□ CASE REPORT □

Giant Cell with Facial Edema Presenting with Delayed Jugular Venous Flow

Yohei Kanzawa 1, Yasushi Mizuno 1, Yukihiro Imai 2 and Hiroaki Nishioka 1

Abstract

The detection of abnormalities of the cranial on magnetic resonance imaging (MRI) is useful for the diagnosis of (GCA). However, reports on the of GCA patients are rare. We report the case of an elderly woman with GCA who presented with facial edema. She presented with a one month history of headache and facial edema. After MRI and enhanced computed tomography revealed delayed blood flow in the left jugular , a temporal biopsy was performed. She was diagnosed with GCA based on the biopsy findings. Following corticosteroid therapy, her symptoms and venous flow improved. The present case indicates that delayed jugular venous flow can occur in GCA patients with facial edema.

Key words: giant cell arteritis, facial edema, jugular vein, prednisolone

(Intern Med 55: 2077-2080, 2016) (DOI: 10.2169/internalmedicine.55.5647)

early-stage GCA who present with facial edema. Introduction Case Report Giant cell arteritis (GCA) is a systemic granulomatous that occurs in older individuals (1-3). Early diag- A 73-year-old woman was referred to our hospital due to nosis and immediate treatment with corticosteroids are im- an approximately 1-month history of temporal headache, portant to prevent the severe vascular complications of neck pain, facial edema, low-grade fever, and jaw claudica- GCA, which include blindness and cerebrovascular acci- tion. On physical examination, the patient was conscious dents. The usual systemic features of the disease include and alert. Her , pulse rate, respiratory rate and headache, scalp tenderness, jaw , malaise, and temperature were 120/70 mmHg, 62 beats/min, 16 breaths/ arthralgia in the proximal joints. Facial edema is sometimes min, and 36.9°C, respectively. Her temporal artery was pal- observed in patients with GCA, and must be appreciated as pable and felt similar to a cord-like structure with pulsation another presentation of GCA, especially when it is accompa- but without tenderness. Her face was swollen (Fig. 1a), and nied by other symptoms (4, 5). GCA affects the large- and her left jugular vein was distended. She had trismus and medium-sized arteries, predominantly the cranial arteries. pain upon opening her mouth. She had no ophthalmological The investigation of cranial arteries by magnetic resonance problems. Her breath and heart sounds were clear. The labo- imaging (MRI) has been reported to be useful for the diag- ratory findings revealed a white blood cell count of 10,300/ nosis in patients suspected of having GCA. However, few μL, a hemoglobin level of 10.7 g/dL, a C-reactive protein reports have focused on the imaging of the veins of GCA level of 9.68 mg/dL, and an erythrocyte sedimentation rate patients. We herein report a case of GCA in an elderly of 118 mm/h. Her prothrombin time (PT)-INR was 1.06, her woman who presented with facial edema, in whom delayed activated partial thromboplastin time (aPTT) was 40.8 s, and blood flow in the jugular vein was revealed by MRI and en- her D-dimer level was 0.98 μg/mL. hanced computed tomography (CT). The case demonstrates The patient had previously undergone head MRI at an- that MRI might show delayed venous flow in patients with other hospital, 1 week after the onset of her symptoms. T2-

１Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan and ２Department of Pathology, Kobe City Medi- cal Center General Hospital, Japan Received for publication April 22, 2015; Accepted for publication August 23, 2015 Correspondence to Dr. Hiroaki Nishioka, [email protected]

2077 Intern Med 55: 2077-2080, 2016 DOI: 10.2169/internalmedicine.55.5647

a) b)

Figure 1. (a) Facial edema was observed on admission. (b) It Figure 2. Magnetic resonance T2-weighted imaging shows diminished after the initiation of treatment with prednisolone the high intensity of the left internal jugular vein (arrow). (PSL).

