Review

Respiratory and otolaryngologic manifestations of arteritis T.F. Imran1, S. Helfgott2

1Rutgers University, New Jersey Medical ABSTRACT disease and “acute, sharp, catarrhal af- School, Newark, USA; Objective. The classical presentation fections, including those showing heat 2 Division of Rheumatology, Brigham and of giant cell arteritis (GCA) includes in and of the temporal Women’s Hospital and Harvard Medical the new onset of headache, scalp ten- muscles” and that these conditions may School, Boston, MA USA. derness, facial or jaw claudica- lead to vision loss (1). In the English Tasnim F. Imran, MD tion in an older patient. Many patients literature, one of the earliest descrip- Simon Helfgott, MD with GCA have features consistent with tions of GCA is attributed to Sir Jona- Please address correspondence to: the diagnosis of polymyalgia rheumat- Simon Helfgott, MD, than Hutchinson, who, in 1890, de- Division of Rheumatology, ic (PMR) and nearly all have elevated scribed a patient who had “red streaks Brigham and Women’s Hospital, markers of inflammation such as the on his head” which were painful and 45 Francis Street B-3, erythrocyte sedimentation rate (ESR) prevented him from wearing his hat. Boston MA 02115, USA. or the serum C-reactive protein (CRP) These red streaks were thought to be E-mail: [email protected] Respiratory and -nose-throat (ENT) swollen temporal arteries (2). Horton et Received on September 30, 2014; accepted signs and symptoms such as cough, al. characterised GCA as being a sys- in revised form on February 10, 2015. tongue infarction, trismus, temic illness (3). They observed ten- Clin Exp Rheumatol 2015; 33 (Suppl. 89): and facial swelling are less commonly derness over the scalp, painful nodules S164-S170. described, yet they may be the initial along the temporal arteries, headaches, © Copyright Clinical and presentation of GCA and weight loss and jaw stiffness in Experimental Rheumatology 2015. Our aim was to review the published two patients. In 1938, the observation literature on the topic of respiratory of an increased erythrocyte sedimen- Key words: giant cell arteritis, and otologic manifestations of GCA. tation rate was first noted (4) and a temporal arteritis, respiratory Methods. A literature search was per- decade later striking improvement of manifestations, otologic disease formed on PUBMED and MEDLINE symptoms after steroid treatment was using the following keywords: GCA, first reported (5). temporal arteritis, pulmonary, respira- Headache is the most common symp- tory, ENT, cough, tongue necrosis. tom, occurring in about 70% of pa- Results. The upper and lower airways tients with GCA. The headache may be manifestations of GCA include a wide variable in location, intensity and qual- variety of conditions that could be caused ity. However, it is often of new onset. by ischaemia due to the vasculitis. Jaw claudication occurs due to ischae- Conclusions. It is important to recog- mia of the masseter muscles, leading to nise these atypical presentations be- pain when chewing tough foods. Visual cause they may be the sole initial mani- symptoms such as vision loss and di- festation of the disease. Early suspicion plopia may develop in about a third of and confirmation of the diagnosis of patients. The most concerning compli- GCA can help to prevent more cata- cation is blindness due to its irrevers- strophic consequences of unrecognised ible nature. Other manifestations entail disease, including stroke and blindness. large vessel involvement including aortic aneurysm and dissection, aortic Introduction arch syndrome, and limb artery steno- Giant cell arteritis (GCA) is an ancient sis (6, 7). disease. One of the first descriptions Respiratory symptoms involving the of GCA can be found in Ali Ibn Isa’s upper and lower airways are occa- Tazkiratul-Kahhaleen, Notebook of sionally observed. These include dry the Oculist, published in the tenth cen- cough, throat and tongue pain and tury AD. Ibn Isa describes migraines, hoarseness. Patients may present with Competing interests: none declared. headaches in patients with chronic eye otolaryngologic symptoms such as

