What can vasculitis be secondary to?
- SLE
- RA
- Hepatitis B + C
- HIV
How is vasculitis categorised?
By the side of blood vessel affected eg large or medium
What category is GCA in terms of type of vasculitis?
Large cell vasculitis (some sources say medium too)
What is another name for GCA commonly used?
Temporal arteritis?
What are the symptoms of GCA?
- Headache (unilateral and temporal)
- Temporal artery and scalp tenderness
- Difficult to comb hair
- Tongue/Jaw claudication
- Amaurosis fugax
- Sudden unilateral blindness
- Constitutional symptoms - Fever, weight loss, fatigue
What are some risk factors for GCA?
- Peak onset 70-79
- Rarely seen before 50
- White Northern European
- Female
- HLA-DR4 genetic predisposition
What is the pathophysiology of GCA?
- Inflammation of medium and large sized arteries
1. Local vessel inflammation and macrophage are recruited
2. Damage of vessel wall
3. Growth and angiogenic factor release which thickens vessel intima
4. Hyperplasia and ischaemia to areas supplied by the artery
What arteries does GCA preferentially involve?
- Branches of the carotid eg temporal, opthalmic, occipital
- Sometimes vertebral, carotid, subclavian, aorta
What are signs of GCA on examination?
- Abnormal temporal artery, reduced pulse and thickened
- Scalp tenderness on palpation
- Visual field defects
- Optic disc changes (pale swollen if anterior ischaemic optic neuritis)
- Retinal changes (pale with red cherry spot if central retinal artery)
What should you consider in any older patient (>50) with new onset unilateral headache?
GCA!!!
What is the major risk with GCA?
Irreversible bilateral visual loss
What 5 criteria is there for the diagnosis of GCA?
- Age of onset >50yrs
- New headache
- Temporal artery abnormality
- Elevated ESR
- Abnormal temporal artery biopsy
What condition is GCA associated with?
Polymyalgia rheumatica (40-50% of patients with GCA)
What investigations would you undertake in GCA?
- FBC, U+E, LFT, CRP/ESR - Raised inflammatory markers, raised platelets, raised ALP, low Hb
- Temporal artery biopsy - Skip lesions occur so don’t worry if negative
What additional assessment do GCA patients require?
Opthalmic assessment
Characteristic finding is pale, swollen optic disc with anterior ischaemic optic neuritis
What is the treatment regimen for GCA?
- Start prednisolone 60mg/day immediately
- IV methylprednisolone for 3 days if visual symptoms
What additional medication does the patient need to prevent side effects of treatment?
- Bisphosphonates/vit D - bone protection
- PPI - Gastric protection against GI bleeds
- Monitor blood sugar - diabetes
- Low dose aspirin - Reduce thrombotic events
What is the prognosis for GCA?
- 2 year course of prednisolone, then complete remission
- Reduce dose once symptoms have resolved and ESR has lowered
- If tapered off too quickly, risk of relapse
What are some other complications of GCA (not visual)?
- Aortic aneurysm
- Aortic dissection
- Large artery stenosis
- CVD
- Steroid related complications
What else can GCA present as?
Stroke
