Royal College of Surgeons in Ireland school of medicine, 216 Smoothwater Terrace, Markham, Ontario, L6B 0M8, Canada.
University of Ottawa and The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Box 678, Ottawa, Ontario, K1Y 4E9, Canada.
BMC Geriatr. 2018 Feb 21;18(1):55. doi: 10.1186/s12877-018-0738-y.
Giant cell arteritis (GCA) is an immune mediated inflammatory disease of medium and large arteries which afflicts older people. The classical presentation features include: headache, visual disturbances, and jaw claudication. Patients diagnosed with GCA have also been observed to be at higher risk for the subsequent development of strokes.
We describe a case of an 84-year old right-handed man who presented to hospital with dysarthria, dysphagia, right-sided facial drop, a history of generalized weakness and multiple falls. He was admitted to geriatric medicine with the working diagnosis of a posterior circulation stroke syndrome. He was also started on antibiotic treatment for a possible community-acquired pneumonia because of the presence of a low-grade fever and a chest radiograph showing ill-defined left lower lobe airspace disease. Initial lab results were remarkable for an erythrocyte sedimentation rate (ESR) of 112 mm/h and a C-reactive protein (CRP) level of 110 mg/L consistent with an active inflammatory state. Neurovascular imaging showed mild atherosclerotic changes of the aortic arch and proximal great vessels without significant stenosis. The patient was started on daily high-dose prednisone because of the possibility of a cerebral vasculitis. Bilateral biopsy of temporal arteries showed giant cell arteritis. The patient's neurologic status and inflammatory markers significantly improved (ESR 52 mm/h, CRP 7.0 mg/L) and he was eventually discharged to a seniors home with services.
The initial presentation of giant cell arteritis as a stroke syndrome, especially in the posterior circulation territory, is exceedingly rare. Other atypical presenting symptoms may include chronic cough and fever of unknown origin. The elevated ESR and CRP levels were clues to the diagnosis and clinical decision-making should be driven by a high index of suspicion since no single test (ESR, CRP, temporal artery biopsy) has perfect sensitivity. Elevated CRP may have a role in increasing stroke risk. This case report illustrates that in older people clinicians must consider atypical presentations of disease more often since timely diagnosis and initiation of treatment can result in optimal outcomes.
巨细胞动脉炎（GCA）是一种影响老年人的中型和大型动脉的免疫介导的炎症性疾病。其典型表现包括：头痛、视力障碍和下颌跛行。患有 GCA 的患者也被观察到发生中风的风险更高。
我们描述了一位 84 岁的右利手男性患者，因构音障碍、吞咽困难、右侧面部下垂、全身无力和多次跌倒就诊。他因后循环中风综合征被收入老年医学病房。由于存在低热和胸片显示左下肺空气腔疾病不明确，他还开始接受抗生素治疗，以治疗可能的社区获得性肺炎。初始实验室结果显示红细胞沉降率（ESR）为 112mm/h，C 反应蛋白（CRP）水平为 110mg/L，提示处于活跃的炎症状态。神经血管成像显示主动脉弓和近端大血管有轻度动脉粥样硬化改变，无明显狭窄。由于可能存在脑血管炎，患者开始每日接受大剂量泼尼松治疗。双侧颞动脉活检显示巨细胞动脉炎。患者的神经状态和炎症标志物显著改善（ESR 52mm/h，CRP 7.0mg/L），最终出院到老年人护理院。
巨细胞动脉炎最初表现为中风综合征，尤其是在后循环区域，极为罕见。其他非典型表现症状可能包括慢性咳嗽和不明原因的发热。ESR 和 CRP 水平升高是诊断的线索，由于没有单一测试（ESR、CRP、颞动脉活检）具有完美的敏感性，因此应高度怀疑并进行临床决策。CRP 升高可能在增加中风风险方面发挥作用。本病例报告表明，在老年人中，临床医生必须更经常考虑疾病的非典型表现，因为及时诊断和开始治疗可以带来最佳的结果。
