Giant cell arteritis
More than just a headache
BY Elizabeth Hazel, MD and Michael
Starr, MD
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Anne S., 70 years old, is brought into
the clinic by her concerned husband. Over the last two months, she
has lost 7 kg and has had intermittent right-sided headaches that
she attributes to a virus, as she had an associated low-grade fever.
She complains of bilateral shoulder pain that sometimes wakes her
from sleep. Because of persistent fatigue, she stopped her volunteer
activities. She was previously well and a targeted review-of-systems
reveals no prior history of headache. She's also experiencing "heaviness"
in her jaw when eating steak and other solids, and now stays away
from these foods.
Presentation
Physical examination
- warm to the touch
- not in any obvious distress
- blood pressure (BP): 130/70 mm Hg
in both arms
- heart rate: 80 beats/min and regular
- headache localized to right temporal
area
- evaluation of temporal arteries:
normal
- scalp tenderness, more pronounced
on the right side
- cardiac exam: normal
- musculoskeletal exam: normal, aside
from mild pain with supraspinatus stress manoeuvres in both
shoulders
Investigations
- hematology
- hemoglobin: 104 g/L
- mean corpuscular volume: 82 fL
- white blood cells: 6.7 x 109
cells/L
- platelets: 445 x 109/L
- chemistry
- electrolytes: normal
- creatinine: 104 µmol/L
- other tests
- urine analysis: normal
- erythrocyte sedimentation rate
(ESR): 76 mm/hr
- C-reactive protein (CRP): 32
mg/L
Diagnosis
and treatment
Results of tests suggested an inflammatory condition. Anna
S. was started on prednisone and non-steroidal anti-inflammatory
drugs for her pain and headache and scheduled for a temporal
artery biopsy. She was later diagnosed with giant cell arteritis
(GCA) and referred to a rheumatologist. After eight months,
she is now doing well and her corticosteroids dose is being
tapered.
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Making the case
Giant cell arteritis is the most common of the vasculitides. It's
a chronic inflammation of the large- and medium-sized arteries,
often the cranial branches of the aortic arch. GCA is synonymous
with temporal arteritis, though that term minimizes its systemic
nature and may be misleading. While many of the symptoms appear
nonspecific and are related to generalized inflammation, there are
some characteristic findings. Two-thirds of GCA patients complain
of a new headache and half of affected individuals have constitutional
symptoms such as fever, fatigue and weight loss. Half of the patients
experience fatigue of the chewing muscles, or jaw claudication,
15% have permanent partial or complete loss of vision, up to half
have symptoms of polymyalgia rheumatica (PMR) and 4-15% present
with arm claudication (this group contains significantly more women
of younger age, and fewer complaining of headache). GCA is a common
cause of fever of unknown origin in the elderly.
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