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 **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]