Facial edema is sometimes recognized in GCA patients weighted imaging, which was performed at that time, and may herald the presence of the disease (4, 5). Facial showed high intensity of the left internal jugular vein, indi- edema might be caused by the inflammatory involvement of cating that the flow was diminished, with concomitantly de- the branches of the external carotid artery. Few reports have layed venous flow (Fig. 2). No arterial abnormalities were focused on the veins of GCA patients with or without facial indicated. Enhanced CT revealed that her left internal jugu- edema. In the present case, MRI and enhanced CT demon- lar vein was not apparent during the early arterial phase strated delayed jugular venous flow at the time at which the (Fig. 3a), and also suggested that venous flow was slow. patient had facial edema. After the administration of PSL, The vein was seen during the equilibrium phase. There was which was used to treat the patient’s GCA, the patient’s fa- no apparent venous thrombus. Ultrasonography of the tem- cial edema improved and the delayed venous flow rapidly poral artery detected no abnormalities. regressed. A few cases of venous in GCA pa- We performed a biopsy of her right temporal artery on tients have been reported (6). There is an almost 2.5-fold in- day 8 after admission at our hospital. Histologically, the crease in the risk of venous thromboembolism in patients specimens revealed hypertrophy of the vascular intima, rup- with GCA in comparison to the general population (7). This ture of the internal elastic membrane and tunica media, and suggests the possibility of phlebostasis in GCA patients. In invasion by giant cells (Fig. 4). Based on the findings, the the present case, MRI and enhanced CT did not show ve- patient was diagnosed with GCA presenting with facial nous thrombus, and her PT-INR, aPTT, and D-dimer levels edema. were normal. As a result, we did not suspect the presence of On admission day 9, we initiated treatment with predniso- venous thrombus and did not investigate coagulopathy any lone (PSL) (40 mg/day). Her headache and low-grade fever further. The facial edema might have been caused by the disappeared rapidly on the same day. The patient’s facial widespread inflammatory involvement of branches of the ex- edema and the distension of her left jugular vein were obvi- ternal carotid artery (e.g., facial, internal maxillary, and as- ously diminished on the next day (Fig. 1b). She was dis- cending pharyngeal arteries), although such situations have charged on day 12, with regular follow-up examinations per- only rarely been documented (8, 9). Alternatively, the abnor- formed in our outpatient department. Enhanced CT at mal release of vascular endothelial growth factor, a protein follow-up revealed that her left internal jugular vein was ap- that both induces hyperpermeability and stimulates endothe- parent early during the arterial phase, which was considered lial cell growth (10), could play a role in the development normal (Fig. 3b). We added methotrexate to her regimen to of local or distant swelling in some GCA patients (11, 12). reduce the dose of PSL, which was successfully decreased The altered fluid distribution in the face might influence the to 4 mg/day without a flare-up. Regular follow-up examina- local hemodynamics. The interstitial pressure might be ele- tions have continued. vated due to the increase of interstitial fluid volume. This elevation could place some stress on the veins, leading to Discussion the change of the jugular venous flow that was observed in the present case. Although the rate at which asymmetric The course of this patient suggested two important clini- blood flow in the jugular vein occurs in the general popula- cal issues: 1) GCA patients with facial edema can present tion is unknown, it is sometimes observed in the MRI scans with delayed jugular venous flow; and 2) MRI might show of healthy individuals. The left jugular vein is considered to the delayed flow at an early stage of GCA with facial be easily affected - probably for anatomical reasons. This edema. patient showed delayed venous flow in the left jugular vein,

2078 Intern Med 55: 2077-2080, 2016 DOI: 10.2169/internalmedicine.55.5647

a) b)

Figure 3. Enhanced computed tomography during the early arterial phase. (a) On admission, the left internal jugular vein is not apparent. (b) After treatment with PSL, the vein has become apparent (arrow).

a) b)

