A direct comparison in diagnostic performance of CDUS, FDG-PET/CT and MRI in patients suspected of giant cell arteritis.

OBJECTIVES: This study directly compares diagnostic performance of Colour Duplex Ultrasound (CDUS), Fluor-18-deoxyglucose Positron Emission Tomography Computed Tomography (FDG-PET/CT) and Magnetic Resonance Imaging (MRI) in patients suspected of giant cell arteritis (GCA). METHODS: Patients with suspected GCA were included in a nested-case control pilot study. CDUS, whole body FDG-PET/CT and cranial MRI were performed within 5 working days after initial clinical evaluation. Clinical diagnosis after six months follow-up by experienced rheumatologists in the field of GCA, blinded for imaging, was used as reference standard. Diagnostic performance of the imaging modalities was determined. Stratification for GCA subtype was performed and imaging results were evaluated in different risk stratification groups. RESULTS: In total, 23 patients with GCA and 19 patients suspected of but not diagnosed with GCA were included. Sensitivity was 69.6% (95%CI 50.4%-88.8%) for CDUS, 52.2% (95%CI 31.4%-73.0%) for FDG-PET/CT and 56.5% (95%CI 35.8%-77.2%) for MRI. Specificity was 100% for CDUS, FDG-PET/CT and MRI. FDG-PET/CT was negative for GCA in all isolated cranial GCA patients (n = 8), while MRI was negative in all isolated extracranial GCA patients (n = 4). In 4 GCA patients with false-negative (n = 2; intermediate and high risk) or inconclusive (n = 2; low and intermediate risk) CDUS results, further imaging confirmed diagnosis. CONCLUSIONS: Sensitivity of CDUS was highest, while specificity was excellent in all imaging modalities. Nevertheless, confidence intervals of all imaging modalities were overlapping. Following EULAR recommendations, CDUS can be used as a first test to diagnose GCA. With insufficient evidence for GCA, further testing considering GCA subtype is warranted.

Diagnostic delay in patients with giant cell arteritis: results of a fast-track clinic.

Giant cell arteritis (GCA) can lead to severe complications if left untreated. The aim of this study was to describe time from onset of symptoms to diagnosis and treatment in GCA suspected patients in a fast-track clinic (FTC), and secondarily to assess the influence of GCA symptoms on this time. A retrospective cohort consisting of suspected GCA patients who visited the FTC between January 2017 and October 2019 was used. Time between symptom onset, first general practitioner visit, FTC referral, first FTC visit, and treatment initiation was analysed. Furthermore, this was stratified for subtypes of GCA and GCA symptoms. Of 205 patients referred with suspected GCA, 61 patients received a final diagnosis of GCA (GCA+) and 144 patients had no GCA (GCA-). Median time after onset of symptoms to first FTC visit was 31.0 days (IQR 13.0-108.8) in all referred patients. Time between onset of symptoms and first GP visit was 10.5 (4.0-36.3) days, and time between first GP visit and FTC referral was 10.0 (1.0-47.5) days. Patients were generally seen at the FTC within 1 day after referral. For patients with isolated cranial GCA (n = 41), median delay from onset of symptoms to treatment initiation was 21.0 days (11.0-73.5), while this was 57.0 days (33.0-105.0) in patients with extracranial large-vessel involvement (n = 20) (p = 0.02). Our results indicate considerable delay between symptom onset and FTC referral in patients suspected of GCA. Suspected patients were examined and GCA+ patients were treated instantly after referral. Key Points • GCA can cause severe complications with delayed treatment, but non-specific symptoms make diagnosis challenging. • Diagnostic delay still occurs despite introducing a successful fast-track clinic resulting from delay between start of symptoms and FTC referral. • Patients who presented with constitutional symptoms had longer delay than patients who presented with isolated cranial symptoms.

The provisional OMERACT ultrasonography score for giant cell arteritis.

