AB0581 AN ATYPICAL PRESENTATION OF GIANT CELL ARTERITIS WITH SCALP LUMPS: A CASE REPORT
Authors: Uthpala Dissanayake, Risniya Hassan
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background:</h3> Giant cell arteritis (GCA) also referred as temporal arteritis is a systemic inflammatory vasculitis of unknown etiology which can result in wide range of systemic, neurologic and ophthalmic complications. It predominantly occurs in older people and may be associated with Polymyalgia Rheumatica. It must be treated urgently as it is associated with significant risk of permanent visual loss, stroke, aneurysm and possible death. Diagnosis of GCA can be based on clinical findings such as headache, scalp tenderness, jaw claudication and temporal artery problems, an elevated ESR and biopsy temporal artery showing typical histopathological findings. Diagnosis of GCA may be delayed when presentation is atypical. <h3>Objectives:</h3> We report a case of an elderly lady presenting with scalp lump as an unusual presentation of GCA. <h3>Methods:</h3> 70 years old lady presented with multiple painful scalp lumps to the surgeon was referred to the Rheumatologist when the excision biopsy of the lump diagnosed the GCA. (Sub cutis medium sized artery with severe arteritis composed with lymphocytes, neutrophils and occasional Eosinophills). On enquiry she revealed a history of generalized malaise and lethargy at the outset of the illness preceded by jaw pain She had been initially referred to the dental surgeon which resulted in multiple carious tooth extractions without a relief. She didn't have any eye symptoms or headache at the outset. She lately developed headache and pain on touching the lumps. On examination she had bilateral hardened thickened palpable non pulsatile temporal arteries. Her scalp was tender with multiple small cystic lumps. Her ESR was highly elevated 141mm/hr. WBC 9.7, Hb 9.5 and PLT 283. Her ANA, liver and renal profiles were normal. Her BL Doppler USS was consistent with BL temporal arteritis. <h3>Results:</h3> She was soon started on high dose prednisolone with low dose aspirin which improved her systemic symptoms along with inflammatory markers significantly over a few days. She was referred for eye assessment and the involvement of other systemic larger arteries was ruled out. <h3>Conclusion:</h3> Most of the cases the diagnosis of GCA is obvious but in patients with uncommon clinical presentation the diagnosis may be difficult.GCA is classified as disease of large vessel vasculitis but typically also involves medium and small arteries.The granulomatous inflammation in the vessel wall leads to obstruction of the lumen and ischemia in the territory distal to it. GCA involves almost all speciality and it is associated with increased mobility and mortality if not diagnosed and treated early. Awareness of rare presentation of GCA avoids unnecessary investigation and delaying the treatment.If there is no rapid improvement of symptoms within few weeks of starting treatment other diagnosis should be considered. <h3>References</h3> [1] Gunawardena H, Kyle M.V, Atypical presentation s of Giant cell arteritis-A District General Hospital perspective, Rheumatology, volume 44, Issue suppl_3, 1 July 2005, pages iii17-iii18 [2] Weyand CM,Goronzy JJ. Giant cell arteritis and Polymalgia rheumatica. N Engl J Med 2014;371:50-7 [3] Shambu.S, Suarez. L, Giant cell arteritis: An atypical presentation diagnosed with the use of MRI imaging, Case Reports in Rheumatology, volume 2016, article ID8239549 <h3>Acknowledgement:</h3> Dr Nayana Ratnayake, Dr Wasula Rathnaweera <h3>Disclosure of Interests:</h3> None declared