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From the American College of Rheumatology

Rheumatology for Primary Care
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Giant Cell Arteritis Case Studies

Home ยป Giant Cell Arteritis Case Studies
Giant Cell Arteritis Case Studies
  • Case 1

  • Case 2

  • Case 1

An 80 yo M with history of HLD and CAD presents to clinic with complaint of muscle pain and weakness in his shoulders.

History & Physical Exam

  • He recently noticed pain in his temples (worse on L) and difficulty chewing because his jaw will become tired.
  • He had one episode of transient vision loss in his L eye, but this resolved within 2-3 minutes and has not recurred. He has never had these symptoms before.
  • He has had some low-grade fevers recently, but thought this was secondary to being around his grandchildren.
  • He is also having difficulty lifting his arms above his head when he tries to wash his hair in the shower.
  • On PE, he is unable to lift his shoulders above his head without discomfort, and he has tenderness to touch of his L temple. His vision is normal in clinic today.
  • His vital signs are within normal limits.

Diagnostic Workup

  • ESR and CRP are both elevated.
  • CBC and CMP are within normal limits.
Diagnosis

Treatment & Management

  • Start on high dose steroids (1 mg/kg)
  • Schedule temporal artery biopsy within the next 2 weeks
  • Consider start of tocilizumab to decrease steroid burden, also given patient’s CAD history
  • Case 2

An 80 yo M with hx of HLD, CAD presents with new onset of unilateral headaches refractory to OTC medications, including NSAIDs and acetaminophen. 

History

  • No vision changes
  • Few weeks of girdle stiffness
  • Symptoms of tiredness when chewing on food for long, such as food like steak

Physical Exam

  • Normal VS
  • Shoulders tender to palpation bilaterally
  • Scalp tender to palpation over the area of the temporal artery with diminished temporal artery pulse on right (view image)
  • High-dose steroids started for high suspicion of giant cell arteritis

Diagnostic Workup

  • Labs: CRP 50 mg/L, ESR >120, CBC and CMP wnl
  • Biopsy:
    • Temporal artery biopsy pathology obtained within 2 weeks of steroid start.
    • Granulomatous inflammation of the inner half of the media, centered on the internal elastic lamina, with a mononuclear infiltrate, multinucleated giant cells, and fragmentation of the internal elastic lamina (view image)

Treatment

  • High doses of systemic steroids with taper yielded improvement in headache
  • Also started tocilizumab to decrease steroid burden, given patient’s CAD 

Diagnosis

This is a 75 yo white female of Northern European descent with scalp tenderness, which should raise suspicion for a possible giant cell arteritis (GCA). She has only had symptoms for 1 week, but this could be an early sign of GCA. It is prudent to further investigate her symptoms for GCA. 

It is also important to keep in mind that she may have elevated inflammatory markers as a sign of cancer recurrence, and this would also need to be considered.

Diagnosis

This patient is >50 yo with concerning symptoms of giant cell arteritis (GCA). His polymyalgia rheumatica (PMR)-like symptoms of muscle pain/weakness in his shoulders, temporal headache, jaw claudication, transient vision loss, and systemic symptoms, with elevated inflammatory marker, are all highly suspicious for GCA.

Photomicrograph

Photomicrograph showing multiple giant cells lining up near the internal elastic lamina.

Photomicrograph showing multiple giant cells lining up near the internal elastic lamina.

Dilated Branches of Temporal Artery

Shows dilated branches of the temporal artery. On palpation they were tender and indurated, but pulsations were still felt. These characteristic signs of swelling, tenderness, and inflammation may not always be present, even when biopsy results of the temporal artery are abnormal. In many patients, pulsations are absent in the affected arteries. Giant cell arteritis is frequently associated with headaches, jaw claudication, visual changes, and polymyalgia rheumatica. Wilske KR. Clinical spectrum of giant cell arteritis. In: Internal Medicine for the Specialist. 1982;3(10):82-97. Healey LA. The Systemic Manifestations of Giant Cell Arteritis. New York, NY, Grune and Stratton; 1978.

Dilated branches of this temporal artery are seen. On palpation they were tender and indurated, but pulsations were still felt. These characteristic signs of swelling, tenderness, and inflammation may not always be present, even when biopsy results of the temporal artery are abnormal. In many patients, pulsations are absent in the affected arteries. Giant cell arteritis is frequently associated with headaches, jaw claudication, visual changes, and polymyalgia rheumatica. Wilske KR. Clinical spectrum of giant cell arteritis.
In: Internal Medicine for the Specialist. 1982;3(10):82-97. Healey LA. The Systemic Manifestations of Giant Cell Arteritis. New York, NY, Grune and Stratton; 1978.

Related Content

Giant Cell Arteritis Overview

 

Polymyalgia Rheumatica Overview

 

ACR Vasculitis Treatment Guideline

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Primary Care2024-05-21T13:46:02+00:00

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