Figure 4. (a) Low- and (b) high-power field images of the temporal artery (Elastica van Gieson staining). Hypertrophy of the vascular intima, rupture of the internal elastic membrane and tunica media, and giant cell invasion (black arrow heads) are observed. which promptly improved after corticosteroid therapy. In cases should be accumulated to determine how frequently this case, it seems that the patient’s delayed venous flow delayed venous flow is observed in GCA patients with facial was influenced by GCA. edema and to elucidate its meaning and pathogenesis. MRI might show delayed jugular venous flow at an early stage of GCA in patients presenting with facial edema. In The authors state that they havenoConflictofInterest(COI). this case, phlebostasis was observed on MRI just 1 week af- ter the onset of symptoms, whereas no abnormal arterial References findings were indicated. Klink et al. (13) reported that MRI of the cranial arteries is accurate and reproducible during the 1. Sehra ST, Setty A. Giant cell arteritis: a series of cases and review initial diagnosis in patients with suspected GCA, with a sen- of literature. Curr Rheumatol Rev 9: 138-143, 2013. sitivity of 88.7% and a specificity of 75.0% in comparison 2. Weyand CM, Goronzy JJ. Clinical practice: giant-cell arteritis and polymyalgia rheumatica. N Engl J Med 371: 50-57, 2014. to the reference standard. In addition to the arterial findings, 3. González-Gay MA, Pina T. Giant cell arteritis and polymyalgia abnormal jugular venous flow might be detected by MRI at rheumatica: an update. Curr Rheumatol Rep 17: 480, 2015. an early stage of GCA in patients presenting with facial 4. Plantin P, Caplanne D, Rosenberg F, Le Parc JM. Facial edema edema. and giant cell arteritis. Rev Rhum Engl Ed 63: 145-147, 1996. In conclusion, delayed jugular venous flow can be de- 5. Liozon E, Ouattara B, Portal MF, Soria P, Loustaud-Ratti V, Vidal E. Head-and-neck swelling: an under-recognized feature of giant tected in GCA patients with facial edema by MRI and en- cell arteritis: a report of 37 patients. Clin Exp Rheumatol 24: S20- hanced CT. MRI might show delayed venous flow at an S25, 2006. early stage of GCA in patients with facial edema. Further

2079 Intern Med 55: 2077-2080, 2016 DOI: 10.2169/internalmedicine.55.5647

6. Audia S, Falvo N, Leguy-Seguin V, et al. Scalp vein thrombosis N. VEGF induces hyperpermeability by a direct action on endo- mimicking giant cell arteritis relapse. Intern Med J 41: 492-495, thelial cells. Am J Physiol 274: L678-L684, 1998. 2011. 11. Kaiser M, Younge B, Björnsson J, Goronzy JJ, Weyand CM. For- 7. Aviña-Zubieta JA, Bhole VM, Amiri N, Sayre EC, Choi HK. The mation of new vasa vasorum in vasculitis: production of angio- risk of deep and pulmonary in giant genic cytokines by multinucleated giant cells. Am J Pathol 155: cell arteritis: a general population-based study. Ann Rheum Dis 765-774, 1999. 74: e28, 2014. 12. Boiardi L, Casali B, Nicoli D, et al. Vascular endothelial growth 8. Godeau P, Herreman G, Merlan G, Ghozlan C, Ghozlan R. [Exter- factor gene polymorphisms in giant cell arteritis. J Rheumatol 30: nal carotid arteriography in Horton’s disease: a report on 11 ob- 2160-2164, 2003. servations]. Sem Hop 55: 965-968, 1979 (in French, Abstract in 13. Klink T, Geiger J, Both M, et al. Giant cell arteritis: diagnostic English). accuracy of MR imaging of superficial cranial arteries in initial di- 9. González-Gay MA, García-Porrúa C, González-Rosón O. Facial agnosis: results from a multicenter trial. Radiology 273: 844-852, pain and giant cell arteritis. J Rheumatol 25: 1242-1243, 1998. 2014. 10. Hippenstiel S, Krüll M, Ikemann A, Risau W, Clauss M, Suttorp

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