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Презентация на тему Giant cell arteritis

IntroductionGiant cell arteritis (GCA) is categorized as a vasculitis of large- and medium-sized vesselsSystemic symptoms are common in GCA and vascular involvement can be widespreadTargeting of the muscular arteries from cranial branches of the aortic arch
Giant cell arteritis Dr Katya DolnikovD_katya@rambam.health.gov.il2017 IntroductionGiant cell arteritis (GCA) is categorized as a vasculitis of large- and EpidemiologyGCA is the most common systemic vasculitisThe lifetime risk of developing GCA Clinical findingsThe onset of symptoms tends to be subacuteAbrupt presentations occurs less Clinical findings - HeadacheLocated over the temples, but can also be frontal Temporal artery Jaw Claudication Trismus-like symptomsFatigue of the muscles of masticationRapid onset after the start VisionTransient visual loss (amaurosis fugax) — Transient monocular (and, rarely, binocular) impairment of vision Large vessel GCA Involvement of the aorta and its major proximal branches - External carotid artery- branchesMaxillary and dental painFacial swellingThroat painTongue pain Physical examinationPulses – carotid, brachial, radial, femoral, pedalBlood pressureBruits – carotid or AION Laboratory findingsNormochromic anemia is often present prior to therapy and improves promptly DiagnosisThe diagnosis of giant cell arteritis (GCA) should be considered in a DiagnosisPatient suspected of having GCA should undergo temporal artery biopsy~85% sensitivityOther arteries Biopsy-negative GCAThe patient may not have GCA. If the clinical story is ImagingMRI/MRAUSDAngiographyPET-CT TreatmentUncomplicated GCA - 40 to 60 mg of prednisone in a single doseAfter achieving TreatmentAdd aspirin (80 to 100 mg/day) to reduce the risk of visual loss, transient
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Слайд 3 Introduction
Giant cell arteritis (GCA) is categorized as a

IntroductionGiant cell arteritis (GCA) is categorized as a vasculitis of large-

vasculitis of large- and medium-sized vessels
Systemic symptoms are common

in GCA and vascular involvement can be widespread
Targeting of the muscular arteries from cranial branches of the aortic arch gives rise to the most characteristic symptoms of GCA
The most feared complication of GCA, visual loss, is one potential consequence of such cranial arteritis

Слайд 5 Epidemiology
GCA is the most common systemic vasculitis
The lifetime

EpidemiologyGCA is the most common systemic vasculitisThe lifetime risk of developing

risk of developing GCA is ~1% in women and

0.5% in men
The greatest risk factor for developing GCA is aging
The disease almost never occurs before age 50
Over 80 percent of patients are older than 70 years
Ethnicity is a major risk factor for GCA. The highest incidence figures are found in Scandinavian countries
F>M


Слайд 6 Clinical findings
The onset of symptoms tends to be

Clinical findingsThe onset of symptoms tends to be subacuteAbrupt presentations occurs

subacute
Abrupt presentations occurs less frequently
Systemic symptoms are frequent and

include fever, fatigue, and weight loss
Fever occurs in up to one-half of patients with GCA and is usually low-grade
In ~ 10% of patients constitutional symptoms and/or laboratory evidence of inflammation dominate the clinical presentation and can be the only clues to the diagnosis




Слайд 8 Clinical findings - Headache
Located over the temples, but

Clinical findings - HeadacheLocated over the temples, but can also be

can also be frontal or occipital or generalized
The headaches

can progressively worsen, or wax and wane, sometimes subsiding temporarily before treatment is started
Tenderness of the scalp to touch


Слайд 9 Temporal artery

Temporal artery

Слайд 10 Jaw Claudication
 Trismus-like symptoms
Fatigue of the muscles of mastication
Rapid

Jaw Claudication Trismus-like symptomsFatigue of the muscles of masticationRapid onset after the

onset after the start of chewing and the ensuing

severity of pain
Patients seldom recognize the significance of symptoms of jaw claudication and must be questioned directly about this symptom
Claudication-like symptoms occasionally occur with repeated swallowing and in the tongue during eating
Jaw claudication is the symptom most highly associated with a positive temporal artery biopsy


Слайд 11 Vision
Transient visual loss (amaurosis fugax) — Transient monocular (and, rarely,

