Vasculitis - GCS

Question 1

What is Giant Cell Arteritis or Temporal Arteritis? RF?

Answer 1

(1. ) Type of chronic vasculitis characterised by granulomatous inflammation in walls of large and medium sized arteries
(2. ) Including the extracranial branches of the carotid arteries and branches of the ophthalmic artery, such as short ciliary branches
(3. ) RF = >50 years (peaks in 70-80years), white populations in particular Scandinavian, Female.
(4. ) It is a medical emergency - strokes, blindness, morbidity

Question 2

Presentation of GCA (7.)

Answer 2

AGED >50 years, NEW ONSET LOCALISED HEADACHE = GCA until proven otherwise

(1. ) New-localised headache in temporal area
(2. ) Temporal artery: abnormality/tenderness/thickening
(3. ) Polymyalgia rheumatica Sx: Bilateral upper arm stiffness, Aching, Tenderness, Pelvic girdle pain
(4. ) Jaw and tongue claudication
(5. ) Visual disturbances: Blurring, amaurosis fugax (temporary vision loss), diplopia, visual loss
(6. ) Neurological features: Mononeuropathy, Polyneuropathy of arms or legs, TIA, Stroke
(7. ) Systemic features = Fever, fatigue, anorexia, weight loss, depression

Question 3

Examination and Signs of GCA (5.)

Answer 3

(1. ) Temporal artery:
- prominent, tender, pulseless
- Abnormal palpation of temporal artery
- NOTE: normal appearance does not exclude Dx

(2. ) Bruits (vascular murmur/turbulent flow)
- Heard over carotid, axillary, brachial artery

(3. ) Fever
(4. ) Muscle and joints may be tender
(5. ) Visual loss: Ocular and funduscopic

Question 4

GCA Ix (4)

Answer 4

(1. ) Bloods: ESR, CRP, FBC, LFTs
- Thrombocytosis
- Elevated CRP, ESR, normal values does NOT rule out dx

(2. ) Temporal Artery biopsy
- Evidence of granulomatous inflammation, multinucleated giant cells

(3. ) Temporal Artery US
(4. ) PET-CT and axillary ultrasound: used to investigate for extra cranial disease

Question 5

Dx of GCA

Answer 5

American College of Rheumatology GCA criteria requires at least three:

• ≥50 years.
• New onset headache
• Temporal artery abnormality: tenderness or decreased pulsation
• Elevated ESR
• Abnormal artery biopsy

Question 6

Treatment and Management of GCA

Answer 6

(1. ) High dose corticosteroids immediately + taper this over 12-18m provided no Sx return:
- 40mg Oral prednisolone
- 60mg Oral prednisolone if ischaemic Sx (limb, jaw claudication)
- IV methylprednisolone in visual Sx

(2. ) Consider prophylaxis for steroid Tx
- Steroid Complications and pre-existing comorbidities:
- Steroid induced diabetes OR worsen pre-exiting DM
- Osteoporosis (consider bisphosonates, calcium, colecalciferol)
- Infection
- GI toxicity, peptic ulcerations (Consider PPI, aspirin)

(3. ) Methotrexate and/or Tocilizumab
- If pt has high risk of corticosteroid toxicity or in pt with relapses on corticosteroid weaning

Question 7

GCA Complications

Answer 7

• Permeant visual loss
• Aneurysm, dissections, stenotic lesions
• CNS disease - seizures