A 74-year-old woman with no significant past medical history presents with 1 week of fever, unremitting headache and hip and shoulder stiffness. She denies any vision changes. Physical examination is remarkable for right scalp tenderness and range of motion is limited due to pain and stiffness. Neurological testing is normal. Laboratory studies are significant for an erythrocyte sedimentation rate (ESR) at 75 mm/h (normal range 0-22 mm/h for women). Which of the following is the most appropriate next step in management?

Obtain CT head without contrast

Perform a temporal artery biopsy

A 40-year-old woman comes to the emergency department because of difficulty walking for the past 4 hours. She first noticed her symptoms after getting up this morning and her foot dragging while walking. She feels tired. She has a history of chronic sinusitis. Six months ago, she was diagnosed with asthma. Current medications include an albuterol inhaler and inhaled corticosteroids. Her temperature is 38.9°C (102°F), pulse is 80/min, and her blood pressure is 140/90 mm Hg. Auscultation of her lungs shows diffuse wheezing over bilateral lung fields. Physical examination shows tender subcutaneous nodules on the extensor surfaces of the elbows. There are palpable, non-blanching erythematous lesions on both shins. Dorsiflexion of the right foot is impaired. Sensation to pinprick, light touch, and vibration is decreased over the ulnar aspect of the left forearm. Laboratory studies show: Hemoglobin 11.3 g/dL Leukocyte count 24,500 Segmented neutrophils 48% Eosinophils 29% Lymphocytes 19% Monocytes 4% Platelet count 290,000/mm3 Serum Urea nitrogen 32 mg/dL Creatinine 1.85 mg/dL Urine Blood 2+ Protein 3+ Which of the following is the most likely diagnosis in this patient?

Eosinophilic granulomatosis with polyangiitis

Granulomatosis with polyangiitis

A 62-year-old man presents to the emergency department with hematuria and hemoptysis that started in the morning. He notes that he has had frequent lung infections throughout his adult life, the most recent being 2 weeks ago. He also mentions that he has had hematuria twice before but never as severe as he is having currently. His medical history is otherwise non-significant, and his only medication is acetaminophen as needed. His blood pressure is 136/92 mm Hg, heart rate is 86/min, respiratory rate is 16/min, and temperature is 37.0°C (98.6°F). Chest radiography shows a resolving right middle lobe airspace opacity. His initial laboratory tests are notable for elevated erythrocyte sedimentation rate and C-reactive protein level. While in the examination room, the patient develops a spontaneous nosebleed. What is the most likely diagnosis?

Granulomatosis with polyangiitis

Post-streptococcal glomerulonephritis

A 45-year-old man comes to the physician because of fatigue and joint pain for 8 months. He has pain in both knees, both elbows, and diffuse muscle pain. He does not have dyspnea. He also had several episodes of a nonpruritic rash on his lower extremities. Eight years ago, the patient was diagnosed with hepatitis C. His temperature is 37.9°C (100.2°F), pulse is 90/min, and blood pressure is 140/90 mm Hg. Examination of the lower extremities shows raised purple papules that do not blanch when pressure is applied. Cardiopulmonary examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.9 g/dL Leukocyte count 8,500/mm3 Platelets 160,000/mm3 Serum Creatinine 1.1 mg/dL ALT 123 U/L AST 113 U/L Further evaluation of this patient is most likely to show which of the following findings?

Granulomatous inflammation of vessels

Elevated perinuclear anti-neutrophil cytoplasmic antibodies

A 32-year-old woman who recently emigrated to the USA from Japan comes to the physician because of a 3-month history of night sweats, malaise, and joint pain. During this time, she has also had a 6-kg (13-lb) weight loss. Physical examination shows weak brachial and radial pulses. There are tender subcutaneous nodules on both legs. Carotid bruits are heard on auscultation bilaterally. Laboratory studies show an erythrocyte sedimentation rate of 96 mm/h. A CT scan of the chest shows thickening and narrowing of the aortic arch. Microscopic examination of the aortic arch is most likely to show which of the following findings?

Granulomatous inflammation of the media

Fibrinoid necrosis of the intima and media

Subendothelial hyaline deposition

Subendothelial immune complex deposition

Large vessel vasculitis for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

Giant Cell Arteritis - The Blinding Headache

Patho: Granulomatous vasculitis of large & medium vessels, esp. cranial branches from aortic arch.
Classic Patient: Female > 50 years old, often with Polymyalgia Rheumatica (PMR).
Symptoms:
- New-onset, unilateral temporal headache.
- Jaw claudication (pain on chewing).
- Amaurosis fugax (transient vision loss) → can lead to permanent blindness.
- Constitutional: fever, fatigue, weight loss.
Exam: Tender, thickened, or pulseless temporal artery.

Giant Cell Arteritis Histopathology with Giant Cells

Diagnosis & Management

⭐ High-Yield: Up to 50% of patients with GCA have concurrent Polymyalgia Rheumatica (PMR), presenting with pain and stiffness in the shoulders and hips.

Takayasu Arteritis - The Pulseless Disease

Pathophysiology: Granulomatous vasculitis affecting the aorta and its major branches.
Epidemiology: Typically presents in women of Asian descent, age < 50 years.
Clinical Features ("Pulseless Disease"):
- - Systemic: Fever, malaise, weight loss, arthralgias.
- - Vascular: ↓ pulses, limb claudication, arterial bruits, and BP discrepancy >10 mmHg between arms.
Diagnosis:
- - Labs: ↑ ESR, ↑ CRP.
- - Imaging: CT or MR Angiography (CTA/MRA) is the gold standard to visualize vessel wall thickening and stenosis.
Treatment: High-dose corticosteroids (e.g., prednisone).

⭐ The subclavian artery is the most commonly affected vessel.

Diagnosis & Treatment - Compare & Conquer

Feature	Giant Cell Arteritis (GCA)	Takayasu Arteritis (TAK)
Gold Std	Temporal Artery Biopsy: mononuclear infiltrates, giant cells	N/A (clinical + imaging)
Imaging	Ultrasound: "Halo sign" (edema)	MRA/CTA: Aortic/branch stenosis, wall thickening
Labs	↑↑ ESR (>50), ↑ CRP	↑ ESR, ↑ CRP
Initial Tx	High-dose prednisone (40-60mg/day) immediately to prevent blindness	High-dose prednisone
Long-term	Tocilizumab (anti-IL-6), Methotrexate	Tocilizumab, Methotrexate
Adjunct	Low-dose Aspirin (reduces stroke risk)	Anti-hypertensives, anti-platelets

⭐ Visual confirmation is key: A positive "halo sign" on temporal artery ultrasound is highly specific for GCA, while angiography revealing stenosis or aneurysms of the aorta and its main branches is the cornerstone of Takayasu diagnosis.

High‑Yield Points - ⚡ Biggest Takeaways

Giant Cell Arteritis (GCA) typically affects females >50 with new-onset headache, jaw claudication, and scalp tenderness; it is strongly associated with Polymyalgia Rheumatica (PMR).

The greatest risk is irreversible blindness, mandating immediate high-dose corticosteroids even before diagnosis is confirmed.

Takayasu Arteritis (“pulseless disease”) classically affects Asian females <40, involving the aortic arch and causing disparate BPs and claudication.

Definitive diagnosis for GCA is temporal artery biopsy; for Takayasu, it's imaging (MRA/CTA).

Both present with constitutional symptoms and markedly elevated ESR and CRP.

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