Giant cell arteritis

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Background

  • Systemic vasculitis most commonly involving medium-sized arteries in the carotid circulation affection 1% of the population[1]
  • Giant cell arteritis, with possible involvement of large vessels like aorta leading to[2]:
  • Elevated risk in Women and 50-70 yrs of age
  • "Rule of 50s" can help remember useful points - "temporal arteritis affects patients at least 50 years of age, with a serum ESR > 50 mm/hr and is treated with 50mg of prednisone daily"
  • Can cause painless, ischemic optic neuropathy with severe vision loss if left untreated
  • Associated with polymyalgia rheumatica [3]
    • 50% of patients with Giant Cell Arteritis have concomitant Polymylalgia Rheumatica. 15% of patients with Polymyalgia Rheumatica develop Giant Cell Arteritis

Clinical Features

  • Fever
  • Headache in 85%
    • Gradually worsens over days
    • Worse at night
    • Usually unilateral near temple
  • Tender pulseless temporal artery
  • Jaw claudication
    • Weight Loss
  • Myalgias (polymyalgia rheumatica)
  • Visual loss in one eye in 50%
    • Posterior ciliary artery
    • May present as amaurosis fugax
    • Second eye may be affected within weeks after first

American College of Rheumatology Criteria[4]

  • 3 or more criteria 93% sensitive and 91% specific
    • Age ≥ 50 years old
    • New onset of headache
    • Temporal artery tenderness or DECREASED temporal pulse (not related to carotid disease)
    • ESR ≥ 50 mm/hr
    • Artery biopsy with necrotizing arteritis or a granulomatous process with multinucleated giant cells

Likelihood Ratio of Findings

Jaw claudication and a beaded temporal artery increase the likelihood of temporal arteritis the greatest[5]

Finding (+) Likelihood Ratio of Temporal Ateritis Negative Likelihood Ratio
Jaw claudication 4.2 (2.8-6.2) 0.72 (0.65 - 0.81)
Diplopia 3.4 (1.3-8.6) 0.95 (0.91 - 0.99)
Temporal artery beading 4.6 (1.1 - 18.4) 0.93 (0.88-0.99)
Enlarged temporal artery 4.3 (2.1-8.9) 0.67 (0.5-0.89)
Painful temporal artery 2.6 (1.9-3.7) 0.82 (0.74-0.92)
Absent temporal artery pulse 2.7 (0.55 - 13.4) 0.71 (0.38 - 1.3)
Abnormal ESR 1.1 (1.0-1.2) 0.2 (0.08 - 0.51)

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Acute Vision Loss (Noninflamed)

†Emergent Diagnosis

Evaluation

  • Temporal artery tenderness
  • Afferent pupillary defect
  • Pale and edematous optic disc
  • ESR ~70-110
    • 84% sensitivity, 30% specificity[6]
    • >15% of patients can have a normal ESR
  • CRP elevated
  • 4% of patients have normal CRP and ESR with biopsy confirmed diagnosis[7]

Management

Disposition

  • Admission

See Also

References

  1. ↑ Gonzalez-Gay, MA et al. Epidemiology of the vasculitides. Rheum Dis Clin North Am. 2001;27:729-749
  2. ↑ Morabito GC, Tartaglino B. Chapter 279. Emergencies in Systemic Rheumatic Diseases. In: JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. 's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hil
  3. ↑ Lehrmann JF, Sercombe CT: Systemic Lupus Erythmatosus and the Vasculitides, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 116: p 1497-1510.
  4. ↑ Hunder GG. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990; 33(8):1122-8
  5. ↑ Smetana GW, et al. Does this patient have temporal arteritis? JAMA. 2002;287:92-101
  6. ↑ Kermani TA, et al. Utility of erythrocyte sedimentation rate and C-reactive protein for the diagnosis of giant cell arteritis. Semin Arthritis Rheum. 2012; 41:866–871.
  7. ↑ Jhun P, et al. Giant Cell Arteritis: Read the Fine Print! Ann Em Med. 2015; 65(5):615–617.
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