Giant cell arteritis presenting as an ischaemic upper limb
Fitzgerald G, Mortimer B. O’Connor, Mark J. Phelan.
Dept of Rheumatology, Mercy University Hospital, Cork
Giant cell arteritis (GCA) is the most common form of systemic vasculitis in patients aged ≥ 50 years of age, it is a large vessel arteritis and commonly involves branches of the carotid and temporal artery. It can however, involve the aorta and other branches including the brachiocephalic, axillary and subclavain arteries which can present with upper limb claudication and signs of limb ischaemia and patients can become systemically unwell.
There are a limited number of cases in the literature outlining the importance of considering arteritis as an important cause of ischaemic limb. The involvement of large arteries makes the formal diagnosis more difficult.
As demonstrated by this case, diagnosis can be challenging, particularly as some cases symptoms associated with the temporal artery may not be present.
To hilight a case of temporal arteritis presenting as an ischaemic upper limb and discuss the presentation, work up and treatment of this patient.
A 64 year old lady presented to the acute medical assessment unit with right upper limb pain, pallor, numbness, paraesthesia and reduced capillary refill. She had a history of migraine and had a vague two week history of headache with “flashing lights”. Of note ESR was 101mm/hr. CT angiogram showed occlusion of the right axillary artery (fig 1). A diagnosis of ischaemic limb secondary to atherosclerosis was made. An angioplasty was attempted but the lesion could not be crossed.
After consultation with the rheumatology service, a temporal artery biopsy was carried out, despite the absence of temporal artery tenderness, and showed a predominantly lymphocytic inflammatory infiltrate in the temporal arterial wall and fractured internal elastic lamina consistent with giant cell arteritis (GCA). The biopsy report along with her age favoured a diagnosis of GCA. She was treated with pulsed methylprednisolone IV followed by oral steroids. The patient went on the make a full recovery.
Occasionally we are presented with a patient where the diagnosis appears obvious. In this case, we present a lady with a painful upper limb with associated numbness, paraesthesia, pallor and weak pulses. Angiography revealed an occluded right axillary artery. The initial diagnosis was one of ischaemic limb secondary to atherosclerosis. As presented in this report, when we delve deeper into the patient’s history and physical exam if becomes apparent that the possibility of an alternate diagnosis exists. We specifically wish to highlight the importance of considering the wide range of conditions which can cause a patient to present with ischaemic upper limb as some are curable. In this case a diagnosis of Giant Cell Arteritis was confirmed and when treated appropriately a full recovery was made.