Giant Cell Arteritis

Question 1

What can vasculitis be secondary to?

Answer 1

• SLE
• RA
• Hepatitis B + C
• HIV

Question 2

How is vasculitis categorised?

Answer 2

By the side of blood vessel affected eg large or medium

Question 3

What category is GCA in terms of type of vasculitis?

Answer 3

Large cell vasculitis (some sources say medium too)

Question 4

What is another name for GCA commonly used?

Answer 4

Temporal arteritis?

Question 5

What are the symptoms of GCA?

Answer 5

• Headache (unilateral and temporal)
• Temporal artery and scalp tenderness
• Difficult to comb hair
• Tongue/Jaw claudication
• Amaurosis fugax
• Sudden unilateral blindness
• Constitutional symptoms - Fever, weight loss, fatigue

Question 6

What are some risk factors for GCA?

Answer 6

• Peak onset 70-79
• Rarely seen before 50
• White Northern European
• Female
• HLA-DR4 genetic predisposition

Question 7

What is the pathophysiology of GCA?

Answer 7

• Inflammation of medium and large sized arteries
  1. Local vessel inflammation and macrophage are recruited
  2. Damage of vessel wall
  3. Growth and angiogenic factor release which thickens vessel intima
  4. Hyperplasia and ischaemia to areas supplied by the artery

Question 8

What arteries does GCA preferentially involve?

Answer 8

• Branches of the carotid eg temporal, opthalmic, occipital

- Sometimes vertebral, carotid, subclavian, aorta

Question 9

What are signs of GCA on examination?

Answer 9

• Abnormal temporal artery, reduced pulse and thickened
• Scalp tenderness on palpation
• Visual field defects
• Optic disc changes (pale swollen if anterior ischaemic optic neuritis)
• Retinal changes (pale with red cherry spot if central retinal artery)

Question 10

What should you consider in any older patient (>50) with new onset unilateral headache?

Answer 10

GCA!!!

Question 11

What is the major risk with GCA?

Answer 11

Irreversible bilateral visual loss

Question 12

What 5 criteria is there for the diagnosis of GCA?

Answer 12

1. Age of onset >50yrs
2. New headache
3. Temporal artery abnormality
4. Elevated ESR
5. Abnormal temporal artery biopsy

Question 13

What condition is GCA associated with?

Answer 13

Polymyalgia rheumatica (40-50% of patients with GCA)

Question 14

What investigations would you undertake in GCA?

Answer 14

1. FBC, U+E, LFT, CRP/ESR - Raised inflammatory markers, raised platelets, raised ALP, low Hb
2. Temporal artery biopsy - Skip lesions occur so don’t worry if negative

Question 15

What additional assessment do GCA patients require?

Answer 15

Opthalmic assessment

Characteristic finding is pale, swollen optic disc with anterior ischaemic optic neuritis

Question 16

What is the treatment regimen for GCA?

Answer 16

• Start prednisolone 60mg/day immediately

- IV methylprednisolone for 3 days if visual symptoms

Question 17

What additional medication does the patient need to prevent side effects of treatment?

Answer 17

1. Bisphosphonates/vit D - bone protection
2. PPI - Gastric protection against GI bleeds
3. Monitor blood sugar - diabetes
4. Low dose aspirin - Reduce thrombotic events

Question 18

What is the prognosis for GCA?

Answer 18

• 2 year course of prednisolone, then complete remission
• Reduce dose once symptoms have resolved and ESR has lowered
• If tapered off too quickly, risk of relapse

Question 19

What are some other complications of GCA (not visual)?

Answer 19

• Aortic aneurysm
• Aortic dissection
• Large artery stenosis
• CVD
• Steroid related complications

Question 20

What else can GCA present as?

Answer 20

Stroke