Giant cell arteritis

(Redirected from Temporal arteritis)

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

Background

The arteries of the face and scalp.
  • 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

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