0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Clinicopathologic Reports, Case Reports, and Small Case Series |

A "Negative" Temporal Artery Biopsy, Positive for Arteritis FREE

Cynthia S. Chiu, MD; Thaddeus P. Dryja, MD; Simmons Lessell, MD
[+] Author Affiliations

Section Editor: W. Richard Green, MD


Arch Ophthalmol. 2004;122(7):1074-1075. doi:10.1001/archopht.122.7.1074.
Text Size: A A A
Published online

Ophthalmologists often participate in the diagnosis and treatment ofpatients with giant cell arteritis (GCA), typically when the diagnosis isheralded by a central retinal artery occlusion or ischemic optic neuropathy.However, even in the absence of eye symptoms or signs, ophthalmologists maybe asked to examine the patient and perform a biopsy of the temporal artery.The microscopic findings in the patient described herein bear on the techniqueof temporal artery biopsy.

A previously healthy 81-year-old woman developed mandibular pain withchewing, low-grade fevers, night sweats, and proximal limb mylagias. She deniedheadache or visual changes. There were no abnormalities on results of physicalexamination, and her temporal arteries were pulsatile and neither induratednor tender. A chest radiograph was unremarkable. The only abnormality on routinelaboratory testing was microscopic hematuria. Her condition did not improveafter a trial of antibiotics for the presumed diagnosis of sinusitis. Threeweeks after onset of symptoms, an erythrocyte sedimentation rate of 131 mm/hand a C-reactive protein level of 7.9 mg/dL prompted referral for neuro-ophthalmicconsultation and biopsy. Although no abnormalities were found on the examinationresults, we performed a biopsy of the left temporal artery.

The biopsy specimen was fixed and serially sectioned. Microscopic examination(Figure 1) showed a normal temporalartery in all sections, but several small adjacent arteries included in thebiopsy specimen showed granulomatous angiitis.

Place holder to copy figure label and caption

A, Low-power microscopic view of the surgical specimen showing alarge-caliber artery that is uninflamed (center of photograph) and a smaller-caliber,inflamed branch artery to the left (hematoxylin-eosin, original magnification×25). B and C, Higher magnification of the inflamed, smaller-caliberartery shows granulomatous inflammation including a Langhans multinucleatedgiant cell (B, arrow) and a fragmented internal elastic lamina (C, arrow)(hematoxylin-eosin, original magnification ×100).

Graphic Jump Location

The patient's symptoms improved with oral prednisone therapy, but furtherinvestigations prompted by persistent hematuria resulted in the diagnosisof Wegener granulomatosis.

As demonstrated by this case, symptoms, signs, and even histologic findingsclassically associated with GCA can be found with other systemic vasculitides.Features attributed to GCA, such as jaw claudication, amaurosis fugax, andan erythrocyte sedimentation rate greater than 100 mm/h, have been seen inpatients with Wegener granulomatosis.13 Likepatients with GCA, patients with Wegener granulomatosis can improve with corticosteroidtreatment, at least initially. However, patients with Wegener granulomatosiswho are misdiagnosed as having GCA and who are treated only with corticosteroidsmay develop acute renal failure and respiratory tract disease.4 Whenfaced with a "positive" temporal artery biopsy, the physician must alwaysconsider a diagnosis of a systemic vasculitis other than GCA, as the patientmay experience a fulminant and downhill course if appropriate therapy is notinstituted.

From personal experience with a patient whose diagnosis of GCA was establishedfrom angiitis in small vessels adjacent to a normal temporal artery, one ofus (S.L.) routinely includes the periarterial tissue in temporal artery biopsyspecimens. Had this tissue been stripped from the specimen in our patient,the biopsy would have been interpreted as negative. Temporal artery biopsyspecimens from other patients with Wegener granulomatosis have also shownonly small-vessel involvement.13 Whena temporal artery biopsy is performed, the surgeon should refrain from removingthe periarterial tissues except to the extent necessary to ensure accurateidentification and secure ligation of the vessel. Nor should the pathologiststrip the artery before embedding.

Correspondence: Dr Lessell, Department of Ophthalmology, MassachusettsEye and Ear Infirmary, 243 Charles St, Ninth Floor, Boston, MA 02114 (simmons_lessell@meei.harvard.edu).

Genenreau  TLortholary  OPottier  MA  et al. French Vasculitis Study Group, Temporal artery biopsy: a diagnostic tool for systemic necrotizingvasculitis. Arthritis Rheum. 1999;422674- 2681
PubMed Link to Article
Small  PBrisson  M Wegener's granulomatosis presenting as temporal arteritis. Arthritis Rheum. 1991;34220- 223
PubMed Link to Article
Nishino  HDeRemee  RARubino  FAParisi  JE Wegener's granulomatosis associated with vasculitis of the temporalartery: report of five cases. Mayo Clin Proc. 1993;68115- 121
PubMed Link to Article
Tierney  LMMcPhee  SJPapadakis  MA Current Medical Diagnosis and Treatment. 37th East Norwalk, Conn Appleton & Lange1998;

Figures

Place holder to copy figure label and caption

A, Low-power microscopic view of the surgical specimen showing alarge-caliber artery that is uninflamed (center of photograph) and a smaller-caliber,inflamed branch artery to the left (hematoxylin-eosin, original magnification×25). B and C, Higher magnification of the inflamed, smaller-caliberartery shows granulomatous inflammation including a Langhans multinucleatedgiant cell (B, arrow) and a fragmented internal elastic lamina (C, arrow)(hematoxylin-eosin, original magnification ×100).

Graphic Jump Location

Tables

References

Genenreau  TLortholary  OPottier  MA  et al. French Vasculitis Study Group, Temporal artery biopsy: a diagnostic tool for systemic necrotizingvasculitis. Arthritis Rheum. 1999;422674- 2681
PubMed Link to Article
Small  PBrisson  M Wegener's granulomatosis presenting as temporal arteritis. Arthritis Rheum. 1991;34220- 223
PubMed Link to Article
Nishino  HDeRemee  RARubino  FAParisi  JE Wegener's granulomatosis associated with vasculitis of the temporalartery: report of five cases. Mayo Clin Proc. 1993;68115- 121
PubMed Link to Article
Tierney  LMMcPhee  SJPapadakis  MA Current Medical Diagnosis and Treatment. 37th East Norwalk, Conn Appleton & Lange1998;

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 4

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles