinter shaped hemorrhages, and in Europe, notably among women. The optic atrophy. Center: an example of central retinal artery occlusion in GCA. At right: a histology of giant cell arteritis. mean age of onset is 70 years. GCA predominantly affects the cranial who headed a working group of the British ticularly in patients at highest risk for neu- timal proliferation, and vascular occlusion. branches of arteries arising from the arch Society for that has drafted ro-ophthalmic complications. The should preferably be done of the , and often coexists with guidelines for the management of GCA. “Pitfalls for the unwary include the fact within a week of starting steroid therapy, (a generalized stiff- While new onset and elevat- that GCA does not always present with but may remain positive for 14-28 days af- ness and aching of the muscles around the ed inflammatory markers are typical, GCA headache, and we now know that jaw ter treatment is initiated. A trial of corti- neck and ), said Dr. Dasgupta, does not always present classically—par- is a cardinal red flag warning costeroids should not substitute for the of imminent vision loss,” Dr. Dasgupta biopsy, Dr. Dasgupta said. said at the annual meeting of the British The usual starting dose of 40- : An Important Sign Society for Rheumatology. 60 mg/day should be continued until symp- Immediate institution of high-dose cor- toms and laboratory abnormalities resolve. r. Dasgupta also presented a protein (CRP) was 13 mg/L. Temporal ticosteroids is needed to avoid loss of vi- However, in the setting of evolving vision Dposter at the meeting of the case artery biopsy confirmed GCA, reveal- sion. Biopsy of the temporal artery also loss or , intravenous of an 81-year-old woman with a 3-day ing severe mediointimal proliferation. should be done, but treatment should not methylprednisolone, 500 mg to 1 g daily for history of complete vision loss in the She was treated with IV methylpred- be delayed in the interim. 3 days followed by oral prednisone, should right eye and 2 weeks of intermittent nisolone for 3 days, with vision im- American College of Rheumatology cri- be used. in the left eye. provement in the left eye and a fall in teria for GCA include age of onset 50 years The steroids should not be tapered too She had been seen by her general CRP to 2 mg/L, but when she was or more, new onset headache, temporal quickly—certainly not before 4 weeks, Dr. practitioner 4 weeks earlier with jaw switched to oral prednisone the left- artery abnormalities, elevated erythrocyte Dasgupta cautioned. But because GCA claudication but had no history of sided vision again deteriorated. Her vi- sedimentation rate, and abnormal artery tends to follow a chronic relapsing course headache, tenderness, or sion is currently 20/200 in the left eye, biopsy. But other features—jaw and and long-term therapy in polymyalgia rheumatica. She was not and she cannot perceive light in her claudication, , and amaurosis fu- these patients is associated with a high rate referred for exclusion of giant cell ar- right. gax—should be considered the “TIAs” of of adverse events—in one series nearly teritis (GCA) or given . “This case illustrates the importance critical , said Dr. Dasgupta, a con- half of patients had fractures—various At Southend Hospital, she was un- of recognizing jaw claudication as a sultant rheumatologist at Southend Uni- immunosuppressive therapies have been able to perceive light in her right eye predictor of vision loss in GCA. This versity Hospital, Westcliff (England). tried. Though methotrexate trials have had and had minimal vision in the left. The patient had none of the other well-rec- “The concept of symptom-to-throm- conflicting results, the drug was shown in right optic disc was swollen and pale ognized features of GCA, and only a bolysis time in myocardial infarct and a meta-analysis to have a small effect in pre- and the retinal arteries were attenuated, modest rise in her inflammatory mark- stroke is well established. We believed venting relapses, he said. There have also while there was pallor and blurring of ers. We suspect that if she had de- that ‘symptom-to-steroid’ time should be been promising case reports of biologics. nasal margin of the left optic disc. Both scribed headache, the diagnosis