USMLE Forum Archives - USMLE Step 3 - Temporal Arteritis (Giant Cell Arteritis
Temporal Arteritis (Giant Cell Arteritis
meduploader - 05-14-09 13:46
A treatable neurologic emergency characterized by subacute inflammation of the external carotid arterial
system and vertebral arteries. Most cases occur in women > 50 years of age.
Presents with temporal or diffuse headache unlike any the patient has had before, along with transient
visual loss, scalp tenderness, jaw claudication, fever, myalgia, malaise, anorexia, weight loss,
tenderness, and stiffness in the shoulders and hips.
On exam, the temporal arteries may be dilated, tender, thickened, and nonpulsatile.
Funduscopic exam may reveal a pale optic disk on the affected side. Cranial neuropathies are common.
Diagnosis is guided by the history and exam. History may reveal coexisting polymyalgia rheumatica.
Biopsy of affected temporal arteries shows vasculitis with mononuclear cell infiltration or granulomatous
inflammation.
An ESR > 50 mm/hr is common (although rare cases may show a normal ESR). Normochromic,
normocytic anemia with thrombocytosis is also common.
TREATMENT
Prednisone 60 mg daily for 1–2 months with slow taper and monitoring of symptoms and ESR. Aspirin ↓
the risk of stroke or visual loss.
Fifty percent of untreated patients suffer permanent visual loss, with half experiencing bilateral loss.
Temporal arteritis is also associated with a risk of cranial neuropathy, TIA, stroke, and thoracic aortic
aneurysm.
HY points
75 yr old man---> suspected temporal arteritis --> routine blood including ESR sent ----> what will u do next?
Start high dose prednisone ---> how will u taper ---> it should be ESR guided ---> as ESR comes down, start tapering.
Pt of temporal arteritis ---> tapering prednisone ---> stopped prednisone today ----> ESR went up ---> what will u do?
Do nothing, it is normal
meduploader - 05-14-09 13:46
A treatable neurologic emergency characterized by subacute inflammation of the external carotid arterial
system and vertebral arteries. Most cases occur in women > 50 years of age.
Presents with temporal or diffuse headache unlike any the patient has had before, along with transient
visual loss, scalp tenderness, jaw claudication, fever, myalgia, malaise, anorexia, weight loss,
tenderness, and stiffness in the shoulders and hips.
On exam, the temporal arteries may be dilated, tender, thickened, and nonpulsatile.
Funduscopic exam may reveal a pale optic disk on the affected side. Cranial neuropathies are common.
Diagnosis is guided by the history and exam. History may reveal coexisting polymyalgia rheumatica.
Biopsy of affected temporal arteries shows vasculitis with mononuclear cell infiltration or granulomatous
inflammation.
An ESR > 50 mm/hr is common (although rare cases may show a normal ESR). Normochromic,
normocytic anemia with thrombocytosis is also common.
TREATMENT
Prednisone 60 mg daily for 1–2 months with slow taper and monitoring of symptoms and ESR. Aspirin ↓
the risk of stroke or visual loss.
Fifty percent of untreated patients suffer permanent visual loss, with half experiencing bilateral loss.
Temporal arteritis is also associated with a risk of cranial neuropathy, TIA, stroke, and thoracic aortic
aneurysm.
HY points
75 yr old man---> suspected temporal arteritis --> routine blood including ESR sent ----> what will u do next?
Start high dose prednisone ---> how will u taper ---> it should be ESR guided ---> as ESR comes down, start tapering.
Pt of temporal arteritis ---> tapering prednisone ---> stopped prednisone today ----> ESR went up ---> what will u do?
Do nothing, it is normal
Page 1
#1
Re: Temporal Arteritis (Giant Cell Arter mtniharika - 09-27-09 04:35 DIAGNOSIS:
1.Physical exam:
-Palpation of the head reveals prominent temporal arteries with or without pulsation.
-The temporal area may be tender.
-Decreased pulses may be found throughout the body.
-Evidence of ischemia may be noted on fundal exam.
2.Laboratory tests
-Erythrocyte sedimentation rate, an inflammatory marker, >60 mm/hour (normal 10-40 mm/hour), but may be normal in approximately 20% of cases.
-C-reactive protein, another inflammatory marker, is also commonly elevated.
-Platelets may also be elevated.
3.Biopsy
The gold standard for diagnosing temporal arteritis is biopsy, which involves removing a small part of the vessel and examining it microscopically for giant cells infiltrating the tissue. Since the blood vessels are involved in a patchy pattern, there may be unaffected areas on the vessel and the biopsy might have been taken from these parts. Unilateral biopsy of a 1.5-3 cm length is 85-90% sensitive. So, a negative result does not definitely rule out the diagnosis.
4.Imaging studies
Radiological examination of the temporal artery with ultrasound yields a halo sign. Contrast enhanced brain MRI and CT is generally negative in this disorder. Recent studies have shown that 3T MRI using super high resolution imaging and contrast injection can non-invasively diagnose this disorder with high specificity and sensitivity.
TREATMENT:
Corticosteroids, typically high-dose prednisone (40–60 mg bd), must be started as soon as the diagnosis is suspected (even before the diagnosis is confirmed by biopsy) to prevent irreversible blindness secondary to ophthalmic artery occlusion. Steroids do not prevent the diagnosis from later being confirmed by biopsy, although certain changes in the histology may be observed towards the end of the first week of treatment and are more difficult to identify after a couple of months. The dose of prednisone is lowered after a 2–4 weeks, and slowly tapered over the course of 9–12 months. Oral steroids are at least as effective as intra venous steroids,except in the treatment of acute visual loss where intravenous steroids appear to offer significant benefit over oral steroids
Page 1