VisionTransient visual loss (amaurosis fugax) — Transient monocular (and, rarely, binocular) impairment of

binocular) impairment of vision can be an early manifestation

of GCA.
Permanent vision loss — The most feared complication of GCA. Commonly is painless and sudden, may be partial or complete, and may be unilateral or bilateral. Even in the era of effective therapy, permanent partial or complete loss of vision in one or both eyes is reported 20% of patients
Risk factors — prior transient visual loss as the strongest predictor for subsequent permanent visual loss
Diplopia


Слайд 12 Large vessel GCA
 Involvement of the aorta and its

Large vessel GCA Involvement of the aorta and its major proximal branches

major proximal branches - especially in the upper extremities
The clinical

consequences comprise aneurysms and dissections of the aorta, particularly the thoracic aorta, as well as stenosis, occlusion and ectasia of large arteries
Axillary arteries, proximal brachial arteries - arterial bruits, diminished or absent blood pressures, and arm claudication may ensue. Cold intolerance is common, but explicit digital ulcerations and gangrene are rare because of the adequacy of collateral arterial supply
Upper-extremity disease is bilateral, though not symmetric,

Слайд 14 External carotid artery- branches
Maxillary and dental pain
Facial swelling
Throat

External carotid artery- branchesMaxillary and dental painFacial swellingThroat painTongue pain

pain
Tongue pain


Слайд 16 Physical examination
Pulses – carotid, brachial, radial, femoral, pedal
Blood

Physical examinationPulses – carotid, brachial, radial, femoral, pedalBlood pressureBruits – carotid

pressure
Bruits – carotid or supraclavicular areas; over the axillary,

brachial, or femoral arteries; over the abdominal aorta
Cardiac auscultation
Temporal a. examination



Слайд 19 Laboratory findings
Normochromic anemia is often present prior to

Laboratory findingsNormochromic anemia is often present prior to therapy and improves

therapy and improves promptly after the institution of glucocorticoids
Thrombocytosis


The leukocyte count is usually normal, even in the setting of widespread systemic inflammation.
Serum albumin — moderately decreased at diagnosis but responds quickly to the institution of glucocorticoids
Hepatic enzymes — Elevated serum concentrations of hepatic enzymes, especially the alkaline phosphatase, occur in 25 to 35 percent of patients
ESR and C-reactive protein — elevated


Слайд 20 Diagnosis
The diagnosis of giant cell arteritis (GCA) should

DiagnosisThe diagnosis of giant cell arteritis (GCA) should be considered in

be considered in a patient over the age of

50 who complains of:
New headaches
Abrupt onset of visual disturbances
Symptoms of polymyalgia rheumatica
Jaw claudication
Unexplained fever or anemia
High ESR/CRP

Слайд 21 Diagnosis
Patient suspected of having GCA should undergo temporal

DiagnosisPatient suspected of having GCA should undergo temporal artery biopsy~85% sensitivityOther

artery biopsy
~85% sensitivity
Other arteries can also be sampled
Scheduling of

the biopsy should NOT interfere with the start of glucocorticoid therapy when there is a significant concern about the possibility of GCA

Слайд 22 Biopsy-negative GCA
The patient may not have GCA. If

Biopsy-negative GCAThe patient may not have GCA. If the clinical story

the clinical story is equivocal, then alternative diagnoses should

be given more weight
The patient may have GCA involving only the great vessels. Among patients with suggestive symptoms (most often arm claudication), an imaging study should be performed
An empiric trial of glucocorticoid therapy may be helpful. Failure of the patient’s symptoms to resolve within one week of high-dose glucocorticoids argues strongly against the diagnosis of GCA


Слайд 23 Imaging
MRI/MRA
USD
Angiography
PET-CT

ImagingMRI/MRAUSDAngiographyPET-CT

Слайд 24 Treatment
Uncomplicated GCA - 40 to 60 mg of prednisone in

TreatmentUncomplicated GCA - 40 to 60 mg of prednisone in a single doseAfter

a single dose
After achieving a daily dose of 10

mg, the prednisone taper should be slow, such that patients remain on some prednisone for 9 to 12 months. Tapering in 1 mg decrements per month once the daily dose is less than 10 mg is appropriate

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