GIANT CELL AERITIS Headache, scalp tenderness, visual symptoms, jaw claudication, or throat pain The temporal aery is usually normal on physical examination but may be nodular, enlarged, tender, or pulseless Blindness Results from occlusive aeritis of the posterior ciliary branch of the ophthalmic aery Ischemic optic neuropathy may produce no funduscopic findings for the first 24-48 hours after the onset of blindness Asymmetry of pulses in the arms, a murmur of aoic regurgitation, or bruits heard near the clavicle resulting from subclan aery stenoses identify an affected aoa or its major branches Foy percent of patients with giant cell aeritis have nonclassic symptoms at presentation, primarily respiratory tract problems (most frequently dry cough), mononeuritis multiplex (most frequently with painful paralysis of a shoulder), or fever of unknown origin The fever can be as high as 40degC and is frequently associated with rigors and sweats Unexplained head or neck pain in an older patient may signal the presence of giant cell aeritis Diagnosis An elevated ESR, with a median result of about 65 mm/h, occurs in more than 90% of patients with polymyalgia rheumatica or giant cell aeritis Magnetic resonance angiography or CT angiography establishes the diagnosis by demonstrating long stretches of narrowing of the subclan and axillary aeries Imaging of the temporal aery with ultrasound, MRI, or CT angiography can sometimes obte the need for biopsy Temporal aery biopsy -Diagnostic findings of giant cell aeritis may still be present 2 weeks (or even considerably longer) after staing coicosteroids . TREATMENT The urgency of early diagnosis and treatment in giant cell aeritis relates to the prevention of blindness When a patient has symptoms and findings suggestive of temporal aeritis, therapy with prednisone, 60 mg daily orally, is initiated immediately Prednisone should be continued in a dosage of 60 mg/day for 1-2 months before tapering Intravenous pulse methylprednisolone (eg, 1 g/day for 3 days) may help patients with visual loss and may increase chance of remission; however, data suppoing this recommendation are preliminary Low-dose aspirin (~81 mg/day orally) may reduce the risk of visual loss or stroke and should be added to prednisone Tocilizumab, an anti-interleukin-6 receptor monoclonal antibody Phase 2 clinical trials have shown that patients initially treated withtocilizumaband prednisone were able to be tapered off prednisone faster than those who were treated with prednisone alone After 1 year of treatment,tocilizumabachieves coicosteroid-free remission in approximately 50% of patients