The sore throat thought it was a minor problem, and one step later would be blind!

*It is only for medical professionals to read.
It is not impossible that the probability is small~ Sore throat, headache, general fatigue.
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What do you think of when you see these symptoms? common cold? bronchitis? A well-dressed and tight-thinking doctor will not be so hasty to make a conclusion.
Through careful inquiry and high-speed brain operation, clues are collected little by little.
An 81-year-old woman has a history of rheumatic polymyalgia for 8 years, and her vision is gradually blurred.
Temporal headache is unbearable.
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At this time the situation becomes complicated
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So what exactly did she get? Please follow the editor to enter this episode of the program-the secret giant cell arteritis of sore throat
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There is no doubt about the symptoms, examination and treatment of giant cell arteritis.
Giant cell arteritis (GCA) is a systemic necrotizing vasculitis that mainly invades cranial arteries.
GCA found in the early years almost always involves temporal arteries.
Temporal pain, scalp and temporal artery tenderness, also known as temporal arteritis, later found that GCA mainly affects the aorta and its branch vessels, as well as other middle arteries.
Granulomas can be formed at the inflammatory site of the blood vessels, with varying amounts.
Giant cell
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It is common in people over 50 years of age
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The specific etiology is not yet clear, and may be related to genetic infection and immune response.
In addition, cell adhesion molecules, macrophages, and multinucleated giant cells may also participate in the occurrence and development of the disease
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40% of GCA patients also suffer from polymyalgia rheumatica
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▌ Clinical manifestations: The vast majority of GCA is accompanied by headache (80%).
Headache can be the first and only clinical manifestation of GCA.
The pain is most commonly found in the temporal artery area
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43.
3% of headache patients had masticatory muscle pain and mandibular joint pain, and 5.
9% had speech disorder
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Eye symptoms and signs: About 10% of patients have transient blackout (suddenly a black eye), and about 80% of untreated patients can develop permanent blindness
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Respiratory symptoms: about 10%, manifested as cough, sputum or no sputum, with sore throat or hoarseness
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Systemic symptoms: fever, muscle aches, fatigue, night sweats, loss of appetite, weight loss, mood changes and so on
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Large vessel related diseases: aortitis, claudication, celiac aneurysm, cardio-cerebrovascular disease
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Very few patients have external carotid artery tenderness, which may be related to vascular complications
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▌ Auxiliary examination: laboratory examination: manifested as rapid red blood cell sedimentation rate, increased C-reactive protein, mild anemia, increased serum α or γ globulin, increased complement, and all autoantibodies were negative
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Pathological biopsy: Select blood vessels with tenderness or reduced pulsation for pathological biopsy.
Clinically, the temporal artery is often selected
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The diagnosis can be made if the temporal artery biopsy is positive, and the specificity is 100% .

Imaging examination: vascular ultrasound is the most widely used.
The positive color Doppler ultrasound examination of GCA is the presence of hypoechoic area (halo sign) around the vascular cavity; other imaging examinations also include vascular CTA and PET-CT
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Figure 1 shows the recommendations for auxiliary examinations in the 2021 GCA treatment guidelines formulated by the American College of Rheumatology (ACR)
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Figure 1 2021GCA treatment guidelines ▌ Treatment: The 2021 treatment guidelines for giant cell arteritis suggest that when newly diagnosed patients use glucocorticoids (GCs): daily use is better than every other day; high-dose oral is better than medium-dose oral; oral GCs combined use Tocilizumab is superior to oral GCs alone
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The guidelines also specifically pointed out that it is not recommended to use hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors for newly diagnosed patients
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At the same time, for relapsed patients, if they are receiving medium-high-dose GCs treatment, the guidelines recommend that they be combined with non-GCs immunosuppressive drugs such as methotrexate, azathioprine, and leflunomide
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Practical exercise-a real patient "One night, I woke up from my sleep and felt like a bomb exploded in my head
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In addition to the constant headache, my throat and jaw were also very painful
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So I went to the emergency department, but they There was nothing I could do
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The
next day, I went to the oral surgeon again, and he did not find any problems
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Then he went to the otolaryngology department.
