temporal arteritis; cranial arteritis; giant cell arteritis; Horton's disease
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Introduction
More appropriately giant cell arteritis as some patients may have arteritis confined to the great arteries.
Etiology
- unknown
- often associated with polymyalgia rheumatica (PMR)
- may occur despite low-dose glucocorticoids used for treatment of PMR
- evidence of Herpes zoster found in temporal arteries of 74% of cases[17]
Epidemiology
- occurs in elderly patients
- average age at diagnosis is 72 years of age
- rare in individuals < 50 years of age
- male:female ratio is 2:1
- rare in blacks
Pathology
- inflammation of medium & large sized arteries
- generally involves one or more branches of the carotid artery, especially superficial temporal artery
- less commonly, branches of the thoracic aorta & abdominal aorta are affected
- infiltrative granuloma with giant cells
- disruption of internal elastic membrane
- intimal proliferation
- thrombosis
- disease may be systemic
- Herpes zoster antigen most frequently located within "skip areas" with giant cell vasculitis adjacent to these areas[17]
Clinical manifestations
- new onset headache, may be localized[7]
- jaw claudication or tongue claudication
- sensitivity 50%, highest diagnostic specificity[41]
- also see diagnostic criteria (below)
- visual changes (involvement of ophthalmic artery)
- acute monocular vision loss
- diplopia (may be binocular)[7]
- amaurosis fugax (most predictive of blindness)[41]
- visual field defects
- unilateral scotoma
- may be transient (5 minutes)
- ophthalmoplegia
- ptosis
- retinal or optic disk ischemia (swelling)
- neurologic deficits
- polymyalgia rheumatica
- weight loss
- malaise, fatigue
- fever (may present as fever of unknown origin)
- temporal artery tenderness & erythema (2/3)*
- decreased temporal artery pulsation
- nodules over the temporal artery[9]
- bruits in head & neck
- diminished pulses in upper extremities
- new onset arm claudication
- differential blood pressure in arms[41]
- systemic inflammatory signs
- scalp tenderness & rarely necrosis
- facial pain
- respiratory symptoms (10%)
- cough (dry)[11]
- sore throat
- hoarseness
- Raynaud's disease
- onset may be sudden or gradual
- initial presentation as ischemic stroke[29] (case report)
* do not be dissuaded by negative physical examination findings alone[42]
Diagnostic criteria
- limb claudication (6.0)
- jaw claudication (4.9)
- temporal artery thickening on biopsy (4.7) or loss of pulse (3.3)
- platelet counts > 400,000/uL (3.8)
- temporal tenderness (3.1)
- erythrocyte sedimentation rate > 100 mm/h (3.1)
findings suggesting another diagnosis[35]
- erythrocyte sedimentation rate < 40 mm/h
- C-reactive protein in serum < 2.5 mg/dL
- age 49-70 years[39]
Laboratory
- increased erythrocyte sedimentation rate [[[A13741|ESR]]] (85%)
- increased serum C-reactive protein [[[A13198|serum CRP]]] (85%)
- complete blood count (CBC)
- anemia of chronic inflammation may be present
- leukocyte count is generally normal
- platelet count is generally high[9]
- serum alkaline phosphatase may be mildly elevated
- serum AST & serum ALT may be mildly elevated[7]
- testing for Herpes in temporal artery biopsy tissue
- Herpes zoster antigen (detected in 74%)[17]
- Herpes zoster DNA (detected in 40%)[17]
- see ARUP consult[10]
Diagnostic procedures
- temporal artery biopsy
- biopsy should not delay glucocorticoid therapy[5]
- results of biopsy not affected by 2-5 days of prednisone therapy[3]
- biopsy specimens remain interpretable for at least 2 weeks after initiation of prednisone[5]
- 6 weeks of prednisone therapy may not affect results of biopsy[43]
- biopsy segment should be > 5 cm
- ultrasound-guided biopsy of contralateral temporal artery 2-5 days after initiation of steroid therapy if initial biopsy is negative[5][12]
- prior to biopsy, check colateral circulation with 1-2 min occlusion
- frozen section examination of an initial biopsy determines need for bilateral biopsies[36]
- bilateral biopsy would net an estimated additional 5% of diagnoses[40]
- biopsy should not delay glucocorticoid therapy[5]
Radiology
- imaging may have a role in diagnosis of temporal arteritis, but are not yet gold standard.
