Giant Cell Arteritis Flashcards
What is giant cell arteritis?
Systemic, chronic, granulomatous vasculitis of medium & large arteries
What is giant cell arteritis often referred to as?
Temporal arteritis
State some risk factors for giant cell arteritis
- Age >50yrs
- Female
- Strong association with polymyagia rheumatica (~50%)
State some symptoms of giant cell arteritis
- Main presenting feature is headache:
- Severe
- Unilateral
- Around temple & forehead
- Scalp tenderness when brushing hair
- Jaw claudication
- Blurred or double vision (potential complication is irreversible painless complete sight loss- amaurosis fugax)
- Associated systemic symptoms
- Fever
- Fatigue
- Muscle aches
- Weight loss, loss of appetite
- Peripheral oedema
What is meant by jaw or tongue claudication?
Pain or weakness in the muscles of mastication that begins just after the onset of chewing and is relieved by rest
State what you might find on clinical examination of someone with giant cell arteritis
*Might not necessarily be any examination findings
- Superficial temporal artery tenderness, thickening or nodularity
- Absent temporal artery pulse
- Abnormal fundoscopy
What investigations would you do if you suspect giant cell arteritis, include:
- Bedside
- Bloods
- Imaging
- Other
*Where appropriate justify why we do each investigation/what it may show
Bedside
- Visual acuity testing
- Fundoscopy: may show pale disc with blurred margins if anterior ischaemic optic neuropathy has occurred
Bloods
- ESR: usually 50mm/hour
- CRP: elevated
- FBC: normocytic anaemia, thrombocytosis
- LFTs: raisd ALP
Imaging
- Duplex ultrasound of temporal: may show thickening (“hypoechoic halo”), stenosis or occlusion
Other
- Biopsy: biopsy revealing necrotizing arteritis and in 50% there are multinucleated giant cells
What sign do you see on duplex ultrasound of temporal artery in giant cell arteritis?
Hypoechoic halo sign
What do you find on/in the biopsy of giant cell arteritis?
- Necrotizing arteritis
- 50% show multinucleated giant cells
What is a definitive diagnosis of giant cell arteritis based on? (3)
Presence of 2 or more in pt who are >50yrs:
- New onset of localised headache
- Raised ESR (usuallyy 50mm/hour or more)
- Tenderness or decreased pulsation of temporal artery
- New visual symptoms
- Temporal artery biopsy findings
*NOTE: DO NOT delay initiation of steroid therapy to await biopsy if strong clinical suspicion or visual changes are reported
Discuss the initial management of giant cell arteritis, think about initial management and on
Initial Management
-
Steroids
- 60-100mg oral prednisolone daily (for at least 2 weeks)
- Or 1g IV methylprednisolone pulse therapy if visual symptoms
- PPI (gastric protection as will be on long term steroids due to tapering down)
- Bisphosphonates (bone protection as will be on long term steroids due to tapering down)
- Sometimes aspirin oral 75mg daily (reduce thrombotic risk-visual loss & stroke- evidence base is weak)
-
Refer to:
- Vascular surgeons- biopsy
- Rheumatology- specialist diagnosis & management
- Opthalmology review same day if they develop visual symptoms
Discuss the ongoing management of giant cell arteritis
- Steroids need to be continued until symptoms have resolved; they then must be slowly weaned off these
State some potential complications of giant cell arteritis, think about early & late complications
Early
- Visual loss
- Stroke
Late
- Relapse of condition
- Steroid related side effects & complications
- Stroke
- Aortitis leading to aortic aneurysm & dissection
Explain why giant cell arteritis can caue visual loss
If vasculitis is severe it can occlude the vessel (occlusive arteritis) and cause anterior ischaemic optic neuropathy and acute visual loss. (Passmed says that in anterior ischaemic neuropathy accounts for most of visual complications and this is caused by occlusion of posterior ciliary artery which is a branch of ophthalmic artery)
Explain why giant cell arteritis can casue jaw claudication
- Inflammation of arteries supply muscles of mastication
- Inflammation/vascualitis causes thickening of wall of artery and occludes lumen
- Ischaemia of muscles
