GCA

Question 1

A 72-year-old woman of Northern European ancestry presents with partial vision loss in the right eye. She reports bitemporal headache for several weeks, accompanied by pain and stiffness in the neck and shoulders.

Impression/DDx/Goals

Answer 1

Impression:
Relatively non-specific presentation, could represent a number of pathologies. RED FLAGS to rule out are stroke, ocular pathology (retinal detachment, tear). With bitemporal headache and stiffness, consider GCA and rule out emergently.

Goals:

• distinguish diagnosis and rule out red flags
• initiate appropriate diagnostic investigations and emergent therapy
• prevent blindness in affected and the fellow eye (GCA can progress to affect contralateral eye in 25% despite early treatment

Question 2

GCA - History

Answer 2

History:

• Sx: jaw/tongue claudication, diplopia/vision change, temporal headache/pain, shoulder/hip girdle stiffness, scalp pain/tenderness, other non-specific sx
• Risk factors diagnosis of PMR, age over 50, female, northern European ancestry, cardiovascular disease risk factors
• PM/FamHx: family history, autoimmune disease
• medications
• SNAP

Question 3

GCA - Examination

Answer 3

Exam:

• End of bed assessment
• Vital signs (BP, BSL - important before starting systemic corticosteroid treatment)
• Fundoscopic assessment: evidence of A-AION (disc pallor, retinal pallor, oedema, etc)
• temporal pulses
• neurological examination (Stroke)

Question 4

GCA - Investigations

Answer 4

Investigations:

• Bedside: temporal artery ultrasound
• Bloods: CRP/ESR, FBC (elevated platelets), UEC, cardiovascular screen, etc
• Imaging: nil
• Other: temporal artery biopsy (at least 2.5cm due to ‘skip lesions’) - histopath shows granulomatous inflammation

Question 5

GCA - Management

Answer 5

Management:

• Need urgent referral to local emergency department for further investigation and treatment. Vision loss is usually profound and unlikely to improve.
• Consider starting oral prednisolone, depending on pre-test probability prior to diagnostic confirmation

Pharmacological:
- IV methylpredisone 3 days then switch to PO prednisolone
Consider
- immunosuppressive therapy
- aspirin (antiplatelet therapy) for patients with increased cardiovascular risk factors

Referral:
- to rheumatologist/immunologist for advice regarding ongoing treatment/management and glucocorticoid taper

Non-pharm
- cardiovascular disease risk lifestyle changes

Opportunistic
- chronic disease management (cardiovascular risk factors, etc)