GIANT CELL ARTERITIS-RELATED STROKE in A MAN with ELDERLY-ONSET RHEUMATOID ARTHRITIS

ABSTRACT

Background: Giant cell arteritis-related stroke is rare, with high early mortality and major morbidity in survivors. Objectives: To increase the awareness of coexistence of giant cell arteritis-re-lated stroke and rheumatoid arthritis. Methods: A case report and discussion. Results: A 73 year-old man with seronegative elderly-onset rheumatoid arthritis (EORA) presented to the emergency department (ED) with a one week history of frontal headache, vomiting and dizziness. He had multiple cardiovascular comor-bidities and took multiple medications, including methotrexate and sulfasalazine. He also had long-standing history of thrombocytopenia without requiring any treatment. Neurological examination performed in the ED was unremarkable. His C-reactive protein (CRP) was 69mg/L and erythrocyte sedimentation rate (ESR) 82mm/hour. Computed tomography (CT) of the brain was normal. The headache settled with analgesia. A diagnosis of probable tension-type headache, with underlying active EORA, was made. One month later, he presented to an ophthalmologist with recurrence of headache associated with visual disturbance and was diagnosed with giant cell arteritis (GCA). Both CRP (77mg/L) and ESR (85mm/hour) remained raised. Neither temporal artery biopsy nor temporal artery ultrasound were possible due to the coronavirus disease 2019 (COVID-19) pandemic. The headache and visual symptoms resolved completely a week after prednisolone 60mg daily was prescribed. In parallel, the CRP dropped to 2mg/L and ESR 16mm/hour. The patient's glucocorticoid dose was then tapered. While on prednisolone 20mg daily, about 3 weeks later, he developed slurred speech and generalized weakness. Examination showed cerebellar signs and MRI brain showed acute cerebellar infarct. He was treated pragmatically as an atherosclerotic stroke with clopidogrel, and the steroid was rapidly tapered in view of absence of headache and normalization of infammatory markers. Four weeks later, he was noted to have persistent confusion and unsteadiness of gait. CRP was elevated at 92mg/L. An urgent positron emission tomography-CT (PET-CT) scan showed infammation in the vertebral arteries [Figure 1] and cerebellar stroke. Prednisolone 40mg daily was restarted which led to a rapid improvement in his symptoms and normalization of infammatory markers. The glucocorticoids were tapered in a slower manner this time. A diagnosis of GCA-related cerebellar stroke with vertebral vasculitis was made and, with glucocorticoids, the patient made a good clinical recovery. His infam-matory joints pain also improved in parallel. Conclusion: Stroke or transient ischemic stroke are rare complications, reported in 2.8-16% of patients with active GCA. Most studies report strokes as occurring between the onset of GCA symptoms and 4 weeks after commencement of glucocorticoids1-3. Vertebrobasilar territory is involved in 60-88% of cases of GCA-related stroke1-3. In contrast, the vertebrobasilar territory is affected only in 15-20% of atherosclerotic strokes1,2. One study reported fatal outcomes in 11 out of 40 patients (28%) with GCA-related stroke, 7 within 2-13 days of stroke2. To conclude, this case demonstrates that high-dose glucocorticoids with slower tapering were able to control GCA-related stroke due to vertebral vasculitis in patient with EORA on background methotrexate and sulfasalazine.