Definition
A.Temporal arteritis, also known as giant cell arteritis (GCA) is a vascular illness that can affect the entire body; however, it primarily affects the blood vessels. There is inflammation of the arteries that begins in the aortic arch and branches out to the cranial arteries.
Incidence
A.GCA occurs in approximately 1 in 500 individuals older than 50 years. GCA rarely occurs in individuals younger than 50 years and is more commonly seen during later years (older than 70 years). It can also be seen in patients diagnosed with polymyalgia rheumatica (PMR). Approximately 50% of patients diagnosed with GCA will also have PMR.
Pathogenesis
A.The cause of GCA is unknown. The immune system attacks the body and causes inflammation of the medium and large arteries, which causes thickening of the arterial walls and narrowing of the lumen. When these changes occur, the result is a decrease in blood flow that can potentially cause an occlusion in the artery, leading to ischemia. Arteries commonly involved include the temporal artery, medium and large vessels, and the vessels of the eyes. Blindness is the major acute morbidity with GCA.
Predisposing Factors
A.Age (older than 50 years).
B.Ethnicity (Scandinavian) Northern European descent.
C.Gender (women > men).
Common Complaints
A.Abrupt onset of headaches.
B.Visual impairment.
C.Joint pain (PMR).
Other Signs and Symptoms
A.Fever.
B.Anemia.
C.Jaw or arm claudication.
D.Fatigue.
E.Weight loss.
Potential Complications
A.Visual loss, blindness.
B.Joint pain.
Subjective Data
A.Have the patient describe the presenting complaints. What makes it better or worse?
B.Ask the patient when presenting symptoms began. Discuss the course of new-onset symptoms. Note systemic symptoms such as fever, weight loss, fatigue, headache, vision changes, jaw/arm pain.
C.Ask the patient to describe pain, for example, crushing, stabbing, or burning.
D.Have patient rate pain on a scale of 1 to 10, with 1 being the least painful.
E.What has the patient taken to relieve the pain or symptoms?
F.Has the patient noted any visual disturbance or changes? Is vision change constant or does it occur when headache is present? What makes the headache worse? What makes the headache better?
Physical Examination
A.Vital signs: Check temperature, pulse, respirations, and blood pressure (BP; take BP in both arms and note discrepancies).
B.Inspect:
1.Inspect overall general appearance. Patients with GCA usually appear chronically ill.
2.Perform funduscopic examination, looking for a pale disc and blurred margins of the disc. Assess pupils equal and reactive to light and accommodation (PERLA), extraocular muscles (EOMs), and visual acuity.
C.Palpate:
1.Palpate pulses (carotid, brachial, radial, pedal, and femoral pulses).
2.Perform range of motion (ROM) of all joints (shoulders, neck, hips, and extremities), noting limitations because of pain and/or swelling.
3.Assess joints for swelling and pain. (Note symptoms of PMR.)
D.Auscultate:
1.Heart for murmurs.
2.Carotid, brachial, femoral arteries for bruits.
3.Abdomen noting any bruits.
Diagnostic Tests
A.Serum laboratory studies (erythrocyte sedimentation rate [ESR], complete blood count [CBC], C-reactive protein [CRP], and comprehensive metabolic profile [CMP]).
B.Temporal artery biopsy. Any patient suspicious of having temporal arteritis should have a temporal artery biopsy performed. This is the gold standard for diagnosing GCA. Recommended sample size of the artery for biopsy should be ≥4 cm. False negative biopsy results may be up to 20%.
Differential Diagnoses
A.Temporal arteritis/GCA.
B.Vasculitis.
C.PMR.
Plan
A.General interventions:
1.Educate the patient and family regarding the disease process of GCA.
B.Patient teaching:
1.Educate the patient and family that common symptoms of GCA include headaches, vision change, and jaw/arm joint pain.
2.Teach the patient that GCA causes inflammation of the blood vessels in the head and neck, but not the blood vessels in the brain.
3.Advise the patient that PMR may also occur in some patients, in which joint pain may be present.
4.Medications commonly used for GCA are steroids. Steroids will improve the inflammation, which in return will improve pain. The steroids are commonly used for the duration of treatment and will be tapered down over several months. Steroids are the only medication that has proven to prevent blindness. Any side effects or problems should be reported to the primary provider.
5.A baby aspirin is commonly used daily.
6.Any vision changes should be immediately reported to the primary provider. Vision loss/blindness is one of the greatest risks of GCA.
C.Pharmaceutical therapy:
1.If GCA is suspected, consult with collaborating physician and begin steroids immediately. Prednisone 40 to 60 mg daily. Do not wait for biopsy results. Steroids are used to suppress the manifestations of symptoms and decrease the risk of blindness. Steroids will eventually be tapered when symptoms begin to improve, commonly after 1 month or so.
2.Aspirin 81 to 325 mg/d is recommended.
Follow-Up
A.Follow up with physician rheumatologist/surgeon as recommended.
Consultation/Referral
A.Consultation with the collaborating physician or surgeon should be obtained regarding any patient with the suspicion of having temporal arteritis.
B.Refer all patients to a rheumatologist within 1 week of diagnosis to manage the patient with GCA.
C.All patients suspicious of having temporal arteritis should be referred to a general surgeon for a temporal artery biopsy within 2 to 3 days after beginning steroids.
D.Refer the patient to the ophthalmologist for evaluation and treatment.
Individual Considerations
A.Geriatrics:
1.Most commonly seen in older patients. Symptoms may occur after the age of 50 years; however, GCA is most commonly seen in patients older than 70 years.
2.Do not delay treatment when waiting for pathology results. Immediately begin prednisone 40 to 60 mg/day and consider adjunct of proton-pump inhibitor to prevent GI bleed.
3.Thirty-five percent of geriatrics diagnosed with GCA experience a relapse. Maintain treatment for 1 year to prevent relapse.
4.Geriatrics suffering from GCA have a higher risk for stroke. Consider low-dose (81–100 mg/d) aspirin to reduce risk of visual loss, transient ischemic attack (TIA)/cerebrovascular accident (CVA) and thoracic aortic aneurysm.