S-164 Respiratory manifestations of GCA / T.F. Imran et al. REVIEW tongue necrosis, dysphagia, and sub- category, one may observe non-specific view of the histopathology of the mass mandibular swelling. The presence of facial swelling (9, 12). In one prospec- (17). Other less commonly reported these symptoms may be overlooked in tive study of 345 patients with GCA, symptoms include necrosis at the tip of some patients, further delaying the di- the frequency of facial oedema was the nose, lip necrosis, paresthesias felt agnosis. Given the risk for permanent 12% (13). Similarly, a chart and litera- over the chin, glossitis, and dental pain visual loss and other major morbidities, ture review of 260 patients with GCA (19). identifying the link between the respir- found 37 cases (14%) of head and neck atory tract, otolaryngologic manifesta- swelling that lasted at least one day Audiovestibular manifestations tions and other more classical features (13). Head and neck swelling appeared One of the earliest links of deafness of GCA can help to expedite the diag- to be a transient but heralding feature, with GCA was provided by Cook et nosis and initiate appropriate therapy. preceding the development of GCA. al., who described seven patients who Glucocorticoids are a highly effective The swelling mainly involved the orbit- developed unilateral, and subsequent- therapy for GCA and should be initi- al region, the lower part of the cheeks ly bilateral deafness which improved ated early and utilised for the shortest and maxillae. Periorbital pain has also spontaneously (20). A later study found period of time, to avoid long-term ad- been described as a presenting feature that 5 out of 68 patients with GCA had verse effects (8). This review is intend- of GCA (14). Less commonly, oedema bilateral sensorineural deafness, which ed to increase clinicians’ awareness of was noted in the lateral and anterior as- did not improve after steroid therapy the less commonly seen respiratory and pects of the neck, the tongue and the su- (21). Progressive hearing loss as an ini- otolaryngologic symptoms of GCA. praclavicular space. The swelling typi- tial manifestation of GCA has also been cally resolves following with therapy reported in a handful of cases, with Methods and in some patients it may spontane- improvement of hearing loss noted in A literature review using the PUB- ously remit over time (13). Tongue pain some patients (21). Whether or not the MED and MEDLINE databases was may be tested by assessing for repetitive hearing loss is reversible and to what performed with the following key- rapid protrusion of the tongue, which extent, may depend on how early the words: giant cell arteritis, temporal may produce pain, burning or fatigue corticosteroid treatment is initiated. arteritis, pulmonary, respiratory, ear- (10). The tongue has a rich blood sup- Audiovestibular manifestations may nose-throat, cough, and tongue necro- ply; thus necrosis is rare and indicates occur prior to other symptoms of GCA sis. Case reports, controlled studies, extensive vascular involvement. The (22). Thus, early recognition of these retrospective studies and review arti- presence of tongue necrosis portends a signs is important since the treatment of cles were included. Studies published worse prognosis as these patients tend this condition with corticosteroids may in languages other than English were to be older and also have a higher inci- be quite different than the more watch- excluded. Table I lists these sources. dence of vision loss. However, the non- ful approach that is often used in the specific swelling may be mistaken for management of patients with these is- Clinical manifestations other diagnoses including sinusitis and sues. In addition, missing the diagnosis Orofacial manifestations angioedema. of GCA and the opportunity to initiate Since GCA has a predilection for in- As noted earlier, jaw claudication, is appropriate therapy may lead to even volvement of cranial arteries, it should the most specific non-neurological sign more dire consequences.Thus, in a pa- not be surprising to observe orofacial of GCA and may be misdiagnosed as tient with PMR and new audiovestibu- signs and symptoms in some patients. a temporomandibular joint disorder lar symptoms, the clinical suspicion of These can be divided into two distinct (15).However, trismus or reduction in underlying GCA should be considered groups: those that are associated with jaw opening, is much less recognised. and higher doses of corticosteroids may ischaemia and those that demonstrate One retrospective analysis of 88 pa- need to be instituted (4). features of localised inflammation. In tients, noted six to have reduction in Spontaneous has been de- the former category, one can observe jaw opening. These patients had a more scribed as an initial manifestation of temporal and scalp pain, jaw pain and acute presentation with shorter time to GCA (23). In addition, a recent pro- complaints of claudication. Jaw clau- diagnosis (average of four weeks ver- spective study with 44 patients with dication is elicited in about half of sus twelve weeks), and there was a high GCA showed that audiovestibular dys- patients. Tongue or scalp necrosis has correlation with eye involvement in function was significantly more -com been rarely observed, yet GCA is the about half of the patients (16). mon in patients with GCA than among most common cause of tongue necrosis Submandibular swelling has also been age-matched controls (4). A patient was (9). It is often localised to small areas noted to be an initial manifestation of defined as having abnormal vestibu- of the tongue mucosa due to an exten- giant cell arteritis (14, 17, 18). Ruiz- lar tests if any of these three findings sive collateral blood supply network in Masera et al. reported a case of a 75 were noted: spontaneous nystagmus, the tongue (10). year-old woman who presented with a head-shaking nystagmus, or an abnor- Some patients complain of dysphagia, submandibular mass, ultimately requir- mal caloric test. Using these criteria, which is due to involvement of the ing resection of the gland. The diagno- audiovestibular manifestations such as pharyngeal vessels (11). In the second sis of GCA was made following a re- hearing loss, , vertigo, and diz-