- superficial temporal artery ultrasound
- temporal artery ultrasound biopsy alternative in centers with expertise[38]
- CT angiography of neck & thorax if giant cell arteritis suspected, but bilateral temporal artery biopsy negative
- magnetic resonance angiography (MRA) may be used rather than CT angiography[5]
- magnetic resonance imaging (MRI) of scalp arteries[27]
- may reveal isolated occipital artery involvement[27]
- MRI has 73% sensitivity & 88% specificity for diagnosis of temporal arteritis
- 18F-FDG PET/CT sensitivity of 82% & specificity of 100%[34]
- annual or regular screening with chest C-ray, CT angiography, of MR angiography to screen for thoracic aortic aneurysm (GRS11)*[7]
* 4-7 years after diagnosis, RR of thoracic aortic aneurysm is 18 & abdominal aortic aneurysm is 2.4[7] (see Complications: below)
Complications
- ischemic optic neuritis
- visual loss (irreversible) resulting from from necrosis of the posterior ciliary branch of the ophthalmic artery
- compression fractures (30%)
- thoracic aortic aneurysm & aortic dissection (11%)[7]
- median time to diagnosis is 5.8 years
- aortic regurgitation & congestive heart failure
- ischemic stroke[8], especially vertebrobasilar stroke[24][41]
- vascular dementia[8]
- peripheral artery disease
- myocardial infarction[5]
- tongue necrosis due to thrombosis of lingual artery[31]*
Differential diagnosis
- Takayasu's arteritis
- Wegener's granulomatosis[44] cANCA in serum (90%) & pANCA in serum
- polyarteritis nodosa
- hypersensitivity
- vasculitis
- atherosclerosis
- amyloidosis
- malignancy
- other causes of: fever, headache, blindness, myalgias, arthralgias
Management
- refer to ophthalmologist[7]
- glucocorticoids (prednisone)
- 40-60 mg QD divided BID-QID (oral noninferior to IV)[32][37]
- change to QD schedule after clinical response
- taper when symptoms have resolved & ESR has normalized
- alternate day therapy not effective in initial treatment
- response to therapy with 3-7 days
- ESR normalizes in 2-4 weeks
- duration of treatment is generally 1-2 years; however, some patients may need up to 5 years of therapy
- 26 week glucocorticoid taper when used with tocilizumab[37]
- tocilizumab[21][22][28] 162 mg SQ weekly or every other week combined with 26 week prednisone taper[37] preferred initial treatment[5][38]
- relapse in 34% of patients[19]
- 73% of relapses occur during glucocorticoid taper
- most common relapse symptoms
- headache (42%)
- polymyalgia rheumatica (51%);
- ischemic symptoms (29%)
- ESR & serum CRP normal in 18% of relapses[19]
- concurrent immunosuppressive agents (tocilizumab) in addition to glucocorticoids might increase risk of relapse[5][19]
- treatment decisions should be based on symptoms, hemoglobin & ESR
- visual loss is a medical emergency
- IV methylprednisolone for recent visual loss (< 36 hours)
- high dose glucocorticoids will prevent blindness
- reversal of blindness is rare
- alternative agents
- methotrexate is not steroid-sparing
- infliximab is not steroid sparing
- dapsone, azathioprine, cyclophosphamide suggested in some sources, but not mentioned in ref[5] (2009)
- temporal artery biopsy
- within first 1-2 weeks of glucocorticoid therapy
- glucocorticoid therapy should NOT be held pending biopsy
- unilateral biopsy is positive in 85% of patients, bilateral biopsy is positive in 95%
- aspirin may lower risk for cerebral ischemia[5]
- treatment of osteoporosis
- patient education
- follow-up
- screening for aortic aneurysm 4-7 years after diagnosis[7]
More general terms
Additional terms
- anemia of chronic inflammation
- C-reactive protein (CRP) in serum/plasma
- erythrocyte sedimentation rate (ESR)
- polymyalgia rheumatica (PMR)
- superficial temporal artery
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1676-7
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 798-800
- ↑ 3.0 3.1 Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 527
