View source for Giant cell arteritis

''The term "temporal arteritis" is no longer used.  It refers to giant cell arteritis that affects the temporal artery.''

==Background==
*Systemic vasculitis most commonly involving medium-sized arteries in the carotid circulation, affecting 1% of the population<ref>Gonzalez-Gay, MA et al. Epidemiology of the vasculitides. Rheum Dis Clin North Am. 2001;27:729-749</ref>
*Giant cell arteritis, with possible involvement of large vessels like aorta leading to<ref>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</ref>:
**[[Temporal arteritis]]
**[[Aortic regurgitation]]
**Aortic arch syndrome
**[[Aortic dissection]]
*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]] <ref> 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.</ref>
**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 or transient diplopia
**Second eye may be affected within weeks after first
===American College of Rheumatology Criteria<ref>Hunder GG. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis.   Arthritis Rheum.  1990; 33(8):1122-8 </ref>===
*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''<ref>Smetana GW, et al. Does this patient have temporal arteritis? JAMA. 2002;287:92-101</ref>
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Finding'''
| align="center" style="background:#f0f0f0;"|'''(+) Likelihood Ratio of Temporal Ateritis'''
| align="center" style="background:#f0f0f0;"|'''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 DDX}}

{{Acute vision loss noninflamed DDX}}

{{Primary Vasculitis DDX}}

==Evaluation==
*Temporal artery tenderness
*Afferent pupillary defect
*Pale and edematous optic disc
*ESR ~70-110
**84% sensitivity, 30% specificity<ref>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.</ref>
**>15% of patients can have a normal ESR
*CRP elevated<ref>Kermani et al. Utility of Erythrocyte Sedimentation Rate and C-Reactive Protein for the Diagnosis of Giant Cell Arteritis. Semin Arthritis Rheum. 2012 Jun; 41(6): 866–871.</ref>
**May be more sensitive than ESR
**Doesn't have normal age related increase like ESR does
*4% of patients have normal CRP and ESR with biopsy confirmed diagnosis<ref>Jhun P, et al. Giant Cell Arteritis: Read the Fine Print!  Ann Em Med. 2015; 65(5):615–617.</ref>

==Management==
*[[Methylprednisolone]] 1000mg IV QD x3d
*Needs temporal artery biopsy, although treatment with high dose corticosteroids should be initiated prior to biopsy to avoid permanent vision loss as a result of ophthalmic artery involvement.

==Disposition==
*Admission

==See Also==
*[[Headache]]

==References==
<references/>

==Videos==
{{#widget:YouTube|id=6nKZ1X-ZYGI}}

[[Category:Ophthalmology]]
[[Category:Neurology]]
[[Category:Rheumatology]]