RHEUM: GCA and polymyalgia rheumatica

Question 2

Define giant cell arteritis

Answer 2

Chronic vasculitis of large and medium sized vessels in individuals over 50yrs.

Question 3

Why is giant cell arteritis an emergency?

Answer 3

Occlusive arteritis can lead to anterior ischaemic optic neuropaty and acute visual loss. The visual symptoms are an opthalmoc emergency

Question 4

What are the risk factors for GCA aka Temporal arteritis?

Answer 4

Age
White ethnicity
PMH of polymyalgia rheumatica
Genetic predisposition with HLA-DR4

Question 5

How does GCA present?

Answer 5

Presentation is acute
Headaches in 70% of presentations
Localised, unilateral, piercing or stabbing over the temple
Tongue and/or jaw claudication upon mastication
Constitutional symptoms
Visual symptoms
Scalp tenderness, especially over temporal artery

Question 6

How is giant cell arteritis diagnosed?

Answer 6

• Over 50
• The presence of two or more of these symptoms:
  Raised ESR, CRP or PV
  New onset of localised headache
  Tenderness or decreased pulsation of temporal artery
  New visual symptoms
  Biopsy of necrotizing arteritis

Question 7

How is GCA treated?

Answer 7

• Prednisolone 60-100mg PO per day for at least 2 weeks then slowly reduce
• if visual symptoms are present - 1g methylprednisolone IV pulse therapy for 1-3 days
• low dose aspirin therapy to reduce thrombotic risks

Question 8

What is your immediate managment in pt with suspected GCA?

Answer 8

Steroid therapy

Question 9

How is polymyalgia rheumatica (PMR) characterised?

Answer 9

Pain and stiffness in shoulder, hip girdles and neck.

Question 10

Who does PMRF usually affect?

Answer 10

The elderly - incidence increases with age. Average age is 70.
Affects patients with GCA (there’s evidence that PMR and GCA are associated to one another)

Question 11

How does PMR present (just from a history)?

Answer 11

Sudden onset of pain in proximal limbs - so the neck, shoulders and hips.
Difficulty getting up from chair (hip pain), and combing hair (shoulder pain).
Pain at night time
Systemic symptoms - fatigue, weight loss, low grade fever

From Z2F:
Presence of symptoms for at least 2 weeks
Bilateral shoulder pain that radiates to the elbow
Bilateral pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 minutes in the morning

May also have systemic symptoms - weight loss, fatigue, low grade fever, low mood 
Upper arm tenderness
Carpal tunnel syndrome
Pitting oedema


Question 12

What investigations may you consider for pt with suspected PMR?

Answer 12

Bloods - ESR, CRP, polycythemia vera

Temporal artery biopsy if symptoms of GCA

Question 13

What is the difference between GCA and trigeminal neuralgia?

Answer 13

GCA- chronic vasculitis of large and medium sized vessels in the head whereas TRIGEMINAL NEURALGIA- compression of trigeminal nerve

GCA- presents with headaches, stabbing facial pain and visual disturbances
TRIGEMINAL NEURALGIA- electric shock and knife pain unilaterally

Question 14

Name 2 differentials of poly myalgia rheumatica

Answer 14

Osteoarthritis, rheumatoid arthritis, SLE, myositis, cervical spondylitis, frozen shoulder (in both shoulders), hyper or hypo thyroidism, osteomalacia, fibromyalgia