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The human eye, as an organ, can offer critical clues to the presence of systemic disease. This article discusses the various ophthalmologic manifestations of systemic disease that can be evident on examination by an emergency department provider, as well as some findings that can be discerned with specialty consultation. The following topics are reviewed with respect to potential ocular signs and complications: syphilis, herpes zoster, Lyme disease, acquired immunodeficiency syndrome, Reiter's syndrome, Kawasaki's disease, temporal arteritis, endocarditis, hypertension, and diabetes mellitus. Indications for emergent ophthalmologic consultation are also emphasized.
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PMID:Ophthalmologic complications of systemic disease. 1824 64

Giant cell arteritis is the most common systemic vasculitis in people over the age of 50 years. Ischaemic manifestations are well known. 'Occult' manifestations as aortic aneurysmal disease need consideration. The incidence of aortic aneurysm and/or dissection is about 18.5 per 1000 person-years at risk (18.9 in Lugo(4) and 18.7 in Olmsted County(3)). Predictive factors are hypertension, polymyalgia rheumatica, coronaropathy, and hyperlipaemia. Another factor is the apparition of an aortic regurgitation murmur as in this case. So, these patients should be monitored by echocardiography.
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PMID:Horton's aortitis. 1849 Feb 77

Premature atherosclerosis has been observed during the course of different systemic inflammatory diseases such as rheumatoid arthritis and sytemic lupus erythematosus. Remarkably, relatively few studies have been published on the occurrence of accelerated atherosclerosis in patients with vasculitis. In giant cell arteritis (GCA), mortality because of ischaemic heart disease is not increased. In addition, intima media thickness (IMT) is lower in patients with GCA than in age-matched controls. In contrast, IMT is increased significantly in Takayasu arteritis, another form of large vessel vasculitis occurring in younger patients. In Takayasu arteritis and in Kawasaki disease, a form of medium-sized vessel vasculitis, accelerated atherosclerosis has been well documented. In small vessel vasculitis because of anti-neutrophil cytoplasmic autoantibodies-associated vasculitis, cardiovascular diseases are a major cause of mortality. IMT measurements reveal conflicting results. During active disease these patients experience acceleration of the atherosclerotic process. However, when inflammation is controlled, these patients have atherosclerotic development as in healthy subjects. Several risk factors, such as diabetes and hypertension, are present more often in patients with vasculitis compared with healthy controls. In addition, steroids may be pro-atherogenic. Most importantly, many patients have impaired renal function, persistent proteinuria and increased levels of C-reactive protein, well-known risk factors for acceleration of atherosclerosis. Enhanced oxidation processes, persistently activated T cells and reduced numbers of regulatory T cells are among the many pathophysiological factors that play a role during acceleration of atherogenesis. Finally, autoantibodies that may be relevant for acceleration of atherosclerosis are found frequently in elevated titres in patients with vasculitis. Because patients have an increased risk for cardiovascular events, vasculitis should be treated with as much care as possible. In addition, treatment should be considered with angiotensin-converting-enzyme inhibitors and/or angiotensin receptor-1 blockers, statins and acetylsalicyl acid. Finally, classical risk factors for cardiovascular disease should be monitored and treated as much as possible.
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PMID:Translational mini-review series on immunology of vascular disease: accelerated atherosclerosis in vasculitis. 1930 50

Although giant cell arteritis (GCA) is a rare cause of ophthalmoplegia, swift diagnosis and treatment are necessary to avoid other complications. We report here a case of GCA in a 59-year-old woman with a history of hypertension and thyroid lobectomy. Diagnosis resulted from binocular diplopia, although classical GCA symptoms had been present a few days before. Oral corticotherapy led to a rapid disappearance of headaches and normal ocular motility in 1 month. We discuss the ophthalmological signs of the disease and the place of temporal artery biopsy and treatment.
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PMID:[Acute diplopia after the age of 50; always look for giant cell arteritis]. 1953 71

Patients with giant cell arteritis (GCA) generally present with cranial ischemic manifestations that are directly related to vascular involvement. They may also experience strokes in the territory of the carotid or the vertebrobasilar artery. We conducted the current study to assess the frequency and predictors of strokes in general, and of vertebrobasilar stroke in particular, at the time of diagnosis in a series of 287 consecutive patients with biopsy-proven GCA diagnosed over a 27-year period at the single hospital for a well-defined population of northwestern Spain.During the study period, 8 (2.8%) patients had strokes (1 in the carotid and 7 in the vertebrobasilar territory) between the onset of symptoms of the disease and 4 weeks after the onset of corticosteroid therapy. Six of the 7 patients with vertebrobasilar stroke were men. In most cases the vertebrobasilar stroke occurred after the onset of corticosteroid therapy. Smoking history was more common among patients with vertebrobasilar stroke (p = 0.01). Patients with vertebrobasilar stroke more commonly had permanent visual loss due to arteritic involvement of ophthalmic branches derived from the internal carotid (3/7; 42.9%) than the rest of GCA patients (33/280; 11.8%) (p = 0.05). Patients with strokes had higher hemoglobin values (13.2 +/- 1.5 g/dL) than patients without (11.7 +/- 1.6 g/dL) (p = 0.009). Moreover, only 1 (14.3%) of the 7 patients with vertebrobasilar stroke had anemia compared to 157 (56.1%) of the remaining 280 patients (p = 0.05). The best predictors of stroke were permanent visual loss (odds ratio [OR], 5.42) and arterial hypertension (OR, 5.06). In contrast, women (OR, 0.10) and patients with anemia at the time of disease diagnosis (OR, 0.11) had a significantly reduced risk of suffering strokes. Smoking history was the best positive predictor of vertebrobasilar stroke (OR, 5.22). In contrast, a reduced risk of suffering vertebrobasilar strokes was found in individuals who had anemia at the time of GCA diagnosis (OR, 0.13).Results of the current study show an increased risk of strokes, in the vertebrobasilar territory in particular, at the time of GCA diagnosis. Patients with biopsy-proven GCA and traditional cardiovascular risk factors or permanent visual loss have an increased risk of suffering strokes. Results also suggest a potential protective role of anemia against the development of these cerebrovascular complications.
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PMID:Strokes at time of disease diagnosis in a series of 287 patients with biopsy-proven giant cell arteritis. 1959 28