The doctor thought there was a problem with the nerves in my larynx
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At the same time, I always felt pain, so I went In the emergency department of another hospital, the doctor advised me to see a neurologist
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The
neurologist thought I had GCA, so he suggested that I go to a rheumatologist
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Obviously, I was lucky to find the right department so quickly, because if Without rapid treatment, many patients will become blind due to GCA
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After injecting 40 mg of prednisone and performing head artery biopsy, I was diagnosed with GCA
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At the beginning, I took 40 mg of prednisone every day for more than a month.
I reduced the corresponding dose in a few weeks, and now only 25mg a day is enough
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Although GCA is a very painful and terrifying diagnosis, thank goodness I have fully recovered and I am very grateful for the current results
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"(81-year-old female patient, Polymyalgia rheumatica for 8 years, taking 3 mg of prednisone daily) blood pressure 125/86mmHg; heart rate 77 beats/min; BMI 22.
8 kg/m2
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Carotid artery tenderness, no abnormalities in cardiopulmonary examination
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Hemoglobin 111g/L, normocytic anemia, other blood counts and comprehensive metabolic indexes are normal; C-reactive protein 6.
1mg/L; ESR 41mm/h
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Bilateral temporal artery biopsy revealed segmental transmural inflammation, internal elastic membrane destruction, giant cell and intimal hyperplasia
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Show your skills-summary and expansion After the diagnosis of GCA and glucocorticoid treatment, the patient's symptoms such as sore throat and carotid artery tenderness were significantly alleviated, but the blurred vision has not been alleviated
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This case report demonstrates the importance of diagnosing GCA based on relatively uncommon sore throat and carotid tenderness, especially for patients with a history of polymyalgia rheumatica, in order to start treatment before the development of irreversible visual symptoms
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GCA has many common symptoms, including but not limited to headaches, jaw pain, and vision changes.
It rarely has respiratory symptoms such as coughing, hoarseness, or sore throat
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Respiratory tract involvement may be caused by pathological changes to the external carotid artery and ascending to the pharyngeal branches
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With the increase in the dose of prednisone, the main symptoms improved, and sore throat also improved.
Sore throat may also be related to GCA
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Carotid tenderness is also a rare manifestation of GCA, which may indicate more serious disease progression and a higher possibility of vascular complications
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However, anemia may have a protective effect on the development of vascular complications
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Therefore, the patient's orthocytic anemia (hemoglobin of 111g/L) may prevent him from suffering from vascular complications
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The relationship between GCA and polymyalgia rheumatica is also confusing, and the two can occur simultaneously or sequentially
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There are many theories to explain the connection between the two, such as the genetic connection of the HLA-DRB1*04 allele, or various bacterial and viral infections
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There is some controversy as to whether these are actually two different diseases or different manifestations of the same pathology
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Regardless, it is reasonable to assume that the patient’s previous polymyalgia rheumatica increases her likelihood of developing GCA in some cases
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The daily maintenance dose of prednisone for polymyalgia rheumatica is 3 mg, which may not be enough to prevent the onset of GCA
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Patients with recurrence of GCA take an average of 7.
8 mg of corticosteroids per day
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Another study showed that the recurrence rate of GCA was not significantly different between patients taking medium-dose steroids and high-dose steroids
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Therefore, in this patient taking a very small dose, there is no reason not to consider the occurrence of GCA
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All in all, this case confirms the importance of evaluating GCA in patients with polymyalgia rheumatica, even if they show atypical symptoms
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Sore throat and carotid artery tenderness are rarely associated with GCA, but they are associated with more serious vascular complications
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The patient did not consider GCA at the initial visit and delayed the diagnosis.
If the patient has obvious visual symptoms before receiving treatment, it will have a more serious impact on the quality of life
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Reference: [1]Turner KB,et al.
Giant cell arteritis characterised by sore throat.
http://dx.
doi.
org/10.
1136/bcr-2021-246575