S-165 REVIEW Respiratory manifestations of GCA / T.F. Imran et al.

Table I. Patient characteristics, initial presentation and diagnosis.

Author (Year) Study type Study title Patient characteristics Initial presentation Diagnostic methods / Outcome

Huston et al. Retrospective Temporal arteritis: a -Mayo Clinic patients -Headache: 90% Either positive temporal artery biopsy or (1978) 25 year epidemiologic, Olmsted county, MN -Tender temporal artery: 69% -Classic manifestations of temporal clinical and pathologic 1950-1974 -Jaw claudication: 67% arteritis including ESR, and at least 4 of: study -Tongue claudication: 7% tender, swollen temporal artery, jaw -Absent temporal artery pulse: 40% claudication, blindness, PMR and -Weight loss: 55% response to corticosteroids -PMR: 48%

Browne (1982) Case series Oral necrosis -Patient 1: 69-year-old man; Patient 1: hypothermia, lip necrosis, Patient 1: Temoral artery biopsy: Accompanying giant -Patient 2: 89-year-old tongue necrosis, difficulty swallowing non-specific, Buccal biopsy showed cell arteritis woman Patient 2: grossly enlarged and granulation tissue, elevated ESR painful right arm and breast with Patient 2: Clinical findings, elevated ESR ecchymosis; aneurismal dilatation of the aorta, painful and swollen tongue one month later

Cohen et al. Case report Facial swelling and -62-year-old white woman Severe facial swelling, glossitis, Temporal artery biopsy positive (1982) giant cell arteritis odynophagia

Francis et al. Case report Acute hearing loss -59-year-old man -Acute hearing loss: 48 hour history of -Biopsy negative (1982) in GCA ear discomfort with increasing deafness -Symptoms reversed with corticosteroid -4 weeks of temporal-occipital headache therapy - ESR: 102

Pedersen et al. Case report Lingual infarction in -77-year-old woman -3 weeks of left tongue & jaw pain; -Left temporal artery biopsy showed GCA (1983) giant cell arteritis unable to speak or swallow -Tongue biopsy showed ischaemic -6 months prior: muscular and infarction fatigue

Bradley et al. Case report Giant cell arteritis -59-year-old woman -Left arm, bilateral foot and ankle pain -Lung nodule biopsy showed giant cells (1984) with pulmonary for 6 months in nodules -Hip stiffness worse in morning; PMR -Temporal artery biopsy positive symptoms; ESR >100 -Lung biopsy: diffuse granulomatous inflammation and necrosis -After a decrease in prednisone dose, the patient developed lung lesions, chronic productive cough

Coppeto (1984) Case report Spontaneous ear pain -82-year-old woman -Left periauricular pain, Temporal artery biopsy positive as the initial presenting lightheadedness; episodes were manifestation of giant associated with chewing or talking cell arteritis -Left ear-ache -Weight loss over the past month attributed to pain with swallowing

Larson et al. Case series Respiratory tract 16 patient cases -Cough, sore throat, hoarseness Temporal artery biopsy positive (1984) symptoms as a clue -Diffuse tenderness of the anterior neck giant cell arteritis -4 to 9% of patients with GCA had to respiratory manifestations as initial presentation -Cough: most common, non-productive, frequent, dry, sometimes preceded other symptoms, sensation of choking

Acritidis et al. Case-control Pulmonary function 26 non-smoking -Normal lung function: GCA patients -Diffuse interstitial lung disease and (1988) of non-smoking patients patients with GCA 31%, controls: 50% restrictive lung disease were seen only with giant cell arteritis and 28 control patients -Isolated small airway disease: GCA in patients with biopsy proven GCA: and/or PMR; patients 46.2%, Controls: 50% may be related to underlying process a controlled study - Obstructive lung disease: 1 GCA patient -Restrictive: 1 GCA patient -Diffuse interstitial lung disease: 1 patient, controls: none