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 782-83
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Weiner S, In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004;
Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - ↑ 8.0 8.1 8.2 Solans-Laque R et al Stroke and multi-infarct dementia as presenting symptoms of giant cell arteritis: Report of 7 cases and review of the literature. Medicine 2008 Nov; 87:335. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19011505
- ↑ 9.0 9.1 9.2 Khasnis A and Langford CA. Update on vasculitis. J Allergy Clin Immunol 2009 Jun; 123:1226. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19501230
- ↑ 10.0 10.1 ARUP Consult: Giant Cell Arteritis - Temporal Arteritis The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/giant-cell-arteritis
- ↑ 11.0 11.1 Zenone T, Puget M. Dry cough is a frequent manifestation of giant cell arteritis. Rheumatol Int 27 March 2012. [Epub ahead of print] PMID: https://www.ncbi.nlm.nih.gov/pubmed/22451028
Prabhavalkar S, Bogusz P, Merard R, Gormley M. An unusual presentation of giant cell arteritis. Case Report Med 2012; 2012:498174. Epub 2012 Jul 3 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22811725 - ↑ 12.0 12.1 Arida A, Kyprianou M, Kanakis M, Sfikakis PP. The diagnostic value of ultrasonography-derived edema of the temporal artery wall in giant cell arteritis: a second meta- analysis. BMC Musculoskelet Disord. 2010 Mar 8;11:44 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20210989
- ↑ Marie I, Proux A, Duhaut P et al Long-term follow-up of aortic involvement in giant cell arteritis: a series of 48 patients. Medicine (Baltimore). 2009 May;88(3):182-92 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19440121
- ↑ Salvarani C, Cantini F, Boiardi L, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med. 2002 Jul 25;347(4):261-71. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12140303
Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet. 2008 Jul 19;372(9634):234-45 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18640460 - ↑ Gonzalez-Gay MA, Vazquez-Rodriguez TR, Lopez-Diaz MJ et al Epidemiology of giant cell arteritis and polymyalgia rheumatica. Arthritis Rheum. 2009 Oct 15;61(10):1454-61 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19790127
- ↑ Kale N, Eggenberger E. Diagnosis and management of giant cell arteritis: a review. Curr Opin Ophthalmol. 2010 Nov;21(6):417-22. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20811283
- ↑ 17.0 17.1 17.2 17.3 17.4 Gilden D et al. Prevalence and distribution of VZV in temporal arteries of patients with giant cell arteritis. Neurology 2015 Feb 18 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25695965 <Internet> http://www.neurology.org/content/early/2015/02/18/WNL.0000000000001409
- ↑ The NNT: Temporal Arteritis Diagnostics and Likelihood Ratios, Explained http://www.thennt.com/lr/temporal-arteritis/
Smetana GW, Shmerling RH Does this patient have temporal arteritis? JAMA. 2002 Jan 2;287(1):92-101 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11754714 - ↑ 19.0 19.1 19.2 19.3 19.4 Kermani TA et al. Disease relapses among patients with giant cell arteritis: A prospective, longitudinal cohort study. J Rheumatol 2015 Jul; 42:1213 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25877501 <Internet> http://www.jrheum.org/content/42/7/1213
- ↑ Fraser JA, Weyand CM, Newman NJ, Biousse V The treatment of giant cell arteritis. Rev Neurol Dis. 2008 Summer;5(3):140-52. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18838954
- ↑ 21.0 21.1 Loricera J et al. Tocilizumab in giant cell arteritis: Multicenter open-label study of 22 patients. Semin Arthritis Rheum 2015 Jun; 44:717 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25697557
- ↑ 22.0 22.1 Villiger PM et al. Tocilizumab for induction and maintenance of remission in giant cell arteritis: A phase 2, randomised, double-blind, placebo-controlled trial. Lancet 2016 Mar 4 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26952547
