Giant Cell Arteritis

What is it?

GCA (Giant cell arteritis) or temporal arteritis is a well known Ophthalmology emergency. GCA is a type of vasculitis that affects medium to larger sized vessels

Who gets it?

  • Older patients >75 years old
  • European population
  • Women are 2x more likely
  • Former pregnancy is believed to be protective
  • Patients who have other rheumatological conditions eg PMR

Signs and symptoms:

Local symptomsSystemic symptoms
Headache Jaw claudication Pain in tongue Painful scalp/over temporal area Persistent pain Hardening of temporal artery Pulsating arteryCan be prodromal (before onset of fulminant disease) Malaise Fever Weight loss
Specific ophthalmic symptoms:Specific ophthalmic signs:
Transient severe vision loss Sudden in onset Double vision Eye pain Can be bilateral (rare)Fundoscopy can show “cotton wool” spots, papilloedema. 

How do I diagnose it?

Diagnosis is mostly based on symptoms and physicians should have a low suspicion, especially in older women presenting with headache/temporal artery tenderness.

According to NICE guidelines GCA should be suspected in any patient who is at least 50 years old with any of the following:

  • New onset headache
  • Temporal artery abnormality (tender/thickened/reduced or absent pulsation)
  • Visual disturbances: diplopia/change in colour vision
    • Fundoscopic findings are not diagnostic for GCA but include oedema and ‘cotton-wool spots’
  • Scalp tenderness
  • Jaw claudication
  • Systemic features eg neurological symptoms (TIA/neuropathies); URTI symptoms; other vascular symptoms eg bruits/dissection

To confirm the disease standard practice is bloods, temporal artery biopsy and ultrasound imaging. Although temporal artery biopsy is now performed less commonly as it is invasive and a negative result does not rule out GCA.

Bloods: 

  • ESR (although not always elevated)
  • CRP
  • FBC

Imaging: 

  • Duplex ultrasound: swelling around vessel and non-compressible artery.
  • Fluorescein angiography: filling defects observed
  • MRI/PET scans – not routinely used

Biopsy: temporal artery biopsy (can be done bilaterally)

Downside is this can be negative due to “skip-lesions” being present.

Okay, we think they have it, how do I treat it?

According to NICE guidelines:

  • GCA is a medical emergency and high dose steroids should be started (oral ASAP) 
  • If any visual changes – referral to an ophthalmologist for an urgent (same day) assessment
    • Acute visual loss with GCA is treated with IV glucocorticoids usually
  • If no visual symptoms – oral prednisolone daily 40-60mg
  • Urgently discuss patient with Rheumatologist – ideally seen on the same day; in all cases must be seen within 3 days.
  • Follow up will usually be with rheumatology however may exist in a shared care model as patients will likely need long-term steroid therapy (around 2 years).

Additional treatments in literature:

  • Some studies showing azathioprine/cyclosporine but limited benefits recorded
  • Usually will need steroids for a long duration, in order to try and wean patients off steroids can also use immunological therapy eg tocilizumab (IL-6 inhibitor)

Complications

  • Vision loss can progress to the other eye
  • Permanent vision loss
  • Stroke
  • Side effects of steroid therapy 

References

https://eyewiki.aao.org/Giant_Cell_Arteritis

https://next.amboss.com/us/article/1T02p2?q=giant%20cell%20arteritis#Z2d454d961f764521463153db6e93633c

https://cks.nice.org.uk/topics/giant-cell-arteritis/diagnosis/suspecting-giant-cell-arteritis/

Written by Dr Shuchi Kohli (FY2) & reviewed by Dr Kate Reed (ST4 Ophthalmology)

How useful was this post?

Click on a star to rate it!

Average rating 5 / 5. Vote count: 11

No votes so far! Be the first to rate this post.

As you found this post useful...

Follow us on social media!

We are sorry that this post was not useful for you!

Let us improve this post!

Tell us how we can improve this post?

Related Posts

Orbital Cellulitis
Periorbital and Orbital Cellulitis
Introduction The orbital septum is a fibrous connective tissue...
Chronic Pancreatitis
Chronic Pancreatitis
Chronic pancreatitis is characterised by repeated pancreatic...
Ophthalmology Selection
Updates to Ophthalmology National Selection 2024
The national selection process for ophthalmology is coordinated...

Leave a Comment

Your email address will not be published. Required fields are marked *

Follow us

Favourites

Newsletter

Trending Now

Understanding the MSRA
The Multiple Specialty Recruitment Assessment (MSRA) is a computer-based exam increasingly being used...
Passing the Prescribing Safety Assessment (PSA)
The PSA is aimed at final year medical students and those graduating overseas to assess their competency...
Resident Doctor's Pay Calculator 2024
We’ve created a pay calculator to help you better understand your salary, how much tax you’ll...
Paracetamol Overdose
Paracetamol overdose is a common presentation in A&E and so you may often find yourself looking after...
Common Viral Infections (exanthem) in Paediatrics
Viral infections are extremely common in paediatrics and a common presentation to paediatric A&E is...
Prescribing IV Fluids
There are certain situations where you need to prescribe IV fluids which vary from fluid resuscitation...
PICC Lines and Midlines
You may well be asked to take blood from a PICC line or be called to see a patient because their PICC...

Sign up for our awesome resources & exclusive discount codes!

Join 80,000+ users who have signed up for our free weekly webinars, referral cheat sheet, pay calculator & exclusive discount codes for Pastest, Quesmed, Medibuddy and many others!