Giant Cell Arteritis - LARGE CELL Flashcards
Vasculitis is an autoimmune inflammatiion of the blood vessels. Vasculitis can be classified into 3 categories. Which of the following is NOT one of these categories?
1 - Large Vessel
2 - Medium Vessel
3 - Moderate Vessel
4 - Small Vessel
3 - Moderate Vessel
- Large Vessel = Takayasu’s, Giant Cell arteries
- Medium Vessel = Polyarteritis nodosa, Kawasaki’s
- Small = Henoch Schonlein purpura, EGPA and GPA, MPA
Giant cell arteritis, a form of large vessel vasculitis is the most common vasculitis. What age does this occur in most commonly?
1 - 20-35 y/o
2 - 35-50 y/o
3 - >50 y/o
4 - >60 y/o
- > 50 years
- peak 70-79
Which of the following is NOT a risk factor for giant cell arteritis?
1 - Aging
2 - Ethnicity
3 - Female sex
4 - BMI
5 - Genetics
4 - BMI
Ethnicity
- highest in Scandinavian countries and Americans of Scandinavian descent)
Genetics
- HLA-DRB1, DQA1 and DQB1
What is the most common vasculitis?
1 - Takayasu’s
2 - Giant Cell arteritis
2 - Polyarteritis nodosa
4 - Kawasaki’s
2 - Giant Cell arteritis
- form of large vessel vasculitis
Vasculitis is an autoimmune inflammatory condition where immune cells mistake antigens on the endothelium for foreign antigens. What is the called?
1 - immune tolerance
2 - molecular mimicry
3 - cross reactivity
4 - all of the above
2 - molecular mimicry
Although the exact pathophysiology of giant cell arteritis is unknown, which cell has been associated with being a trigger of the adventitia?
1 - dendritic cells
2 - B cells
3 - neutrophils
4 - cytotoxic T cells
1 - dendritic cells
Dendritic cells have been suggested to be a trigger of giant cell arteritis, where they mistakably target the adventitia of the blood vessels. Which of the following then occurs following this initial trigger?
1 - Dendritic cells produce chemokines and recruit T cells
2 - T cell activation
3 - T cells produce IFN gamma & IL 17
4 - all of the above
4 - all of the above
In the pathophysiology of giant cell arteritis, giant cells are formed from which cell that differentiates into them?
1 - dendritic cells
2 - neutrophils
3 - macrophages
4 - NK cells
3 - macrophages
In vasculitis damaged endothelium tries to repair itself. Which of the does not occur during this healing process?
1 - tissue factor and collagen are exposed to coagulation factors
2 - increased risk of coagulation
3 - walls become thinner and weaker, increasing risk of aneurysms
4 - fibrin is deposited into vessel walls
5 - walls become more elastic
5 - walls become more elastic
- walls actually become stiffer due to all the other factors such as fibrin deposits
Which of the following is NOT a general symptom of vasculitis?
1 - fever
2 - weight loss
3 - anaemia
4 - fatigue
5 - myalgia/arthralgia
3 - anaemia
There are generic symptoms patients with vasculitis can present with, such as fever, weight loss and fatigue. Which of the following specific organs can be affected?
1 - ENT = nasal bridge collapse
2 - Skin = purpura rash (non-blanching), can cause necrosis
3 - Oral = mucus membrane ulcers, necrosis and haemorrhage in gums
4 - Neural = cerebral vasculitis (white matter on T2 scan)
5 - all of the above
5 - all of the above
Patients with giant cell arteritis can experience headaches and tenderness of the skull. The following can all be affected, but which blood vessel and its location is most commonly affected?
1 - extra-cranial branches of external carotid artery near the ear
2 - temporal artery at temple of head
3 - ophthalmic branch of internal carotid resulting in blindness.
4 - facial artery near mandible bone
2 - temporal artery at temple of head
- associated with high risk of stroke
If ophthalmic branch of internal carotid artery is affected it can cause blindness.
Patients with giant cell arteritis can experience headaches and tenderness of the skull, with the temporal artery at temple of head most commonly affected. However, if the ophthalmic artery near eyes is affected what can this cause?
1 - blindness
2 - diplopia (double vision)
3 - painless
4 - all of the above
4 - all of the above
- if not treated quickly with corticosteroids this can cause ischaemia and blindness
Patients with giant cell arteritis can experience headaches and tenderness of the skull, with the temporal artery at temple of head most commonly affected. However, if the facial artery near mandible bone is affected what can this cause?
1 - claudication
2 - paralysis
3 - hypoesthesia
4 - all of the above
1 - claudication
- muscle pain due to lack of oxygen that’s triggered by activity and relieved by rest.