Machado et al. Retrospective Trends in incidence and Population of Olmsted Respiratory symptoms occurred in: Temporal artery biopsy positive or (1988) clinical presentation County, MN -31% 1950-69 classic manifestation of GCA, including of Temporal Arteritis -16% 1970-79 elevated ESR and 4 of: tender, swollen in Olmsted County, -26% 1980-85 temporal artery or jaw claudication or MN 1950-1985 Facial pain occurred in: blindness or PMR or favorable response -19% 1950-69 to corticosteroids -11% 1970-79 -13% 1980-85

Sonnenblick Review Non-classical organ -Patients with respiratory -Respiratory tract symptoms: dry cough Lung biopsies confirmed diagnosis et al. (1989) involvement in symptoms -Direct lung involvement: diffuse temporal arteritis reticular pattern, visceral disseminated form -Involvement of large pulmonary arteries -Auditory system: sensorineural hearing loss Table I continues

S-166 Respiratory manifestations of GCA / T.F. Imran et al. REVIEW

Author (Year) Study type Study title Patient characteristics Initial presentation Diagnostic methods / Outcome

Ginzburg et al. Case report Lingual infarction: a -79-year-old woman -Tongue necrosis -Patient refused biopsy (1992) review of the literature -3 month history of right facial and -Clinical diagnosis jaw pain -Improvement with glucocorticoid -Acute right ocular blindness therapy -1 month prior: fatigue, lethargy, tongue swelling with inability to eat

Mangenelli Case report Trismus and facial -71-year-old woman -Left temporal headache, , malaise, Biopsy of left temporal artery et al. (1992) swelling in a case of with euthyroid goiter anorexia -Oedema improved with 4-6 weeks of temporal arteritis -3 weeks later: masseter spasm, painful steroid therapy chewing -Lower facial swelling -One episode of amaurosis fugax

Romero et al. Case series Pleural Effusion as -67-year-old woman Patient 1: -Temporal artery biopsy positive (1992) manifestation of -71-year-old woman -3 month history of malaise, weight loss, -1 patient had pleural biopsy: atypical temporal arteritis shoulder pain, frontoparietal headache, mesothelial hyperplasia with jaw claudication, cough, scanty sputum, inflammatory cells and left pleuritic chest pain -Pleural effusion: with high protein Patient 2: -1 month history of temporal headache, fatigue and jaw claudication -Right pleuritic chest pain, productive cough -Pleural effusion:

Zenone et al. Case report Unusual manifestations Fever, dry cough, -Bilateral conjunctivitis, otitis with hearing Temporal artery biopsy positive (1994) of GCA: pulmonary dyspnea and chest pain loss, weight loss, rhinitis nodules, cough, -ESR: 58 conjunctivitis & otitis -Headaches, muscle pain with deafness

Ruiz-Masera Case report Submandibular -75-year-old woman -Right submandibular pain and difficulty Submandibular mass histopathology et al. (1995) swelling as the first swallowing for several months confirmed the diagnosis of GCA manifestation of giant cell arteritis

Ghanchi et al. Case report Facial swelling in giant 79-year-old Caucasian -Sudden, painless blurring of vision Confirmed later with left temporal (1996) cell (temporal) arteritis woman with hypertension -Shoulder pain, malaise, fatigue artery biopsy -“Heavy” feeling on the affected side of the face -A month prior: swelling of face on left and around left eye, pain with chewing

Hellmann Case report Temporal Arteritis: -79-year-old woman -Blindness in right eye Temporal artery biopsy positive et al. (2002) a cough, toothache -1 month prior: fatigue, dry cough, then and tongue infarction toothache, burning sensation on left side of tongue, weight loss; ESR: 115

Amor-Dorado Prospective Audiovestibular -44 patients with GCA -90% of GCA patients had abnormal Hearing loss, vestibular function et al. (2003) manifestations in GCA -10 patients with biopsy vestibular tests compared to patients improved after 3 months of therapy in negative, isolated PMR with isolated PMR some cases, and in almost all cases with 6 months of therapy

