Difference between revisions of "Giant cell arteritis"

(Text replacement - "==Diagnosis==" to "==Evaluation==")
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''The term "temporal arteritis" is no longer used.  It refers to giant cell arteritis that affects the temporal artery.''
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==Background==
 
==Background==
*Systemic vasculitis most commonly involving medium-sized arteries in the carotid circulation affection 1% of the population<ref>Gonzalez-Gay, MA et al. Epidemiology of the vasculitides. Rheum Dis Clin North Am. 2001;27:729-749</ref>
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*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>:
 
*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]]
 
**[[Temporal arteritis]]
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**[[Aortic dissection]]
 
**[[Aortic dissection]]
 
*Elevated risk in Women and 50-70 yrs of age
 
*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"
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*"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
 
*Can cause painless, ischemic optic neuropathy with severe vision loss if left untreated
*Associated with [[polymyalgia rheumatica]] (30-40%)<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>
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*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>
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**50% of patients with Giant Cell Arteritis have concomitant Polymylalgia Rheumatica. 15% of patients with Polymyalgia Rheumatica develop Giant Cell Arteritis
  
 
==Clinical Features==
 
==Clinical Features==
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*Jaw claudication
 
*Jaw claudication
 
**Weight Loss
 
**Weight Loss
*Myalgias
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*[[Myalgia]] ([[polymyalgia rheumatica]])
*Visual loss in one eye in 50%
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*[[Visual loss]] in one eye in 50%
 
**Posterior ciliary artery
 
**Posterior ciliary artery
**May present as amaurosis fugax
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**May present as amaurosis fugax or transient diplopia
 
**Second eye may be affected within weeks after first
 
**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>===
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*Tender, pulseless temporal artery
*3 or more criteria 93% sensitive and 91% specific
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*Afferent pupillary defect
**Age ≥ 50 years old
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*Pale and edematous optic disc
**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===
 
===Likelihood Ratio of Findings===
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==Evaluation==
 
==Evaluation==
*Temporal artery tenderness
 
*Afferent pupillary defect
 
*Pale and edematous optic disc
 
 
*ESR ~70-110
 
*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>
 
**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
 
**>15% of patients can have a normal ESR
*CRP elevated
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*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>
*4% of patients have normal CRP and ESR with biopsy confirmed dx<ref>Jhun P, et al. Giant Cell Arteritis: Read the Fine Print!  Ann Em Med. 2015; 65(5):615–617.</ref>
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**May be more sensitive than ESR
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**Doesn't have normal age related increase like ESR does
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*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>
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 +
===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>===
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*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
  
 
==Management==
 
==Management==
 
*[[Methylprednisolone]] 1000mg IV QD x3d
 
*[[Methylprednisolone]] 1000mg IV QD x3d
*Needs temporal artery biopsy
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*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==
 
==Disposition==
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==References==
 
==References==
 
<references/>
 
<references/>
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==Videos==
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{{#widget:YouTube|id=6nKZ1X-ZYGI}}
  
 
[[Category:Ophthalmology]]
 
[[Category:Ophthalmology]]
 
[[Category:Neurology]]
 
[[Category:Neurology]]
 
[[Category:Rheumatology]]
 
[[Category:Rheumatology]]

Revision as of 15:16, 18 August 2019

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[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
  • Jaw claudication
    • Weight Loss
  • Myalgia (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
  • Tender, pulseless temporal artery
  • Afferent pupillary defect
  • Pale and edematous optic disc

Likelihood Ratio of Findings

Jaw claudication and a beaded temporal artery increase the likelihood of temporal arteritis the greatest[4]

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

  • ESR ~70-110
    • 84% sensitivity, 30% specificity[5]
    • >15% of patients can have a normal ESR
  • CRP elevated[6]
    • 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[7]

American College of Rheumatology Criteria[8]

  • 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

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

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. Smetana GW, et al. Does this patient have temporal arteritis? JAMA. 2002;287:92-101
  5. 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.
  6. 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.
  7. Jhun P, et al. Giant Cell Arteritis: Read the Fine Print! Ann Em Med. 2015; 65(5):615–617.
  8. Hunder GG. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990; 33(8):1122-8

Videos