- ↑ Weyand CM and Goronzy JJ. Giant-cell arteritis and polymyalgia rheumatica. N Engl J Med 2014 Oct 23; 371:1653 http://www.nejm.org/doi/full/10.1056/NEJMc1409206
- ↑ 24.0 24.1 NEJM Knowledge+ Question of the Week. July 19, 2016 http://knowledgeplus.nejm.org/question-of-week/730/
- ↑ Caselli RJ, Hunder GG, Whisnant JP. Neurologic disease in biopsy-proven giant cell (temporal) arteritis. Neurology. 1988 Mar;38(3):352-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/3347337
- ↑ Tomasson G, Peloquin C, Mohammad A et al Risk for cardiovascular disease early and late after a diagnosis of giant-cell arteritis: a cohort study. Ann Intern Med. 2014 Jan 21;160(2):73-80. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24592492 Free PMC Article
- ↑ 27.0 27.1 27.2 Rheaume M, Rebello R, Pagnoux C et al. High-resolution magnetic resonance imaging of scalp arteries for the diagnosis of giant cell arteritis: Results of a prospective cohort study. Arthritis Rheumatol 2017 Jan; 69:161-168 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27483045 <Internet> http://onlinelibrary.wiley.com/doi/10.1002/art.39824/abstract
- ↑ 28.0 28.1 Stone JH, Tuckwell K, Dimonaco S et al Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med 2017; 377:317-328. July 27, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28745999 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1613849
Hellmann DB. Giant-cell arteritis - more ecstasy, less agony. N Engl J Med 2017 Jul 27; 377:385 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28745998 <Internet> http://www.nejm.org/doi/10.1056/NEJMe1706439 - ↑ 29.0 29.1 Kuganesan T, Huang AR Stroke as an Atypical Initial Presentation of Giant Cell Arteritis. BMC Geriatrics February 21, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29466947 https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-018-0738-y
- ↑ 30.0 30.1 30.2 Smith M, Hendren E, Vinik O. A Case of Preventable Vision Loss. JAMA Intern Med. Published online April 9, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29630686 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2677064
- ↑ 31.0 31.1 Truffaut L, Lefebvre P. Tongue Necrosis in Giant-Cell Arteritis. N Engl J Med 2018; 378:2517. June 28, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29949496 https://www.nejm.org/doi/full/10.1056/NEJMicm1709412
- ↑ 32.0 32.1 Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia Rheumatica and Giant Cell Arteritis: A Systematic Review. JAMA. 2016 Jun 14;315(22):2442-58. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27299619
- ↑ Gonzalez-Gay MA, Pina T. Giant cell arteritis and polymyalgia rheumatica: an update. Curr Rheumatol Rep. 2015 Feb;17(2):6. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25618572
- ↑ 34.0 34.1 Nielsen BD, Hansen IT, Kramer S et al. Simple dichotomous assessment of cranial artery inflammation by conventional 18F-FDG PET/CT shows high accuracy for the diagnosis of giant cell arteritis: A case-control study. Eur J Nucl Med Mol Imaging 2019 Jan; 46:184. Epub 2018 Jul 31. https://link.springer.com/article/10.1007%2Fs00259-018-4106-0
- ↑ 35.0 35.1 35.2 van der Geest KSM, Sandovici M, Brouwer S et a; Diagnostic Accuracy of Symptoms, Physical Signs, and Laboratory Tests for Giant Cell Arteritis. A Systematic Review and Meta-analysis. JAMA Intern Med. Published online August 17, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32804186 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769372
Dhaliwal G Clinical Diagnosis - Is There Any Other Type? JAMA Intern Med. Published online August 17, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32804219 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769367 - ↑ 36.0 36.1 Cohen DA, Chen JJ, Neth BJ et al. Discordance rate among bilateral simultaneous and sequential temporal artery biopsies in giant cell arteritis: Role of frozen sectioning based on the Mayo Clinic experience. JAMA Ophthalmol 2021 Apr 1; 139:406 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33599705 PMCID: PMC7893541 (available on 2022-02-18) https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2776356
