A 72-year-old woman with a 3-month history of headache, jaw claudication, and visual symptoms is found to have elevated ESR (95 mm/h) and temporal artery biopsy showing granulomatous inflammation with giant cells. Which of the following is NOT true regarding giant cell (temporal) arteritis (GCA)?

Question

Accepted Answer

D. The pathology shows acute suppurative inflammation with neutrophil predominance and microabscess formation. ## Giant Cell (Temporal) Arteritis — Pathology and Clinical Management

### Pathologic Hallmark: Granulomatous, NOT Suppurative

**Key Point:** GCA is characterized by **granulomatous inflammation** with **giant cells, lymphocytes, and macrophages** — NOT acute suppurative inflammation with neutrophil predominance. The hallmark is a **granuloma** at the intima–media junction with fragmentation of the internal elastic lamina.

**High-Yield:** The pathology of GCA is **granulomatous and chronic**, not acute and purulent. Suppurative (acute) inflammation with microabscesses is seen in bacterial infections (e.g., syphilitic aortitis or acute bacterial aortitis), NOT in GCA.

### Why Option 3 Is WRONG

GCA does **NOT** show acute suppurative inflammation or microabscess formation. These features are characteristic of:
- **Bacterial aortitis** (e.g., *Staphylococcus aureus*, *Salmonella*)
- **Syphilitic aortitis** (tertiary syphilis)
- **Acute necrotizing vasculitis** (not GCA)

The confusion may arise because GCA is a **necrotizing vasculitis**, but the necrosis is accompanied by **granulomatous** inflammation, not suppuration.

### Correct Features of GCA (Options 0, 1, 2)

| Feature | Details |
|---------|----------|
| **Large-vessel vasculitis** | Affects aorta, carotid, subclavian, temporal, ophthalmic arteries |
| **Corticosteroid therapy** | First-line; initiate immediately if clinical suspicion is high (before biopsy if vision-threatening) |
| **PMR association** | Present in 40–60% of GCA patients; may precede GCA by months to years |

### Pathologic Features of GCA

**Mnemonic — GCA Pathology (GIANT):**
- **G**ranulomatous inflammation
- **I**ntima–media junction involvement
- **A**rterial wall necrosis (fibrinoid)
- **N**ormal or low complement
- **T**emporal artery (classic site, but systemic)

### Clinical Pearl

**Clinical Pearl:** The presence of **jaw claudication** and **visual symptoms** (amaurosis fugax or arteritic anterior ischemic optic neuropathy) in an elderly patient with elevated ESR is a medical emergency. Corticosteroids should be initiated **immediately** without waiting for biopsy confirmation if vision is threatened, as GCA can cause irreversible blindness within days.

**Tip:** On exam, distinguish GCA (granulomatous, large-vessel, elderly) from:
- **Takayasu arteritis** (granulomatous, large-vessel, young women, Asian)
- **Polyarteritis nodosa** (necrotizing, medium-vessel, no granulomas)
- **ANCA-associated vasculitis** (small-vessel, necrotizing, granulomatous in GPA)

[cite:Robbins 10e Ch 11]

Answer

A. It is a large-vessel vasculitis affecting the aorta and its branches

Answer

B. Polymyalgia rheumatica occurs in approximately 40–60% of GCA patients

Answer

C. Corticosteroids are the first-line treatment and should be initiated before biopsy confirmation if clinical suspicion is high

A 72-year-old woman with a 3-month history of headache, jaw claudication, and visual symptoms is found to have elevated ESR (95 mm/h) and temporal artery biopsy showing granulomatous inflammation with giant cells. Which of the following is NOT true regarding giant cell (temporal) arteritis (GCA)?

Explanation

Giant Cell (Temporal) Arteritis — Pathology and Clinical Management

Pathologic Hallmark: Granulomatous, NOT Suppurative

Why Option 3 Is WRONG

Correct Features of GCA (Options 0, 1, 2)

Pathologic Features of GCA

Clinical Pearl

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Feature	Details
Large-vessel vasculitis	Affects aorta, carotid, subclavian, temporal, ophthalmic arteries
Corticosteroid therapy	First-line; initiate immediately if clinical suspicion is high (before biopsy if vision-threatening)
PMR association	Present in 40–60% of GCA patients; may precede GCA by months to years