Giant-Cell Arteritis

Posted by Graham McMahon • July 8th, 2011

The latest article in our Clinical-Problem Solving series, A Sleeping Giant, presents this case: A 71-year-old woman presented with abdominal pain and night sweats. Four weeks earlier, headache, sinus pressure, and night sweats had developed, and amoxicillin was prescribed for presumed sinusitis. Her symptoms improved, but after 1 week, new abdominal pain developed.

The article was first presented as an Interactive Medical Case, giving readers the opportunity to test their diagnostic skills.

GCA, the most common form of systemic vasculitis in patients over age 50, preferentially involves large- and medium-sized arteries.

Clinical Pearls

What are the classic manifestations of GCA?

The classic manifestations are headache, jaw claudication, PMR, and visual symptoms. However, 40% of patients present with less typical manifestations, such as breast or ovarian masses, peripheral neuropathy, SIADH, or mesenteric ischemia.

What laboratory findings are typical among patients with GCA?

In a large case series of patients with GCA, over 95% had an ESR above 50 mm/h, and over 40% had an ESR over 100mm/h. Elevation of CRP and hepatic enzymes, particularly alkaline phosphatase, a normocytic anemia, hypoalbuminemia, reactive thrombocytosis, and increased immunoglobulin levels are also commonly associated with GCA.

Morning Report Questions

Q: How is uncomplicated GCA generally managed?

A: Uncomplicated GCA can generally be controlled in the acute setting with 40 to 60 mg prednisone daily; this dose is typically tapered slowly over 9 to 12 months. For patients with visual loss, aortitis, or other widespread involvement, higher dose therapy is recommended (e.g., 1000 mg methylprednisolone intravenously each day for three days, followed by oral therapy of 1 mg/kg daily).

Q: Is the use of glucocorticoid-sparing agents recommended for patients with GCA?

A: Randomized, placebo-controlled trials have evaluated the use of methotrexate, infliximab, and etanercept as glucocorticoid sparing agents; however, the data are conflicting and further investigation is needed.

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