Updated: 7/10/2019

Giant Cell Arteritis

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Snapshot
  • A 65-year-old woman presents to the emergency department due to a severe headache and visual impairment in the right eye. Her symptoms are associated with pain with chewing and proximal muscle morning stiffness. On physical exam, she has decreased visual acuity of the right eye, scalp tenderness on the right, and an absent pulse in the right temporal area. Laboratory testing is significant for an elevated erythrocyte sedimentation rate. She is admitted and immediately started on systemic glucocorticoids. 
Introduction
  • Clinical definition
    • a chronic large- and medium-sized vessel vasculitis that typically involves the
      • temporal artery
      • cranial arteries
  • Epidemiology
    • incidence
      • most common systemic vasculitis affecting patients ≥ 50 years of age
    • demographic
      • woman > men
  • Etiology
    • presumed to be autoimmune
  • Pathogenesis
    • T-cells and monocytes are recruited to the vessel wall and result in an inflammatory response
  • Associated conditions
    • polymyalgia rheumatica 
  • Prognosis
    • relapses can occur in 20-50% of patients
Presentation
  • Symptoms
    • temporal headache
    • jaw claudication
    • amaurosis fugax
    • symptoms of polymyalgia rheumatica (PMR)
      • morning stiffness
  • Physical exam
    • scalp tenderness
    • palpation of the temporal area may demonstrate
      • absent pulse
      • knot-like swelling
    • vision loss
    • findings of PMR
      • distal extremity swelling
Imaging
  • Color-coded duplex ultrasound
    • indication
      • to assess the temporal arteries and extracranial vessels
Studies
  • Labs
    • ↑ erythematous sedimentation rate
    • ↑ C-reactive protein
  • Temporal artery biopsy
    • confirms the diagnosis
Differential
  • Migraine
    • distinguishing factors
      • may be accompanied by an aura, photophobia, and phonophobia
  • Takayasu arteritis
    • distinguishing factors
      • typically affects young and Asian women
      • also treated with steroids
Treatment
  • Management approach
    • high-dose systemic glucocorticoids should be promptly administered even before the diagnosis is established 
    • temporal artery biopsy confirms the diagnosis
  • Medical
    • corticosteroids  
      • indication
        • standard initial treatment for patients suspected of having temporal arteritis
Complications
  • Blindness 
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(M2.RH.17.4691) A 74-year-old woman with no significant past medical history presents with 1 week of fever, unremitting headache and hip and shoulder stiffness. She denies any vision changes. Physical examination is remarkable for right scalp tenderness and range of motion is limited due to pain and stiffness. Neurological testing is normal. Laboratory studies are significant for an erythrocyte sedimentation rate (ESR) at 75 mm/h (normal range 0-22 mm/h for women). Which of the following is the most appropriate next step in management? Tested Concept

QID: 107607
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Obtain CT head without contrast

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Perform a lumbar puncture

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Perform a temporal artery biopsy

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Start oral prednisone

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Start IV methylprednisolone

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(M2.RH.17.4691) A 72-year-old man presents to his primary care provider complaining of fatigue, mild headache, and discomfort with chewing for roughly 1 week. Before this, he felt well overall, but now is he is quite bothered by these symptoms. His medical history is notable for hypertension and hyperlipidemia, both controlled. On examination, he is uncomfortable but nontoxic-appearing. There is mild tenderness to palpation over his right temporal artery, but otherwise the exam is not revealing. Prompt recognition and treatment can prevent which of the following feared complications: Tested Concept

QID: 107656
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Renal failure

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Blindness

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Pericarditis

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Pulmonary fibrosis

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Cognitive impairment

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(M3.RH.15.62) A 66-year-old woman presents to the emergency department with a throbbing headache. She states that the pain is worse when eating and is localized over the right side of her head. Review of systems is only notable for some blurry vision in the right eye which is slightly worse currently. The patient's past medical history is notable only for chronic pain in her muscles and joints for which she has been taking ibuprofen. Her temperature is 99.1°F (37.3°C), blood pressure is 144/89 mmHg, pulse is 87/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical examination is significant for tenderness to palpation over the right temporal region. Which of the following is the best initial step in management? Tested Concept

QID: 103085
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100% oxygen

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CT head

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Ibuprofen and acetaminophen

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Methylprednisolone

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MRI head

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