Author(s)

H. Raat

Patient

female, 66 year(s)

A 66- year old woman with progressive joint stiffness and fatigue is presented. Laboratory showed an elevated CRP and BSE. Clinical examination revealed absent radial pulses. Angiography showed symmetric tapered narrowing of the axillary arteries.

Since one year this 66-year old woman complained of progressive atypical joint stiffness and fatigue. Laboratory revealed a strongly elevated sedimentation and CRP (16 Mg/dl). Clinical examination revealed absent radial pulses bilaterally, though the patient was not suffering from arm claudication. Color-duplex ultrasonography showed tapered narrowing of the axillary arteries with increased wall thickness, suggesting an underlying vasculitis. Subsequent angiography confirmed the symmetric tapered stenotic segments of the axillary arteries, nearly pathognomonic for giant cell arteritis. Finally, biopsy of the temporal artery confirmed the diagnosis, though patient was asymptomatic for temporal arteritis.

Giant cell arteritis (GCA) is closely identified with the temporal arteritis polymyalgia rheumatica syndrome of the elderly. Patients with extracranial giant cell arteritis present with occlusive arterial lesions that may be detected with several imaging modalities: angiography, CT scanning or magnetic resonance angiography (MRA). The lesions often present with a typical angiographic pattern of bilateral stenoses or occlusions with a smooth tapered appearance in the subclavian, axillary and proximal brachial arteries. Ultrasound permits quick and direct identification of the edema and inflammation of the vessel wall. This is an important marker for active disease. Around 25% of patients with extracranial GCA have asymptomatic temporal arteritis, which was also the case with this patient. Less commonly involvement may be found in the femoral arteries and their branches. The differential diagnosis includes Takayasu's disease, arteriosclerosis, thoracic outlet syndrome and ergotism.