- can cause jaw claudication
What blood measures can be elevated in giant cell arteritis, a form of large cell vasculitis?
1 - ESR and creatine kinase
2 - CRP and lactate dehydrogenase
3 - CRP and creatine kinase
4 - CRP and ESR
4 - CRP and ESR
- ESR is really high
Are liver enzymes normal or raised in giant cell arteritis?
- ALP raised in 25%-35%
Does giant cell arteritis cause any change in albumin levels?
- yes
- can be low due to chronic inflammation
If a biopsy was taken from a patient with suspected giant cell vasculitis we would see giant cells. What are these cells though?
1 - megakaryocytes
2 - lymphocytes grouped together
3 - reed-sternberg cells
4 - monocytes packed together
4 - monocytes packed together
- typically macrophages at this point
- form a granuloma
- found in internal elastic lamina
If a patient is started on steroids, how soon should a biopsy of the temporal artery be taken to confirm the diagnosis?
1 - <24h
2 - <48h
3 - <1 wk
4 - 2-4 wks
4 - 2-4 wks
- a negative biopsy does NOT rule out giant cell arteritis though
In giant cell arteritis, a form of large cell vasculitis, why would we want to do a chest X-ray?
1 - ensure lungs are ok
2 - common carotid artery could be affected
3 - aorta could be inflamed
4 - check on the heart
3 - aorta could be inflamed
- specifically the branches of the aorta
In giant cell arteritis, a form of large vessel vasculitis why can ultrasound and/or biopsy not be definitive form of diagnosis when assessing the temporal artery?
1 - operator dependent skill set
2 - part of artery sampled may be healthy
3 - not sufficient to effectively diagnose
2 - part of artery sampled may be healthy
- vasculitis is segmental, so parts are healthy
- so may miss the damaged arteries
How can we diagnose vasculitis using imagery?
1 - biopsy or ultrasound
2 - MRI
3 - X-ray
4 - CT scan
1 - biopsy or ultrasound
- biopsy 2-4 weeks from starting steroids
- ultrasound asap
If the temporal artery is affected in giant cell arteritis, which of the following is least likely to be present upon a clinical examination?
1 - thickened temporal artery
2 - nodular temporal artery
3 - tender temporal artery
4 - stronger than normal temporal artery pulse
4 - stronger than normal temporal artery pulse
- typically the temporal artery pulse will be weakened or absent
If the aorta, or its branches are affected in giant cell arteritis, which of the following is least likely to be present upon a clinical examination?
1 - bruits
2 - heart murmurs
3 - collapsing pulse
4 - none of the above are present
3 - collapsing pulse
Bruits
- over the carotids, supraclavicular, axillary
Heart murmurs
- Aortic regurgitation
How can we treat giant cell arteries?
1 - NSAIDS given immediately
2 - strong dose of steroids given immediately
3 - DMARDs given immediately
4 - biologics given immediately
2 - strong dose of steroids given immediately
- prednisolone 40mg-60mg/day
If steroids fail, use:
- Methotrexate
- Leflunomide
- Tociluzumab
How soon should steroids be given if you suspect patient has vasculitis?
1 - immediately
2 - 24-48h
3 - only following ultrasound
4 - only following biopsy
1 - immediately
- delaying treatment can cause permanent and irreversible damage
If a patient presents with suspected giant cell arteritis and they have NO visual loss at presentation, which of the following should be given?
1 - oral prednisolone 4-60mg/day
2 - oral methotrexate
3 - oral tociluzumab
4 - IV Methyl prednisolone 500mg-1g/day for 3 days
1 - oral prednisolone 4-60mg/day
If a patient presents with suspected giant cell arteritis and they have visual loss at presentation, which of the following should be given?
1 - oral prednisolone 4-60mg/day
2 - oral methotrexate
3 - oral tociluzumab
4 - IV Methyl prednisolone 500mg-1g/day for 3 days
4 - IV Methyl prednisolone 500mg-1g/day for 3 days
If steroids fail, use:
- Methotrexate
- Leflunomide
- Tociluzumab
In additional to clinical experience, which 2 markers can be used to monitor disease severity following the treatment with steroids?
1 - ESR and CRP
2 - TNF-a and IL-6
3 - albumin and eGFR
4 - all of the above
1 - ESR and CRP
- must also monitor steroid effects
When placing patients on steroids for prolonged periods of time, which 2 of the following classes of medications are important to prescribe alongside?
1 - statins
2 - proton pump inhibitors
3 - anti-depressants
4 - bone protection
2 - proton pump inhibitors
4 - bone protection
