Giant Cell Arteritis

Question 1

what is the typical presentation for giant cell arteritis?

Answer 1

unilateral headache, scalp tenderness, jaw claudication, loss of vision

associated with polymyalgia rheumatica- high ESR and raised CRP

Question 2

define giant cell arteritis?

Answer 2

granulomatous inflammation of large arteries

affects branches of external carotid artery-> most commonly the TEMPORAL ARTERY

type of VASCULITIS

Question 3

outline the aetiology of GCA?

Answer 3

UNKNOWN

More common with increasing age

Some associations with ethnic background and infections

Associated with HLA-DR4 and HLA-DRB1

Associated with polymyalgia rheumatic in 50%

Most commonly affects temporal artery to cause headache and scalp tenderness but can affect ophthalmic to cause visual defects (posterior ciliary arteries) and facial artery to cause claudication (mandibular branch)

Question 4

what are the risk factors for GCA?

Answer 4

age more than 50

Question 5

outline the epidemiology of GCA?

Answer 5

More common in FEMALES

Peak age of onset: 65-70 yrs

If under 55, consider Takayasu’s

Question 6

What are the presenting symptoms of GCA?

Answer 6

Subacute onset (usually over a few weeks)

Headache

Scalp tenderness i.e. when brushing hair

Jaw claudication – pain when clenching jaw

Blurred vision

Sudden blindness in one eye - ischaemic optic neuropathy

Systemic: malaise, low-grade fever, lethargy, weight loss, depression

Symptoms of polymyalgia rheumatica - early morning pain and stiffness of muscles of the shoulder and pelvic girdle

NOTE: 40-60% of GCA has polymyalgia rheumatica

Question 7

what are the signs of GCA on physical examination?

Answer 7

Swelling and erythema overlying the temporal artery

Scalp and temporal tenderness

Thickened non-pulsatile temporal artery

Reduced visual acuity

Other vessels, such as the occipital, postauricular, or facial arteries, may be enlarged or tender.

Question 8

what are the appropriate investigations for GCA?

Answer 8

High ESR and high CRP

High platelets

High ALP and elevated transaminases

FBC - normocytic anaemia of chronic disease

Temporal Artery biospy

temportal artery ultrasound

Question 9

summarise the prognosis of GCA?

Answer 9

condition lasts 2 years before complete remission

Question 10

what are the possible complications of GCA?

Answer 10

carotid artery aneurysm

aortic aneurysm

thrombosis

embolism to ophthalamic artery

Question 11

Describe the temporal artery biospy for GCA?

Answer 11

Must be performed within 48 hrs of starting corticosteroids

Negative biopsy doesn’t necessarily rule out GCA as GCA is segmental

histopathology typically shows granulomatous inflammation; in about 50% of cases, multinucleated giant cells are present;

inflammatory infiltrate may be focal and segmental

Question 12

What does temporal artery ultrasound show in GCA?

Answer 12

may show wall thickening (halo sign), stenosis or occlusion

Question 13

What are the side effects of glucucorticoids?

Answer 13

osteoporosis (fragile bones),

hypertension (high blood pressure),

diabetes,

weight gain,

increased vulnerability to infection,

cataracts and glaucoma (eye disorders),

thinning of the skin,

bruising easily, and

muscle weakness.

Question 14

outline the management of GCA?

Answer 14

- no visual symptoms- start 40-60mg PREDNISOLONE daily

• start PPIs and biphosphonates – gastric and bone protection
• Refer for urgent rheum assessment ( within 3 working days) -> arrange biopsy for confirmation

- If visual symptoms- start PREDNISOLONE 60-100mg, PPI coverand osteoporosis prophylaxis, and same day assessment with ophthalmology

Question 15

what are the american college of rheumatology guildlines for diagnosis of GCA?

Answer 15

must have 3 of the following:

Age of onset of symptoms > 50 years

New headache

ESR >50mm/h

Clinically abnormal temporal artery – tender or non-pulsatile

Biopsy of temporal artery showing mononuclear cell infiltration or granuloma (giant cells)