Giant Cell Arteritis Temporal Arteritis

Temporal arteritis is a systemic autoimmune disorder. Pathologically, there is a granulomatous inflammation of large and medium-sized arteries. It generally occurs in patients older than 55 years, with no gender predilection. Involvement may occur in any organ system. Ocular involvement is generally associated with inflammation of the posterior ciliary arteries. General symptoms include amaurosis fugax, headaches, scalp tenderness, jaw claudication, occasional ear pain or arthralgias, pain and tenderness on one or both temples, malaise, and intermittent fevers. Ocular symptoms include loss of vision, diplopia, pain, red eye, and ocular-ischemic syndrome. The workup of patients suspected to have giant cell arteritis includes a careful history of nonvisual symptoms, examination, and laboratory studies to include erythrocyte sedimentation rate (ESR), C-reactive protein, and complete blood count with differential. Using the Westergren method, the value for a normal ESR is 30 mm/hr for a 60-year-old man; for women, top of normal range is age plus 10 divided by 2, so 35 mm/hr is the upper range of normal for a 60-year-old woman. The differential diagnosis of sudden vision loss also includes emboli, central retinal artery occlusion, and retinal detachment.

The visual loss of giant cell arteritis is caused by an ischemic process in the optic nerve. Central retinal artery occlusion v m

Figure 41-34 Proliferative diabetic retinopathy. Patient has severe disease, with diffuse retinal hemorrhages in all quadrants and evidence of neovascularization, and requires urgent panretinal photocoagulation. There is evidence of neovascularization of the optic disc in the left eye.

may also occur with giant cell arteritis. It is important to diagnose giant cell arteritis as early as possible. Without corticosteroid treatment, patients often develop permanent vision loss bilaterally. When one eye is involved with giant cell arteritis, the second eye loses vision in 65% of untreated patients. Generally, involvement of the second eye occurs with 10 days of onset. When the diagnosis is suspected on the basis of clinical symptoms and signs, temporal artery biopsy is necessary to confirm the diagnosis. The ESR is often greatly elevated, although it may be normal for age. If there is any doubt regarding the diagnosis, a temporal artery biopsy is warranted.

Once the diagnosis is established, steroid therapy should be instituted immediately. Up to 100 mg of prednisone (1.0-1.5 mg/kg/day) should be given orally if giant cell arteritis is suspected. Some physicians recommend IV steroids. Patients often require treatment for several months pending a positive biopsy or strong suspicion of giant cell arteri-tis. Steroids should not be delayed because of the temporal artery biopsy. Biopsy results will remain positive for up to 1 week after beginning steroid therapy. The patient can be monitored by symptoms occurring after institution of treatment and by ESR. Because of the severe systemic effects of giant cell arteritis, the patient should be followed closely.

KEY TREATMENT

Giant cell arteritis should be promptly treated with oral or intravenous steroids before obtaining a temporal artery biopsy; treatment should not be delayed for laboratory confirmation (Turbin et al., 1999) (SOR: A).

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