would adopted as an audit standard in GCA,” Dr. “In my view the timing of treatment is temporal arteries were thickened, have been recognized when she initial- Dasgupta said in an interview. the most important factor. Our approach to wrote Dr. Frances A. Borg, Dr. Dasgup- ly presented, and steroid therapy Histologic findings on biopsy of the tem- GCA today is almost leisurely compared to ta’s colleague. Erythrocyte sedimenta- would have been instituted in time to poral artery can include mononuclear cell the modern approach to critical ischemia at tion rate was 27 mm/hr and C-reactive save her vision,” Dr. Borg wrote. infiltration; granulomatous , other sites such as the myocardium and the usually with multinucleated giant cells, in- brain,” Dr. Dasgupta said. ■ Minocycline, Others Cause Spike in Drug-Induced Lupus Cases

BY NANCY WALSH the department of dermatology at New York University SCLE can be difficult to sort out, with targetoid lesions New York Bureau Medical Center, New York. mixed with papulosquamous or annular lesions. Presen- Hydralazine, which had fallen out of favor as an anti- tation can also resemble erythema multiforme or toxic epi- N EW Y ORK — The contemporary use of minocycline hypertensive, has regained popularity as part of combi- dermal necrolysis, with disadhesion of the epidermal lay- for acne and hydralazine for heart failure is expanding the nation therapy for heart failure in African Americans fol- er and sloughing of the skin. “Patients with this subtype spectrum of drug-induced lupus. lowing the benefits seen in the African-American Heart have very high morbidity and mortality,” he said. Minocycline-induced lupus was first reported in the ear- Failure Trial (N. Engl. J. Med. 2004;351:2049-57). An audience member asked what happens when the of- ly 1990s, and more than 250 cases have now been report- Hydralazine is one of the “big five” causes of classic fending drug is withdrawn. “It can sometimes take ed to the World Health Organization. There is a 5:1 female- drug-induced lupus, along with procainamide, isoniazid, months for this to remit, and some patients require ad- to-male predominance. Clinical features include , quinidine, and phenytoin, but more than 100 drugs have ditional therapy, but 95% of patients ultimately do remit,” morning stiffness, myalgias, polyarthralgias, and sym- been implicated in the 15,000-20,000 cases reported in the Dr. Franks said at a rheumatology meeting sponsored by metric arthritis. It is also characterized by large vessel vas- United States annually, he said. New York University. culitis, and in more than 60% of patients, antineutrophil “In my opinion, patients starting hydralazine, or any Another audience member asked what to do if a pa- cytoplasmic are present and antihistone anti- drug in the big five for that matter, should have a base- tient’s baseline ANA is positive, and whether that represents bodies are not. This is in contrast to “classic” drug-induced line test for ANA, although that is somewhat controver- a contraindication to hydralazine therapy, for example. lupus, in which antihistone antibodies are prominent. sial,” Dr. Franks said. “That is why I said doing a baseline ANA is controversial,” Other autoantibodies also can be seen in minocycline- The third main type of drug-induced lupus is subacute Dr. Franks replied. “A number of groups do not suggest induced lupus, including antinuclear (ANA) and cutaneous lupus erythematosus (SCLE), which also is as- doing this, but clearly autoantibodies and a loss of toler- anti–double-stranded DNA, said Dr. Andrew G. Franks Jr. sociated with an ever-widening variety of agents, in- ance precede the development of lupus, so one could be “The likelihood of developing a lupuslike syndrome is cluding the thiazide diuretics, antifungals, calcium chan- prudent and repeat the ANA yearly and see if it turns pos- elevated 8.5-fold with minocycline, so many clinicians are nel blockers, and ACE inhibitors. There also have been itive and the titer starts rising,” he said. now moving away from using minocycline for acne and reports involving statins, leflunomide, and tumor necro- Dr. Franks reported having no financial relationships rosacea and switching to doxycycline,” said Dr. Franks of sis factor inhibitors. to disclose. ■