Forderreuther Case report Giant cell arteritis -72-year-old woman -Intense, gnawing, constant pain around Submandibular mass histopathology et al. (2003) presenting as a left eye, mild lacrimation -confimed GCA with transmural periorbital pain -Two years later, the patient developed inflammation syndrome and a a submandibular mass submandibular mass

Gonzalez-Gay Retrospective GCA: Disease patterns -Single hospital population -Headache: 86.4% Temporal artery biopsy positive et al. (2005) of clinical presentation of Lugo, Spain, between -Severe ischaemic manifestations: 54.6% in a series of 240 January 1, 1981, and June - Abnormal temporal artery on exam and patients 15, 2004 anaemia may predict the risk of severe ischaemic complications related to GCA

Shmerling Case report An 81 year-old woman -81-year-old woman -Difficulty opening mouth Temporal artery biopsy positive et al. (2006) with temporal arteritis -Retro-orbital pain -Lumps on head -Upper URI symptoms before onset of headache -No , chills -ESR: 46 -Atypical headache Table I continues

S-167 REVIEW Respiratory manifestations of GCA / T.F. Imran et al.

Author (Year) Study type Study title Patient characteristics Initial presentation Diagnostic methods / Outcome

Manganelli Review Respiratory system -Large-vessel, medium-vessel, Respiratory symptoms in GCA: et al. (2006) involvement in and small vessel vasculitides -Non-productive cough systemic vasculitides are discussed -Sore throat -Hoarseness -Choking sensation -Thoracic pain Less common symptoms: -Pleural effusion, interstitial lung disease -Basal interstitial fibrosis in 16% of 217 patients -Intra-alveolar hemorrhage

Zimmermann Case report Tongue infarction in -81-year old woman -Tongue infarction, prodrome of Bilateral blind temporal artery biopsy et al. (2007) GCA headache and PMR symptoms (10 mm & 25 mm): negative -24 hour history of painful swollen tongue and dysarthria -Months of mild limb-girdle symptoms -ESR: 69, CRP: 61

Zadik et al. Case report A 78-year-old woman -78-year-old woman -Tongue pain Duplex sonography: occlusion of left (2011) with bilateral tongue -Pain of right side of head, neck, face artery, compatible with GCA necrosis and shoulder worse while eating -Fatigue, visual blurring over 2 months, weight loss -ESR: 69, CRP: 6.1 ziness were present in about two thirds ment in GCA have not been clearly elu- pleural effusions with a high protein of patients with GCA. Hearing loss was cidated, and may be related to a primary content and a predominance of poly- noted in 27% of patients. About 30% vasculitis of small and medium-sized morphonuclear cells. However, the of patients had persistent head-shaking vessels (26). Pulmonary symptoms may pleural biopsy and the cytology stud- nystagmus that did not resolve after precede other manifestations of GCA, ies of the effusion yielded non-specific three months of corticosteroid treat- and thus an evaluation for underlying findings (32). ment (4). However, vestibular symp- GCA should be done in an elderly pa- toms generally improved after three tient who may not have the typical fea- Discussion months of treatment with steroids and tures of GCA and PMR. GCA is an inflammatory disease af- some patients may actually compensate Direct involvement of the lung has been fecting large and medium-sized ves- over time without any treatment. reported in a few cases of GCA. Chest sels that is characterised by medial radiographs may demonstrate either and adventitial inflammation with - gi Respiratory manifestations a diffuse reticular pattern or multiple ant cells, leading to the destruction of Respiratory symptoms have been re- nodules (29). Patients promptly im- the elastic laminae (33). Although the ported in up to one third of GCA pa- prove with corticosteroid treatment, but precise etiology is not known, it has tients seen at the Mayo Clinic (24). in one study, the pulmonary abnormali- been proposed that GCA is T cell de- Rarely, the respiratory symptoms may ties relapsed when corticosteroids were pendent and an antigen driven process be the initial form of presentation (25). tapered (30). Intra-alveolar haemor- (26). Though most of the literature on rhage that was responsive to treatment GCA has focused on the visual com- • Chronic cough or sore throat was reported in one case of GCA (31). plications, GCA encompasses a wider A dry non-productive, persistent cough Later reports have observed basal in- spectrum of clinical features, including is the most common respiratory mani- terstitial fibrosis, pleural effusion, - in respiratory and otolaryngologic mani- festation in GCA. It usually improves terstitial infiltrates and nodules. For festations, which are less commonly with steroid treatment (26). It may be example, a case series detected inter- reported but may be equally serious. associated with fever, and in rare cases stitial fibrosis on chest radiographs in Table I summarises the features of the may be the initial manifestation of the one sixth of 217 patients (26). The lung otolaryngologic, audiovestibular and disease (27, 28). Some patients may histopathology has shown a vasculitis pulmonary involvement noted in pro- have concomitant symptoms such as of pulmonary arteries with giant cells spective and retrospective studies, case headache and PMR but may not vol- along with interstitial, bronchial and series and case reports. When patients untarily report these symptoms (19). sometimes peri-bronchial granulomas. present with involvement of one of Thus, it is vital to obtain a thorough re- Bronchoalveolar lavage in three GCA these organs, a high index of suspicion view of systems to determine the likeli- patients with respiratory symptoms re- for GCA is required, since any delay hood of GCA as a cause. vealed a T-lymphocyte alveolitis with can result in detrimental outcomes. a CD4+ predominance (26). Romero The head and neck swelling presenta- • Imaging of pulmonary involvement described two patients diagnosed with tion, and jaw claudication symptoms The mechanisms of pulmonary involve- GCA who presented with exudative may all be explained by involvement

