Giant cell arteritis

Systemic vasculitis Wegener s disease, giant cell arteritis, polyarteritis nodosa... 

Q77 Giant cell arteritis may present with tender and non-pulsatile temporal arteries together with erythema and oedema of the overlying skin. The condition may require the use of prednisolone tablets for at least 2 years. 

Giant cell arteritis (cranial or temporal arteritis) is an inflammatory condition that may affect any of the large arteries, especially the temporal and occipital arteries. The thickened temporal arteries may be tender and non-pulsatile, with erythema and oedema of the overlying skin. Early treatment with high-dose corticosteroids such as prednisolone is essential and should be continued for a minimum of 2-3 years at a reduced dose. 

The autoimmune rheumatic diseases consists of Rheumatoid Arthritis (RA), Spondylarthritis (SpA), Systemic Lupus Erythematosus (SLE), Polymyositis, Dermatomyositis, Polymyalgia Rheumatica, Acute Temporal Arteritis, Giant Cell Arteritis, Behcet s Disease, Sjorgren s Syndrome, Felty s Syndrome and Mixed Connective Tissue Disease (MCTD). Spondylarthritis (SpA) can be subdivided in Reactive Arthritis (ReA), Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Arthritis associated with the inflammatory bowel diseases are Crohn s disease and Ulcerative Colitis (IBD), Undifferentiated SpA (UspA) and Sacro-ilitis, Juvenile SpA and Acute Anterior Uveitis (AAU). 

Other rheumatic diseases in which the corticosteroids potent anti-inflammatory effects may be useful include vasculitis, systemic lupus erythematosus, Wegener s granulomatosis, psoriatic arthritis, giant cell arteritis, sarcoidosis, and gout. 

Collagen-vascular disorders Giant cell arteritis, lupus erythematosus, mixed connective tissue syndromes, polymyositis, polymyalgia rheumatica, rheumatoid arthritis, temporal arteritis... 

This report highlights the risk of cardiovascular adverse effects with short courses of glucocorticoid therapy in elderly patients with inflammatory bowel disease, even with rather low-dosage regimens. Acute myocardial infarction occurred in an old man with coronary insufficiency and giant cell arteritis after treatment with prednisolone (SEDA-10, 343) but could well have been coincidental. 

A 69-year-old man with newly diagnosed giant cell arteritis was given prednisone 30 mg bd, and 2 weeks later developed severe pain along his Achilles tendons bilaterally 1 week later the left tendon ruptured (278). Despite immobilization his pain worsened. The prednisone was gradually tapered and the symptoms abated, with complete recovery. 

Exacerbation of giant cell arteritis, with clinical signs of an evolving vertebrobasilar stroke, has been attributed to prednisolone (310). 

A 64-year-old man with giant cell arteritis was given prednisolone 60 mg/day. Within 5 days he developed double vision and agitation and became drowsy and confused. A cranial MRI scan showed recent cerebral lesions and a Doppler scan showed high-resistant blood flow in both vertebral arteries. He had an episode of complete loss of vision and was given dexamethasone... 

Bunch TJ, Welsh GA, Miller DV, Swaroop VS. Acute spontaneous Achilles tendon rupture in a patient with giant cell arteritis. Ann Clin Lab Sci 2003 33 326-8. 

Staunton H, Stafford F, Leader M, O Riordain D. Deterioration of giant cell arteritis with corticosteroid therapy. Arch Neurol 2000 57(4) 581 1. 

Although the most common methotrexate dosing regimens for the treatment of rheumatoid arthritis are 15 or 17.5 mg weekly, there is an increased effect up to 30 or 35 mg weekly. The drug decreases the rate of appearance of new erosions. Evidence supports its use in juvenile chronic arthritis, and it has been used in psoriasis, psoriatic arthritis, polymyositis, dermatomyositis, Wegener s granulomatosis, giant cell arteritis, subacute lupus erythematosus, and vasculitis. 

B15. Bridgeford, P. H., Lowenstein, M., Bocanegra, T. S., Vasey, F. B., Germain, B. F., and Espinoza, L. R., Polymyalgia rheumatica and giant cell arteritis Histocompatibility typing and hepatitis-B infection studies. Arthritis Rheum. 23, 516-518 (1980). 

PI. Papaionnou, C. C., Gupta, R. C., Hunder, G. G., and McDuffie, F. C., Circulating immune complexes in giant cell arteritis and polymyalgia rheumatica. Arthritis Rheum. 23, 1021-1025 (1980). 

Askling J, Klareskog L, Hjalgrim H, Baecklund E, Bjorkholm M, Ekbom A. Do steroids increase lymphoma risk A case-control study of lymphoma risk in polymyalgia rheumatica/giant cell arteritis. Ann Rheumat Dis 2005 64 1765-8. 

All. Anders, K. H., Wang, Z. Z., Kornfeld, M., Gray F., Soontomniyomkij, V., et al., Giant cell arteritis in association with cerebral amyloid angiopathy Immunohistochemical and molecular studies [published erratum appears in Hum. Pathol. 29(2), 205] (1998). Hum. Pathol. 28(11), 1237-1246 (1997). 

Giant cell arteritis Systematic lupus erythematosus Antiphospholipid antibody syndrome... 

Giant cell arteritis is the most common vascuUtic cause of stroke and is associated particularly with posterior circulation ischemia (Nesher 2000 Ronthal et al. 2003 Eberhardt and Dhadly 2007). Medium and large arteries are affected, especially branches of the external carotid artery, the ophthalmic artery and the vertebral artery. The patients are elderly, with the diagnosis being rare under age 60 years. Malaise, polymyalgia and other systemic symptoms are frequently present. The erythrocyte sedimentation rate is usually raised, often to over 100 mm/h in the first hour. 

Headache is not uncommon around the time of stroke onset. It is more often severe in primary intracerebral hemorrhage than ischemic stroke, and more often severe with posterior than anterior circulation strokes. If the headache is localized at all, it tends to be over the site of the lesion. Headache is more common in cortical and posterior circulation than lacunar infarcts (Kumral et al. 1995). Severe unilateral neck, orbital or scalp pain suggests internal carotid artery dissection, particularly if there is an ipsilateral Horner s syndrome. Severe occipital headache can occur with vertebral artery dissection. Headache is also a particular feature of venous infarcts. Unusual headache in the days before stroke would suggest giant cell arteritis or perhaps a mass lesion rather than a stroke. 

Giant cell arteritis (or other inflammatory vascular disorders) (Ch. 6) Structural intracranial lesion (Chs. 8 and 9) intracranial venous thrombosis (Ch. 29)... 

Stroke in the context of preceeding malaise for up to some months suggests an inflammatory arterial disorder, particularly giant cell arteritis, infective endocarditis, cardiac myxoma, cancer, thrombotic thrombocytopenic purpura or even sarcoidosis (Ch. 6). 

Tenderness of the branches of the external carotid artery (occipital, facial, superficial temporal) points towards giant cell arteritis. Tenderness of the common carotid artery in the neck can occur in acute carotid occlusion but is more Ukely to be a sign of dissection, or arteritis. Absence of several neck and arm pulses in a young person occurs in Takayasu s arteritis (Ch. 6). Delayed or absent leg pulses suggest coarctation of the aorta or, much more commonly, peripheral vascular disease. Other causes of widespread disease of the aortic arch are atheroma, giant cell arteritis, syphihs, subintimal fibrosis, arterial dissection and trauma. 

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