Giant cell arteritis

Giant cell arteritis
	Diagnosis in short
	; Giant cell arteritis. H&E stain.
Synonyms	temporal arteritis
LM	large artery with intramural inflammatory cells (often granulomatous); intimal thickening; frank destruction of arterial wall common - fibrinoid necrosis
Site	large blood vessels - see vasculitides
Clinical history	typically older than 50 years
Signs	loss of vision, weight loss, chills, fever
Symptoms	jaw claudication (classic), headache (classic), double vision, scalp tenderness
Prevalence	uncommon
Blood work	ESR elevated
Prognosis	good if treated
Clin. DDx	other causes of headache
Treatment	steroids

Giant cell arteritis (abbreviated GCA), also known as temporal arteritis, is a type of large vessel vasculitis.

General

Classically afflicts the temporal artery.

Clinical features:

Classic finding: jaw claudication, typically in a patient older than 50 years.
Other findings: headache (very common),^[1] vision loss or diplopia, scalp tenderness, polymyalgia, weight loss, chills, fever.

Work-up:

CRP, ESR, temporal artery biopsy.
- ESR normal (>50 years old): <20 mm/hr males, <30 mm/hr females.^[2]

Treatment:

Treat right away with high dose steroids.
- Biopsy is confirmatory and is still diagnostic if done <7-10 days after treatment starts.^[3]

Microscopic

Features - as per Le et al.:^[1]

Artery with intimal thickening.
Transmural inflammatory cells.
Giant cells.

Notes:

Inflammation classically granulomatous.
- Granulomas not required for the diagnosis!
Often accompanied by frank destruction of the arterial wall, e.g. fibrinoid necrosis (pink anucleate arterial wall).

Images

GCA - very low mag. (WC)
GCA - low mag. (WC)
GCA - intermed. mag. (WC)
GCA - high mag. (WC)
GCA - intermed mag. (WC)
GCA - high mag. (WC)

www:

DDx:

Takayasu arteritis (can be overlapping with GCA)
Aneurysm
Amyloidosis
Granulomatosis with polyangiitis (Wegener Granulomatosis)
Polyarteritis nodosa

Sign out

Note:

The evidence is weak that the biopsy result influences management; a negative biopsy doesn't preclude treatment for clinically presumed giant cell arteritis.^[4]

Positive

Left Temporal Artery, Biopsy:
     - Temporal arteritis (medium size artery with lymphohistocytic inflammation, 
       arterial wall thickening, and elastic fibre fragmentation).

Comment:
The biopsy is suggestive of temporal arteritis. Giant cells are not seen.
The findings should be correlated with the clinical impression.

Minimal findings - positive

Left Temporal Artery, Biopsy:
     - Medium size artery with minimal lymphohistocytic inflammation 
       without definite giant cells or arterial wall thickening, see comment.

Comment:
The biopsy is suggestive of temporal arteritis that is either (1) early/poorly developed from a histomorphological perspective or (2) under-appreciated due to sampling.

The findings should be correlated with the clinical impression. The
management should be dependent upon the clinical impression.

Negative with atherosclerosis

Temporal Artery, Left, Biopsy:
- Medium size artery with mild-to-moderate atherosclerosis, otherwise 
  within normal limits, see comment.

COMMENT:
A negative biopsy does not rule out the possibility of giant cell (temporal) 
arteritis, as this may be a focal disorder. The clinical management is 
dependent upon the clinical impression.

Negative

Temporal Artery, Left, Biopsy:
- Medium size artery without pathologic diagnosis, see comment.

COMMENT:
A negative biopsy does not rule out the possibility of giant cell (temporal) 
arteritis, as this may be a focal disorder. The clinical management is 
dependent upon the clinical impression.

Block letters

TEMPORAL ARTERY, LEFT, BIOPSY:
- MEDIUM SIZE ARTERY WITHOUT PATHOLOGIC DIAGNOSIS, SEE COMMENT.

COMMENT:
A negative biopsy does not rule out the possibility of giant cell (temporal) 
arteritis, as this may be a focal disorder. The clinical management is 
dependent upon the clinical impression.

References

↑ ^1.0 ^1.1 Le, K.; Bools, LM.; Lynn, AB.; Clancy, TV.; Hooks, WB.; Hope, WW. (Oct 2014). "The effect of temporal artery biopsy on the treatment of temporal arteritis.". Am J Surg. doi:10.1016/j.amjsurg.2014.07.007. PMID 25457237.
↑ URL: http://www.nlm.nih.gov/medlineplus/ency/article/003638.htm. Accessed on: 17 August 2012.
↑ Weinberg, DA.; Savino, PJ.; Sergott, RC.; Bosley, TM. (Jul 1994). "Giant cell arteritis. Corticosteroids, temporal artery biopsy, and blindness.". Arch Fam Med 3 (7): 623-7. PMID 7921300.
↑ Lenton, J.; Donnelly, R.; Nash, JR. (Jan 2006). "Does temporal artery biopsy influence the management of temporal arteritis?". QJM 99 (1): 33-6. doi:10.1093/qjmed/hci141. PMID 16287908.

[pmid25457237-1] 1.0 ^1.1 Le, K.; Bools, LM.; Lynn, AB.; Clancy, TV.; Hooks, WB.; Hope, WW. (Oct 2014). "The effect of temporal artery biopsy on the treatment of temporal arteritis.". Am J Surg. doi:10.1016/j.amjsurg.2014.07.007. PMID 25457237.

[2] URL: http://www.nlm.nih.gov/medlineplus/ency/article/003638.htm. Accessed on: 17 August 2012.

[pmid7921300-3] Weinberg, DA.; Savino, PJ.; Sergott, RC.; Bosley, TM. (Jul 1994). "Giant cell arteritis. Corticosteroids, temporal artery biopsy, and blindness.". Arch Fam Med 3 (7): 623-7. PMID 7921300.

[pmid16287908-4] Lenton, J.; Donnelly, R.; Nash, JR. (Jan 2006). "Does temporal artery biopsy influence the management of temporal arteritis?". QJM 99 (1): 33-6. doi:10.1093/qjmed/hci141. PMID 16287908.

[1]

[2]

[3]

[4]