Medical statements from previous epidemiologic studies consider temporal arteritis as extremely rare or absent in Hispanic patients. A probable genetic protective condition was proposed as an explanation for this. We performed a descriptive observational, retrospective, comparable and not randomized study in the southern region of Puerto Rico (Ponce Area). The period for recollection of data was July/2002 to March/2004. We reviewed all the information of the clinical charts of patients diagnosed with temporal arteritis who were seen in the medical offices of one internist and two rheumatologists of the teaching staff of Damas Hospital. The subjects of our study consisted of 11 patients (8 female and 3 male), between the ages of 70 to 90, all of Hispanic origin, with a diagnosis of temporal arteritis. Frequencies and percentages were used to describe the data of the study. Headache was the most common symptom. Other symptoms included the presence of fatigue, malaise, anorexia, scalp tenderness, amaurosis fugax and decreased vision. Laboratory results showed the presence of a mild leukocytosis and anemia in most of the patients. Renal and liver functions were observed to be well-preserved, and serum electrolyte levels were within normal limits. The increase of the ESR and C Reactive Protein values and positive unilateral and bilateral biopsy studies were statistically significant. All of the above characterization of Hispanic population with temporal arteritis cited in our study correlates well with the classic description of the disease in previous epidemiological studies conducted on non-Hispanic subjects. Our study confirmed the presence of temporal arteritis in a Hispanic population. The disease was more prevalent in women than men, with a female to male ratio of 2:6, which is the lowest ratio found for this disease compared to previous epidemiological studies. In our study group, the disease was found in patients over 70 years of age, with a mean age of 75.7. Arterial hypertension was the most commonly associated condition in our patients, probably due to its high prevalence in our community. The clinical characteristics of our patients correlate closely with the previous data from other ethnic groups.
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PMID:Temporal arteritis in Puerto Rico Hispanics. 1961 May 72

A 64-year-old woman with hypertension and hyperlipidemia was admitted to our hospital for the investigation and management of general fatigue, anorexia, a 5-kg weight loss, and a 4-week history of high-grade fever. She had no symptoms of headache, myalgia, or arthralgia, and the physical examination was unremarkable. The laboratory tests revealed renal dysfunction with urine abnormalities that had not been observed 1 year earlier. A renal biopsy showed granulomatous small arteritis without necrotic lesions or glomerular pathology. An immunohistochemical study of the infiltrating leukocytes showed a predominance of CD4+ T cells followed by CD8+ T cells, and only a few macrophages. The condition drastically improved after treatment with 30 mg/day of oral prednisolone. The granulomatous renal arteritis was considered a variant of giant cell arteritis, because it showed the peculiar finding of a few macrophages in the granulomatous lesions.
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PMID:Isolated granulomatous renal arteritis: a variant form of giant cell arteritis with few macrophages. 2007 89

A 63-year-old woman developed consecutive visual loss in the presence of chronic renal failure on hemodyalisis, arterial hypertension, and pulmonary hypertension treated with sildenafil. Temporal artery biopsy was negative for giant cell arteritis. Bilateral, consecutive non-arteritic ischemic optic neuropathy was diagnosed. The implications and potential risk of sildenafil use in women are discussed.
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PMID:Not just for men. 2103 28

Ocular pain is most commonly associated with redness and inflammation; however, eye pain can also occur in the absence of grossly visible pathology. Pain in the quiet eye can be the first sign of a number of threatening conditions. Many of these conditions such as intermittent angle closure glaucoma, carotid artery dissection, idiopathic intracranial hypertension, and giant cell arteritis can lead to permanent vision loss or blindness. In this review, ocular history and examination techniques are summarized. The article also reviews pertinent ocular, orbital, referred, and other causes of eye pain in the quiet eye. The neurologist and headache specialist should recognize when consultation with an ophthalmologist is necessary.
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PMID:Ocular and orbital pain for the headache specialist. 2112 23

Aortic dissection is a very serious condition mainly caused by degenerative diseases of the connective tissue and hypertension. Ascending aortic dissection as a consequence of aortitis in association with giant cell arteritis is very rarely seen. In this article we report on the successful surgical repair of a Stanford type A aortic dissection caused by giant cell arteritis in a 74-year-old patient. We could visualize this dissection via echocardiography and computed tomography. Histopathology confirmed this rare complication of giant cell aortitis.
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PMID:Aortic dissection caused by giant cell arteritis. 2152 78


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