048 It's not always in their head: a case series of atypical presentations of giant cell arteritis

Abstract

Background: GCA is a large vessel vasculitis seen in patients over the age of 50 and is the most common systemic vasculitis. It classically presents with temporal headache, jaw claudication and potentially permanent visual loss. However up to 40% of patients can present with no cranial features. These patients often present to various medical specialities. In this short case series we describe three patients with GCA who presented to non-rheumatologists with symptoms of extra cranial vasculitis. Methods: Retrospective case note review. Results: Case 1: an 81 year old male presented to the lung cancer clinic with weight loss, fatigue and dyspnoea. CRP was 90mg/L. A CT chest revealed a left upper lobe lesion, the nature of which was uncertain. Repeat CT several months later revealed static appearances of the nodule and a PET scan was performed revealing florid abnormality in the aortic, subclavian, axillary and brachial arteries in keeping with vasculitis. A temporal artery biopsy (TAB) was consistent with vasculitis. The patient was treated with oral prednisolone with good symptomatic response and normalisation of inflammatory markers. Case 2 An 83 year old male presented to the acute medical take with a two week history of left sided weakness and sensory loss. There was a one month history of fatigue and weight loss. CRP was 46mg/L and ESR 122mm in 1Hr. MRI brain revealed a right pons infarct. Given the appearances of the changes a CT angiogram was performed to exclude a basilar artery thrombosis. This revealed diffuse thickening of the wall of the aortic arch continuing along the descending aorta. The possibility of aortitis was raised and a TAB result was consistent with arteritis. Case 3 A 61 year old male presented to the acute medical take with nausea, fatigue and raised inflammatory markers. Clinical examination revealed mildly tender pulsatile temporal arteries. A CT chest abdomen and pelvis done to exclude malignancy revealed soft tissue cuffing around the abdominal aorta suggestive of periaortitis. A TAB showed no evidence of arteritis but the patient had an excellent symptomatic response to prednisolone with normalisation of inflammatory markers. Conclusion: Our cases demonstrate the varied and non-specific presentations of extra cranial GCA and the importance of considering such a diagnosis in elderly patients presenting with constitutional upset and raised inflammatory markers. TAB proved a useful diagnostic tool in two of these patients despite the lack of typical cranial symptoms and remains the gold standard test. Our cases presented to various specialities through varied routes highlighting the importance of vigilance by all physicians in considering the diagnosis of GCA in such patients. Unless GCA is considered the diagnosis can be delayed resulting in life threatening complications.