Temporal (Giant Cell) Arteritis: 3 Questions You were Afraid to Ask

Primary care waiting rooms are growing progressively grayer along with the US population. Among the many conditions more prevalent among older adults that can be very dangerous if undetected is giant cell (temporal) arteritis. Serious outcomes include blindness and aortitis leading to dissection. There is no single complaint, physical finding, or lab test that is definitive in making the diagnosis of this large vessel vasculitis.

Let’s ask and answer some questions that will assist PCPs in suspecting and making the diagnosis of this disease in timely fashion.

1. What examination findings may be helpful in suspecting temporal arteritis?

Jaw claudication when chewing has predictive value for the presence of temporal arteritis.¹ Two interesting cases appeared recently in the New England Journal of Medicine.¹ A 66-year-old woman had right jaw pain, temporal headaches, and lethargy after weaning off prednisolone therapy prescribed for a prior diagnosis of giant cell arteritis.¹ She was asked to chew gum at a rate of 1 chew/second. After 2 minutes of the chewing activity, she experienced an ache in her right jaw similar to what she had experienced 2 years previously when her disease was diagnosed. Prednisolone dosage was increased, and 4 days later, the jaw pain with chewing resolved. A second similar patient, 77 years of age, was presented in the same issue. Although the numbers are not “robust” the “chewing gum” test leaves me with two important thoughts. First, I will ask about jaw pain with chewing in my temporal arteritis ROS. Second, the value of this simple and inexpensive office test needs to be established through further study!

Next: What other diagnostic tests?

2. What other diagnostic tests are available?

The sensitivity of an erythrocyte sedimentation rate (ESR) for a diagnosis of temporal arteritis is 84%; an elevated C-reactive protein (CRP), 86%.² Not surprisingly, specificity for both markers is only 30%.² However, another important fact may be helpful. Only 4% of patients with confirmed giant cell arteritis have both a normal ESR and CRP.²

If you send your patient for a temporal artery biopsy, remember the pathological process has “skip areas” of normal artery interspersed with arteritis. At least 1 inch of artery must be submitted for pathological analysis.³

Finally, 25% of patients with temporal arteritis also have large vessel vasculitis in areas other than the eye. Magnetic resonance angiography or computed tomographic angiography of the aortic arch may help confirm diagnosis in this demographic.²

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An angiogram of the left upper extremity of a patient with giant cell arteritis shows serial smooth narrowings of the subclavian artery. This artery is essentially occluded in the area of the axilla, but the axillary artery is reconstituted by extensive collateral circulation.

Next: What to watch for

3. What should the PCP watch for during treatment?

Disease flares are common during corticosteroid tapers!² They often respond to a 10 to 20% increase in dose.² Glucocorticoid treatment in this particular population is associated with bone loss. The PCP is strategically positioned to treat or prevent this complication. These patients are also under an increased risk of Pneumocystis jiroveci infection and should receive prophylaxis with sulfamethoxazole and trimethoprim if not allergic.² Remember the most devastating complication of giant cell arteritis is acute arteritic ischemic optic neuropathy! Use your ophthalmologist liberally and do not forget to include vision in your ROS.²

Please scroll down for references

References:

1. Kuo C-H, McCluskey P, Fraser CL. Chewing gum test for jaw claudiection in giant-cell arteritis. N Engl J Med. 2016;374:1794-1795.

2. Weyand CM, Goronzy JJ. Giant-cell arteritis and polymyalgia rheumatica. N Engl J Med. 2014; 371:50-57.

3. Hayreh S. Diagnostic algorithm for patients with suspected giant cell arteritis: Comment. J Neuro-Ophthalmol. 2016;0:1-2.