Case study by Muhammad Abu-Rmaileh , MD , PHD 1 , Suzanne Abou-Diab , MD 1 , Amad Walajahi , bS , MS 1 , Gayathri Krishnan , MD 2 , Nicholas Gowen , MD 3
1
College of Medicine , University of Arkansas for Medical Sciences ; Little Rock , Ark .
2
Department of Infectious Disease , Washington University in Saint Louis ; Saint Louis , Mo .
3
Department of Medicine and Pediatrics , Central Arkansas VA Hospital ; Little Rock , Ark .
GCA Masquerading as Altered Mental Status and Diarrhea : A Case Report
Abstract
Giant Cell Arteritis ( GCA ) is a large-cell vasculitis with systemic effects . Classic symptoms include fever , night sweats , headaches , jaw claudication , and visual loss ; however , GCA can present initially with psychiatric and neurologic symptoms . Our case highlights a patient who presented with altered mental status leading to functional decline and pellagra-like symptoms associated with GCA . While there have been some documented cases of GCA-related vascular dementia , it would not explain our patient ’ s improvement with prednisone and nutrient replenishment . Identifying atypical manifestations of GCA aids in rapid diagnosis and leads to decreases in fatalities .
Introduction
GCA is a cell-mediated immune response due to endothelial injury . It primarily targets medium and large arteries in the arch of the aorta , with highest involvement of the superficial temporal , vertebral , ophthalmic , and posterior ciliary arteries . Inflammatory changes occur mostly in the intima and internal elastic lamina and is non-contiguous , meaning there are “ skip lesions .” Systemic inflammation is caused by T-cells and macrophages mediated release of IL-6 and other pro inflammatory cytokines . 1
Over 80 % of GCA is found in patients over the age of 70 , and primarily in Caucasian populations . The lifetime risk is 1 % in women and 0.5 % in men . 1 , 2 Common presentation of GCA includes headache , vision loss , jaw claudication , weight loss , night sweats , and fatigue . There are some unusual presentations of GCA that have a predominant neurologic presentation such as GCA-induced vascular dementia and stroke . 2 Even more unusual , there have been some cases of patients presenting with changes in mentation that improved upon diagnosis and treatment of GCA . 2 , 5 , 3 We present a case of a patient with altered mental status ( AMS ) related to GCA and a literature review of similar cases .
Case Report
Our patient is a 74-year-old Caucasian male with past medical history significant for coronary artery disease ( CAD ), hypertension , non-insulin dependent diabetes , and hypothyroidism who presented from an outside hospital for confusion . On initial examination at the outside hospital , his vitals were normal except for a temperature of 100.2 ° F . On exam , patient was noticed to be confused and lethargic . Family reported memory decline and decreased ability to perform instrumental activities of daily living ( IADL ) over the past three months . His initial lab workup was remarkable for white blood cell ( WBC ) count of 19.0 x 103 / mm3 ( normal < 10 ), hypokalemia , hyponatremia , and creatinine of 2.7mg / dL ( baseline was < 1.2 ), all of which improved with hydration . There was concern for sepsis , and he was started on broad-spectrum antibiotics that were narrowed to Levofloxacin after C . difficile rule out . The only remarkable imaging finding was computed tomography ( CT ) of the abdomen , which showed distended bowel loops . During his stay , his WBC remained elevated at 20.0 x 103 / mm3 and patient remained confused .
At that time , the patient was transferred to our institution . Vital signs upon arrival were normal ; he was in no acute distress , but appeared intermittently somnolent and confused — not oriented to place or time . The physical examination was grossly normal except for abdominal distension , clean sacral ulcers , and some desquamation bilaterally on both hands . Laboratory workup showed a WBC count of 14.8 x 103 / mm3 and hemoglobin of 8.1g / dL ( baseline was > 13.5 ). His labs were remarkable for elevated erythrocyte sedimentation rate ( ESR ) and ferritin and low Folate , Vitamin B3 , Vitamin B6 , and Zinc . Head magnetic resonance imaging ( MRI ), CT-angiography ( CTA ), colonoscopy , and biopsy were unremarkable . We considered GCA as a diagnosis based on his age , new onset confusion , elevated inflammatory markers , and negative imaging . We then performed a temporal artery biopsy , which revealed GCA ; the patient was started on high-dose systemic steroids . The patient continued to have diarrhea , which improved after administration of IV-potassium and IV-multivitamin with minerals . After a two-week duration of treatment , the family reported he returned to normal and was discharged from our facility .
Discussion
As demonstrated in our case , AMS in GCA patients is an unusual presentation . While most documented cases attribute this to infarction , we found six cases in the literature where GCA presented with memory alterations not related to depression or infarction . Cognitive changes include memory changes , disorientation , delirium , and hallucinations ( Table 1 ). Five patients improved after steroid
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