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BMJ Case Rep. 2015; 2015: bcr2014206887.
Published online 2015 March 11. doi:  10.1136/bcr-2014-206887
PMCID: PMC4368978

FDG positron emission tomography of giant cell arteritis with polymyalgia rheumatica

Description

An 80-year-old woman presented with low-grade fever, weight loss and shoulder ache persistent over 6 months. She had developed headache with scalp allodynia, though these had improved spontaneously within 2 months. Physical examination revealed an absent temporal artery pulse and decreased range of active shoulder motion. Laboratory findings showed a high erythrocyte sedimentation rate (73 mm/h). Temporal artery ultrasonography revealed no halo sign, stenosis or occlusion. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed increased uptake in the thoracic aorta and carotid and subclavian branches, and bilateral shoulder, hip, and interspinal regions in the lower thoracic and lumbar spine (figures 1 and and2).2). Giant cell arteritis (GCA) with polymyalgia rheumatica was diagnosed. Symptoms improved with prednisolone (30 mg/day).

Figure 1
Fluorodeoxyglucose positron emission tomography image with arrows pointing towards abnormal uptake in the carotid and subclavian arteries as well as the thoracic aorta (arrows), and the bilateral shoulder and hip (arrowheads).
Figure 2
Fluorodeoxyglucose positron emission tomography image with an arrow pointing to abnormal uptake in the interspinal regions in the lower thoracic and lumbar spine (arrows).

GCA is associated with chronic vasculitis of large vessels, primarily the aorta and its main branches. It occurs in individuals aged >50 years. Polymyalgia rheumatica is closely linked to GCA, occurring in about 40–50% of patients. Headache is present in 90% of cases, frequently accompanied by scalp allodynia. In some cases, the inflammatory process may spontaneously become clinically silent,1 requiring clinicians to evaluate symptoms by direct questioning.

Temporal artery ultrasonography, one of the non-invasive tests, is helpful in diagnosing giant-cell arteritis (sensitivity 88% and specificity 78%).2 FDG-PET can be used to detect subclinical inflammation of large vessels in GCA.3 Although there is no perfect method for the diagnosis of GCA at present, FDG-PET may play a role in the management of GCA when the ultrasonography is negative.

Learning points

  • Headache is present in 90% of giant cell arteritis (GCA) cases, frequently accompanied by scalp allodynia.
  • The inflammatory process may spontaneously become clinically silent, requiring clinicians to evaluate symptoms by direct questioning.
  • Fluorodeoxyglucose positron emission tomography may play a role in the management of GCA when the ultrasonography is negative.

Footnotes

Twitter: Follow Kiyoshi Shikino at @K

Contributors: All authors were involved in managing the patient. KS wrote the first draft. MI edited the manuscript.

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Hernández-Rodríguez J, García-Martínez A, Espígol-Frigolé G et al. Sustained spontaneous clinical remission in giant cell arteritis: report of two cases with long-term followup. Arthritis Rheum 2006;55:160–2 doi:10.1002/art.21717 [PubMed]
2. Karassa FB, Matsagas MI, Schmidt WA et al. Meta-analysis: test performance of ultrasonography for giant-cell arteritis. Ann Intern Med 2005;142:359–69 doi:10.7326/0003-4819-142-5-200503010-00011 [PubMed]
3. Besson FL, Parienti JJ, Bienvenu B et al. Diagnostic performance of 18F-fluorodeoxyglucose positron emission tomography in giant cell arteritis: a systematic review and meta-analysis. Eur J Nucl Med Mol Imaging 2011;38:1764–72 doi:10.1007/s00259-011-1830-0 [PubMed]

Articles from BMJ Case Reports are provided here courtesy of BMJ Publishing Group