- ↑ 37.0 37.1 37.2 37.3 Harris S Reem Mustafa, MD, PhD, on Treatment of Giant Cell Arteritis. Review evaluates pros and cons of treatment options and accuracy of commonly used diagnostic tests. MedPage Today July 13, 2021 https://www.medpagetoday.com/reading-room/acrr/generalrheumatology/93541
Dua AB, Husainat NM, Kalot MA et al Giant Cell Arteritis: A Systematic Review and Meta-Analysis of Test Accuracy and Benefits and Harms of Common Treatments. ACR Open Rheumatology. 2021. April 2 https://onlinelibrary.wiley.com/doi/full/10.1002/acr2.11226 - ↑ 38.0 38.1 38.2 Maz M, Chung SA, Abril A et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis. Arthritis Rheumatol 2021 Aug; 73:1349 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34235884 https://onlinelibrary.wiley.com/doi/10.1002/art.41774
- ↑ 39.0 39.1 39.2 Ponte C et al. 2022 American College of Rheumatology/EULAR classification criteria for giant cell arteritis. Ann Rheum Dis 2022 Dec; 81:1647. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36351706 https://ard.bmj.com/content/81/12/1647
- ↑ 40.0 40.1 Mehta K et al. The utility of the bilateral temporal artery biopsy for diagnosis of giant cell arteritis. J Vasc Surg 2022 Dec; 76:1704. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35709855 https://www.jvascsurg.org/article/S0741-5214(22)01624-X/fulltext
- ↑ 41.0 41.1 41.2 41.3 41.4 NEJM Knowledge+ Rheumatology
- ↑ 42.0 42.1 Toren A, Weis E, Patel V, Monteith B, Gilberg S, Jordan D. Clinical predictors of positive temporal artery biopsy. Can J Ophthalmol. 2016 Dec;51(6):476-481. Epub 2016 Oct 1. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27938961
- ↑ 43.0 43.1 Majerovich K et al. Duration of steroid therapy and temporal artery biopsy positivity in giant cell arteritis: A retrospective cohort study. J Rheumatol 2023 Jul; 50:965. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36642440 https://www.jrheum.org/content/50/7/965
- ↑ 44.0 44.1 Garcia N, Halabi M, Dillon S et al Antineutrophil Cytoplasmic Antibody-Masquerading as Giant Cell Arteritis. Ann Intern Med Clinical cases https://www.acpjournals.org/doi/10.7326/aimcc.2023.0840
- ↑ Rubenstein E, Maldini C, Gonzalez-Chiappe S et al. Sensitivity of temporal artery biopsy in the diagnosis of giant cell arteritis: a systematic literature review and meta-analysis. Rheumatology (Oxford). 2020;59(5):1011-1020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31529073 https://academic.oup.com/rheumatology/article/59/5/1011/5569830
- ↑ Ling ML, Yosar J, Lee BW et al The diagnosis and management of temporal arteritis. Clin Exp Optom. 2020 Sep;103(5):572-582. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31663193 Free article. Review.
- ↑ Serling-Boyd N, Stone JH. Recent advances in the diagnosis and management of giant cell arteritis. Curr Opin Rheumatol. 2020 May;32(3):201-207. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32168069 PMCID: PMC7228540 Free PMC article. Review.
- ↑ 48.0 48.1 Denis G et al. Diagnostic strategy using color doppler ultrasound of temporal arteries in patients with high clinical suspicion of giant cell arteritis: A prospective cohort study. Ann Intern Med 2024 May 7; PMID: https://www.ncbi.nlm.nih.gov/pubmed/38710093 https://www.acpjournals.org/doi/10.7326/M23-3417
- ↑ Q&A About Polymyalgia Rheumatica and Giant Cell Arteritis http://www.niams.nih.gov/hi/topics/polymyalgia/index.htm
- ↑ NINDS Vasculitis Syndromes of the Central and Peripheral Nervous Systems Information Page https://www.ninds.nih.gov/Disorders/All-Disorders/Vasculitis-Syndromes-Central-and-Peripheral-Nervous-Systems-Information-Page
Patient information
temporal or cranial (giant cell) arteritis patient information