OBJECTIVES: To develop an Outcome Measures in Rheumatology (OMERACT) ultrasonography score for monitoring disease activity in giant cell arteritis (GCA) and evaluate its metric properties. METHODS: The OMERACT Instrument Selection Algorithm was followed. Forty-nine members of the OMERACT ultrasonography large vessel vasculitis working group were invited to seven Delphi rounds. An online reliability exercise was conducted using images of bilateral common temporal arteries, parietal and frontal branches as well as axillary arteries from 16 patients with GCA and 7 controls. Sensitivity to change and convergent construct validity were tested using data from a prospective cohort of patients with new GCA in which ultrasound-based intima-media thickness (IMT) measurements were conducted at weeks 1, 3, 6, 12 and 24. RESULTS: Agreement was obtained (92.7%) for the OMERACT GCA Ultrasonography Score (OGUS), calculated as follows: sum of IMT measured in every segment divided by the rounded cut-off values of IMTs in each segment. The resulting value is then divided by the number of segments available. Thirty-five members conducted the reliability exercise, the interrater intraclass correlation coefficient (ICC) for the OGUS was 0.72-0.84 and the median intrareader ICC was 0.91. The prospective cohort consisted of 52 patients. Sensitivity to change between baseline and each follow-up visit up to week 24 yielded standardised mean differences from -1.19 to -2.16, corresponding to large and very large magnitudes of change, respectively. OGUS correlated moderately with erythrocyte sedimentation rate, C reactive protein and Birmingham Vasculitis Activity Score (corrcoeff 0.37-0.48). CONCLUSION: We developed a provisional OGUS for potential use in clinical trials.

External validation of the giant cell arteritis probability score in the Netherlands.

OBJECTIVES: To prevent complications of giant cell arteritis (GCA), early and accurate diagnosis is essential. Recently, Laskou et al. (2019) developed the giant cell arteritis probability score (GCAPS) which allows physicians to assess the likelihood of GCA at an early stage. The aim of this study was to validate the GCAPS in a Dutch hospital. METHODS: A retrospective cohort of patients with suspected GCA between January 1st, 2017 and October 1st, 2019 was used. As the variable extracranial artery abnormality was not measured, a modified GCAPS was used (m-GCAPS). Clinical diagnosis of the rheumatologist after six months follow-up was used as reference. The m-GCAPS was assessed for discrimination and calibration. We applied risk stratification according to Sebastian et al. (2020) (low, intermediate and high-risk groups based on the median and 75th percentile). RESULTS: Our study included 209 suspected GCA patients. 135 patients had complete records. Of these patients, 40 had GCA. The m-GCAPS had an area under the curve of 0.83, a sensitivity of 80.0% and specificity of 75.8% at the optimal cut-off value >10.5. The Hosmer-Lemeshow test was non-significant. Using risk stratification, GCA prevalence was 12.5% in the low (score<9), 23.3% in the intermediate (9-12) and 78.6% in the high-risk group (>12). CONCLUSIONS: The m-GCAPS showed good discrimination and calibration in a Dutch retrospective cohort and can aid early recognition of GCA. Stratification into low, intermediate and high-risk is promising, but might need optimisation.

A Case of Hypercalcemia in an Immunocompetent Patient with Disseminated Mycobacterium marinum Infection with a Rain Barrel as the Most Likely Primary Source.

Infection with Mycobacterium marinum is common in fish, and so human infection usually arises from contact with contaminated water or fish. A solitary papulonodular lesion on a finger or hand is the typical presentation. Disseminated infections are rare and mostly seen in immunocompromised patients. We present a rare case of disseminated M. marinum infection presenting with polyarthritis, tenosynovitis, dactylitis, and (sub)cutaneous and intramuscular lesions in an immunocompetent patient. This case was complicated by hypercalcemia, renal failure and eventually death. A contaminated rain barrel was most likely the primary source of the infection. LEARNING POINTS: Given the similarities, it is key to differentiate Crohn's disease from intestinal tuberculosis as early as possible.Patients undergoing colonoscopy for possible Crohn's disease should have colonic biopsy samples sent for AFB culture.Consider investigations for intestinal tuberculosis in uncontrolled Crohn's disease where intestinal tuberculosis has not been worked up previously.

A Tale of Diagnostic Delay with Detrimental Consequences: Illustrating the Challenging Nature of Diagnosing Giant Cell Arteritis.

