Giant cell arteritis

Revision as of 18:11, 25 March 2016 by Ostermayer (talk | contribs) (Background)

Background

  • Systemic vasculitis most commonly involving medium-sized arteries in the carotid circulation affection 1% of the population[1]
  • Giant cell arteritis, with possible involvement of large vessels like aorta leading to[2]:
  • Temoral arteritis
  • 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 w/ severe vision loss if left untreated
  • Associated with polymyalgia rheumatica (30-40%)[3]

Clinical Features

  • Fever
  • Headache in 85%
    • Gradually worsens over days
    • Worse at night
    • Usually unilateral near temple
  • Jaw claudication
    • Weight Loss
  • Myalgias
  • Visual loss in one eye in 50%
    • Posterior ciliary artery
    • May present as amaurosis fugax
    • Second eye may be affected within weeks after first

American College of Rheumatology Criteria[4]

  • 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

Differential Diagnosis

Headache

Common

Killers

Maimers

Others

Aseptic Meningitis

Acute Vision Loss (Noninflamed)

Emergent Diagnosis

Diagnosis

  • Temporal artery tenderness
  • Afferent pupillary defect
  • Pale and edematous optic disc
  • ESR ~70-110
    • 84% sensitivity, 30% specificity[5]
    • >15% of patients can have a normal ESR
  • CRP elevated
  • 4% of patients have normal CRP and ESR with biopsy confirmed dx[6]

Management

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: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli'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. Hunder GG. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990; 33(8):1122-8
  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. Jhun P, et al. Giant Cell Arteritis: Read the Fine Print! Ann Em Med. 2015; 65(5):615–617.