Comparison of temporal artery ultrasound versus biopsy in the diagnosis of giant cell arteritis.

BACKGROUND/OBJECTIVES: Giant cell arteritis (GCA) is a medical and ophthalmological emergency due to risk of stroke and sudden irreversible loss of vision. Fast and accurate diagnosis is important to prevent complications and long-term high dose glucocorticoids toxicity. Temporal artery biopsy is gold standard for diagnosing GCA. However, temporal artery ultrasound is a fast and non-invasive procedure which may provide a supplement or an alternative to biopsy. This study assesses the diagnostic performance of ultrasound and biopsy in the diagnosis of GCA. SUBJECTS/METHODS: Examination results of patients suspected of having GCA in the period from August 2018 to June 2019 were reviewed. Patients underwent clinical examination and blood tests. Within a few days of starting glucocorticoid treatment, temporal ultrasound and unilateral biopsy were performed. Experienced physicians established the final clinical diagnosis at 6-months follow-up. RESULTS: Seventy-eight patients underwent both ultrasound and biopsy. Thirty-five (45%) received the final clinical diagnosis of GCA. Compared with the final clinical diagnosis, biopsy had a sensitivity of 69% (51-83%) and a specificity of 100% (92-100%), and ultrasound a sensitivity of 63% (45-79%) and a specificity of 79% (64-94%). Area under the receiver operating characteristics curves were 0.84 and 0.71 for biopsy and ultrasound respectively (p = 0.048). False negative rate of ultrasound was 4 out of 78 (5%). CONCLUSION: Sensitivity of ultrasound is almost on par with that of biopsy although the overall diagnostic accuracy of ultrasound was slightly lower. We find that ultrasound is a reliable tool for first line diagnosis of GCA.

Multimodality Imaging in Cranial Giant Cell Arteritis: First Experience with High-Resolution T1-Weighted 3D Black Blood without Contrast Enhancement Magnetic Resonance Imaging.

In order to support or refute the clinical suspicion of cranial giant cell arteritis (GCA), a supplemental imaging modality is often required. High-resolution black blood Magnetic Resonance Imaging (BB MRI) techniques with contrast enhancement can visualize artery wall inflammation in GCA. We compared findings on BB MRI without contrast enhancement with findings on 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/low-dose computed tomography (2-[18F]FDG PET/CT) in ten patients suspected of having GCA and in five control subjects who had a 2-[18F]FDG PET/CT performed as a routine control for malignant melanoma. BB MRI was consistent with 2-[18F]FDG PET/CT in 10 out of 10 cases in the group with suspected GCA. In four out of five cases in the control group, the BB MRI was consistent with 2-[18F]FDG PET/CT. In this small population, BB MRI without contrast enhancement shows promising performance in the diagnosis of GCA, and might be an applicable imaging modality in patients.

An update on the clinical approach to giant cell arteritis.

Recent national and international guidance from rheumatology societies have reflected the advances in evidence for both the investigation and management of giant cell arteritis. Cranial ultrasound reduces diagnostic delay and improves clinical outcomes. Immediate high-dose glucocorticoids remain the standard treatment for giant cell arteritis. Randomised controlled trial evidence using tocilizumab, an interleukin-6 receptor antagonist, has been shown to have good clinical efficacy with glucocorticoid sparing effects. Overall patient outcomes appear to be improved by formalising pathways for diagnosis to include clinical experts' opinion early in decision making.

Bilateral Vertebral Artery Vasculitis-A Rare Manifestation of Giant Cell Arteritis and a Difficult Diagnosis Made Possible by 2-[18F]FDG PET/CT.

Giant cell arteritis (GCA) is the most common form of large vessel vasculitis. GCA is a medical and ophthalmological emergency, and rapid diagnosis and treatment with high-dose corticosteroids is critical in order to reduce the risk of stroke and sudden irreversible loss of vision. GCA can be difficult to diagnose due to insidious and unspecific symptoms-especially if typical superficial extracranial arteries are not affected. In these cases, verification of clinical diagnosis using temporal artery biopsy is not possible. This example illustrates the diagnostic value of hybrid imaging with 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (2-[18F]FDG PET/CT), and the limitations of the temporal artery biopsy in bilateral vertebral GCA, causing transient ischemic attack in the visual cortex. In addition it indicates that inflammation in the artery wall can be visualized on 2-[18F]FDG PET/CT despite long term and ongoing high dose glucocorticoid treatment.

Periocular necrotizing soft tissue infection in Greater Copenhagen.

PURPOSE: Necrotizing soft tissue infection, also known as necrotizing fasciitis (NF), is a fast-spreading life-threatening infection that most commonly affects the lower limbs, groin, or abdomen. Periocular necrotizing fasciitis (PNF) is rare. Limited data exist on PNF immune cell subset; hence, this study aims to determine the representation of immune cell subsets in patients diagnosed with PNF using immunohistochemical stainings. METHODS: All patients diagnosed with PNF at Copenhagen University Hospital from 2008 to 2018 were included. Their electronic medical records and pathology reports were assessed, and available tissue specimens were reviewed and stained with monoclonal antibodies for CD1a+ Langerhans' cells, CD3+ T lymphocytes, CD15+ granulocytes, CD44+ lymphohematopoietic cells, CD68+ histiocytes, CD79α+ B lymphocytes, and FXIIIa+ dendritic macrophages and Langerhans' cells. The number of positive cells was counted, and an average score was calculated. The location of immune cells and bacteria was assessed. RESULTS: The specimens were characterized by acute inflammation and necrosis of the fascia, while striated muscle involvement was less frequent. Haemolytic group A streptococci and Staphylococcus aureus were identified and mainly located in the deep dermis and subcutis in close relation to the fascia. Only few areas harboured both bacteria and inflammatory cells. Granulocytes, histiocytes and CD44+ lymphohematopoietic cells were demonstrated to be abundant in all patients, while B and T lymphocytes, dendritic macrophages and Langerhans' cells were less frequent. CONCLUSION: The immune cell subsets found in this study of PNF were consistent with those identified in the literature on NF in other anatomical locations. This study concludes that immune cells are abundant and exhibit a typical pattern in PNF.

[White pupil in an infant]. / Hvid pupil hos børn kan være tegn påalvorlig øjensygdom.

A whitish pupillary reflex (leukocoria) indicates abnormal reflection from intraocular pathology. In a child, leukocoria may be a sign of serious and even life-threatening eye disease (retinoblastoma), but the most common cause is congenital cataract. Both diagnoses require immediate referral to an ophthalmologist. Leukocoria is best detected by evaluating the reflex from the pupil with a handheld ophthalmoscope. We here present a case story of an infant with leukocoria that proved to be caused by unilateral congenital cataract.