Giant cell arteritis is a medical emergency as severe, irreversible complications may occur if it is not treated in a timely manner. However, in daily practice early diagnosis can be challenging. We report the case of a 70-year-old woman who presented with multiple ischaemic cerebral vascular accidents related to newly diagnosed giant cell arteritis. Review of her charts revealed a substantial delay from the onset of symptoms to diagnosis. This case demonstrates the need for additional efforts to reduce delay in referring patients with giant cell arteritis and the need to implement fast-track clinics to prevent serious complications. LEARNING POINTS: Giant cell arteritis is a medical emergency and unnecessary diagnostic delay can result in severe complications.Despite implementation of fast-track clinics, diagnostic delay still occurs due to the generic nature of signs and symptoms and inadequate case finding.As diagnostic delay can lead to preventable complications, increased knowledge and awareness of the characteristics and urgency of giant cell arteritis is needed among referring physicians.

Splenic artery rupture during pregnancy concealed by a pancreatic lymphangioma: a rare co-occurrence.

A pregnant woman presented to a local hospital with abdominal pain and hemorrhagic shock. Emergency caesarean section ruled out an obstetric cause and revealed a large mass, interpreted as a hematoma, with active bleeding of unknown origin. Because of her poor clinical condition, the patient was admitted to our hospital. Computed tomographic findings were suspicious for bleeding originating from the splenic artery. Laparotomy confirmed the presence of a ruptured splenic artery. A splenic artery aneurysm-a relatively well known entity during pregnancy-was absent. Hemostasis was achieved by clipping the artery. A large pancreatic cystic mass, which was misinterpreted earlier as a hematoma, was surgically removed. The pathologic examination revealed a pancreatic lymphangioma, an uncommon benign tumor. The ruptured splenic artery was presumably related to the pancreatic lymphangioma and vascular changes caused by pregnancy. A splenic artery rupture in co-occurrence of a pancreatic lymphangioma is a unique presentation which has not been reported previously.

[A marine with acute dyspnea]. / Een marinier met acute dyspneu.

A 29-year-old male marine presented with acute dyspnea and abdominal discomfort. The complaints were caused by a diaphragmatic rupture with an intrathoracic stomach and spleen probably due to an explosion during a military mission a year earlier. Subsequent operative intervention was initiated.

[A woman with fever and a painful hip and lower back]. / Een vrouw met koorts en pijn in heup en onderrug.

A 66-year-old woman presented with fever and acute pain in her lower back and left hip. She used prednison for arteritis temporalis. Abdominal radiography revealed no signs of free intraperitoneal gas, but instead a radiolucent area below the spleen suggesting free retroperitoneal gas. This was confirmed by CT-scan of the abdomen and surgery, when a diverticulitis of the colon descendens with retroperitoneal perforation was diagnosed.

Public beliefs on antibiotics and respiratory tract infections: an internet-based questionnaire study.

BACKGROUND: Patient expectations are among the strongest predictors of clinicians' antibiotic prescribing decisions. Although public knowledge, beliefs, and experiences of antibiotics contribute to these expectations, little is known about these public views. AIM: To gain insight into public knowledge, beliefs, and experiences of antibiotics and respiratory tract infections. DESIGN OF STUDY: Cross-sectional, internet-based questionnaire study. SETTING: Members of the general public aged 16 years and over in the Netherlands. METHODS: Public knowledge, beliefs, and experiences of antibiotics and respiratory tract infections, as well as predictors of accurate knowledge of antibiotic effectiveness, were measured using 20 questions with sub-items. The questionnaire was given to a Dutch community-based nationwide internet panel of 15 673 individuals. Of these, 1248 eligible responders were invited to participate; 935 responders (75%) completed the questionnaire. RESULTS: Of the participants, 44.6% accurately identified antibiotics as being effective against bacteria and not viruses. Acute bronchitis was considered to require treatment with antibiotics by nearly 60% of responders. The perceived need for antibiotics for respiratory tract infection-related symptoms ranged from 6.5% for cough with transparent phlegm, to 46.2% for a cough lasting for more than 2 weeks. CONCLUSION: Public misconceptions on the effectiveness of, and indications for, antibiotics exist. Nearly half of all responders (47.8%) incorrectly identified antibiotics as being effective in treating viral infections. Doctors should be aware that unnecessary prescribing could facilitate misconceptions regarding antibiotics and respiratory tract infections. Expectations of receiving antibiotics were higher for the disease label 'acute bronchitis' than for any of the separate or combined symptoms prominently present in respiratory tract infection. Public beliefs and expectations should be taken into account when developing interventions targeting the public, patients, and physicians to reduce unnecessary prescribing of antibiotics for respiratory tract infections.