Resolution of large vessel stenosis in giant cell arteritis (GCA) by tocilizumab

Abstract

Abstract Introduction: Progressive large vessel involvements including stenosis are commonly associated with giant cell arteritis (GCA). Glucocorticoids (GCs) are the mainstay of therapy for GCA stenosis, however, adverse effects including cardiovascular events are frequent. Patients concerns: We describe an 87-years old male patient with a medical history of diabetes mellitus and old cerebral infarction who presented with right temporal headache. Diagnosis: Color duplex sonography revealed the thickening of arterial wall and halo sign in the affected temporal arteries. In laboratory data, the elevated levels of acute phase reactants, including C-reactive protein and serum amyloid A were noted. Temporal artery biopsied specimens showed the lymphocytic infiltration and granulomatous inflammation within the arterial media, which are typical findings associated with GCA. Intervention: The patient was treated with subcutaneous injections of tocilizumab (TCZ, 162 mg) once weekly. Initially, glucocorticoids were withheld since the patient was diabetic and had a history of cerebral infarction. However, low dose prednisolone was combined with the reduced doses of TCZ (162 mg biweekly) injections due to the TCZ-related leukopenia. Outcomes: This treatment strategy resulted in the improvement of the patient's temporal headache and normalized levels of C-reactive protein and serum amyloid A. Follow-up imaging by color duplex sonography revealed the resolution of the temporal artery stenosis after 5 months of TCZ treatment. Conclusions: Patients with GCA often require long duration of steroid therapy and commonly suffer steroid-related complications. TCZ monotherapy, could induce early resolution of progressive vascular inflammation and stenosis in untreated GCA cases.