S-168 Respiratory manifestations of GCA / T.F. Imran et al. REVIEW of the external carotid artery system. which may or may not accompany oth- Exp Rheumatol 2006; 24 (Suppl. 41): S20-5. In contrast, since the tongue has a rich er characteristic symptoms of GCA. Pa- 14. FORDERREUTHER S, IHRLER S, KUCHLE CC: Giant cell arteritis presenting as a periorbital blood supply and collateral circulation tients are often misdiagnosed with other pain syndrome and a submandibular mass. with the lingual, facial, pharyngeal, and conditions. The astute clinician should Cephalalgia 2003; 23: 314-7. palatine arteries, tongue necrosis may be keenly aware of these features, as 15. SMETANA GW, SHMERLING RH: Does this be localised to small areas of the tongue timing is critical in establishing the di- patient have temporal arteritis? JAMA 2002: 287: 92-101. mucosa (10). In addition some patients agnosis of GCA to prevent serious com- 16. NIR-PAZ R, GROSS A et al.: Reduction of jaw with GCA may also have show features plications such as blindness and stroke. opening (trismus) in giant cell arteritis. Ann of a peripheral facial paresis, audioves- A better understanding of the respirato- Rheum Dis 2002; 61 832-3. 17. RUIZ-MASERA JJ, ALAMILLOS-GRANADOS tibular symptoms and dysphagia (4). ry and otolaryngologic features of GCA FJ, DEAN-FERRER A et al.: Submandibular The exact mechanism(s) of audioves- may provide clinicians with a better un- swelling as the first manifestation of giant tibular dysfunction in GCA remain to derstanding of the myriad presentations cell arteritis. Report of a case. J Craniomax- be elucidated. However, it is likely that of GCA. illofac Surg 1995; 23: 119-21. 18. PORTER MJ: Temporal arteritis presenting as ischaemic complications of the vascu- a submandibular swelling. J Laryngol Otol litis, and inflammatory involvement of References 1990; 104: 819-20. the vertebrobasilar arteries or the termi- 1. ALI IBN ISA, WOOD CA: Memorandum book 19. HELLMANN DB: Temporal arteritis: a cough, nal branches of the cochleovestibular of a tenth-century oculist for the use of modern toothache, and tongue infarction. JAMA ophthalmologists; a translation of the Tadhkirat 2002; 287: 2996-3000. vasculature are responsible (34).Audi- of Ali ibn Isa of Baghdad (cir. 940-1010 AD), 20. COOKE WT, CLOAKE PCP, GOVAN ADT, tory and vestibular functional areas are the most complete practical and original of all CLOCK JC: Temporal arteritis: a generalized supplied primarily by the labyrinthine the early textbooks on the eye and its diseases. vascular disease. Q J Med 1946; 15: 47-62. artery, which branches off of the ante- Chicago Northwestern University: 1936. 21. FRANCIS DA, BODDIE HG: Acute hearing 2. HUTCHINSON J: Diseases of the arteries. On loss in giant cell arteritis. 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