Sorry it turned out to be long, but this is how I can summarize the NICE guideline for Giant cell arthritis. Should be edited according to the case itself.
Who you are:
You are a F2 in general medicine.
Who the patient is:
Maria, aged 55, came to the hospital with a headache.
What you should do:
Take a focused history, assess the patient, do examination and discuss further management with the patient.
Suspect GCA in patients aged 50+ presenting with:
- New-onset headache:
- Common in about 2/3 of GCA patients.
- Typically temporal but can vary (generalized, occipital, parietal).
- Temporal artery abnormality:
- Tenderness, thickening, nodularity in up to 30% of cases.
- Overlying skin may be red; pulsation may be reduced/absent.
Other Symptoms/Signs:
- Visual disturbances:
- Vision loss (transient/permanent) in 30% of patients.
- Double vision, visual field defects, changes in color vision.
- Fundoscopic findings: pallor/oedema of optic disc, ‘cotton-wool’ patches, small retinal hemorrhages.
- Scalp tenderness:
- Occurs in 50% of patients, especially over temporal/occipital arteries.
- Less common: scalp necrosis.
- Intermittent jaw claudication:
- In nearly 50% of patients, causing jaw pain after chewing.
- May also affect tongue or swallowing muscles.
- Systemic features:
- Fever (low grade), fatigue, anorexia, weight loss, depression.
- Polymyalgia rheumatica (PMR):
- Present in 40% of GCA patients.
- Symptoms: proximal muscle pain, stiffness, tenderness.
- Neurological features:
- Mononeuropathy/polyneuropathy, transient ischemic attack, stroke, upper cranial nerve palsies.
- Respiratory or ENT symptoms:
- Cough, sore throat, hoarseness, audiovestibular symptoms.
- Extra-cranial large vessel involvement:
- Bruits, decreased arterial pulsation/blood pressure differences between arms.
- Intermittent limb claudication, back/chest pain due to aortitis/aortic dissection.
Consider other diagnoses if:
- Neurological deficits, severe systemic features, localized ENT signs.
RISK FACTORS:
Age should be more than 50. More frequent in 70-80.
Women have 2-3 times higher chance.
Common in Scandinavian decent
Differentials:
Shingles
Migraine - Cluster Headache
Acute glaucoma
Malignancy
Temporomandibular joint pain
Cervical spondylosis
Examinations for Suspected Temporal Arteritis (Giant Cell Arteritis - GCA)
- Temporal arteries: Tenderness, thickening, nodularity, reduced pulsation.
- Visual: Visual acuity/fields, fundoscopy for optic disc changes.
- Scalp: Tenderness, necrosis.
- Jaw: Pain during chewing.
- Systemic: Fever, fatigue, weight loss, proximal muscle pain.
- Neurological: Cranial nerve palsies, peripheral neuropathy.
- Cardiovascular: Carotid bruits, BP differences between arms.
- ENT/Respiratory: Cough, sore throat, hoarseness
SUMMARY: General, physical and neurological examination
DIAGNOSIS: Temporal arteritis (giant cell arteritis) is where the arteries, particularly those at the side of the head (the temples), become inflamed. It’s serious and needs urgent treatment.
Investigations for Suspected Giant Cell Arteritis (GCA) in Primary Care
Immediate Actions:
- Do not delay referral if GCA is suspected; consult a specialist if unsure.
Initial Tests:
- Full Blood Count:
- Look for normochromic normocytic anaemia.
- Check for elevated platelet count.
- C-Reactive Protein (CRP):
- Typically elevated in GCA.
- Erythrocyte Sedimentation Rate (ESR):
- Often >50 mm/hour but can be normal at presentation or during flare-ups.
Additional Tests (Based on Clinical Situation):
- Exclude Alternative Diagnoses / Assess Glucocorticoid Risk:
- Baseline urea and electrolytes.
- HbA1c.
- Calcium and liver function tests.
- Further Investigations if ESR > CRP:
- Serum protein electrophoresis.
- Urine Bence–Jones protein/serum-free light chains.
- Screen for Serious Infection Risks:
- Urine dipstick.
- Chest X-ray.
- Tests for latent tuberculosis.
- Assess Osteoporosis Risk:
- TSH and vitamin D levels.
- Bone density test (DEXA)
Treatment of Giant Cell Arteritis (GCA)
- Corticosteroids:
- High-dose prednisolone initially.
- Gradual tapering over time.
- Aspirin:
- Low-dose aspirin to reduce stroke risk.
- Bone Protection:
- Calcium and vitamin D supplements.
- Bisphosphonates to prevent osteoporosis.
- Monitoring:
- Regular blood tests for ESR and CRP.
- Monitor for side effects of long-term corticosteroid use.
- Additional Treatments:
- Tocilizumab for patients not responding to steroids or with relapses.
- Specialist Referral:
- Referral to a rheumatologist for ongoing management.
Regular follow-ups are essential to adjust treatment and monitor for complications.
Complications:
- Loss of Vision: Up to 30% of GCA patients may experience partial or total vision loss, mostly before starting corticosteroid therapy.
- Large Artery Complications: Large artery complications like aortic aneurysm, aortic dissection, and stenosis occur in up to 27% of GCA patients.
- Cardiovascular Disease: GCA increases the risk of cardiovascular diseases such as myocardial infarction, heart failure, stroke, and peripheral arterial disease.
- Other Complications: GCA can lead to scalp necrosis, peripheral neuropathy, depression, confusion, encephalopathy, deafness, and adverse effects from long-term corticosteroid use.
