Table 1 : Review of Literature showing similar manifestations of GCA .
Article |
Age |
Gender |
Memory |
|
|
|
Changes |
Lahaye 2020 ( 3 ) 70
Mahraj 2014 ( 4 )
Pascuzzi 1989 ( 5 )
Cochran 1978 ( 6 )
Pauley and Hughes 1960 ) 7 )
Vereker 1952 ( 8 )
Disorientation |
Delirium |
Impaired |
|
|
Attention |
Hallucinations |
Treatment |
Did patient |
|
|
improve ? |
M |
Yes |
Yes |
Yes |
Yes |
Yes |
0.7 mg / kg / day of |
|
|
|
|
|
|
Oral Prednisone |
70 |
M |
No |
Yes |
Yes |
No |
Yes |
High Dose IV Methylprednisolone |
|
|
|
|
|
|
|
|
72 |
M |
Yes |
Yes |
Yes |
Yes |
No |
Daily Prednisone |
|
|
|
|
|
|
|
60mg |
77 |
M |
Decrease in |
|
|
nonverbal |
No |
No |
Mild |
No |
Prednisone 20mg |
|
|
|
|
four times daily |
72 |
F |
Yes |
No |
No |
No |
Yes |
Prednisone 20mg |
|
|
|
|
|
|
|
four times daily |
67 |
M |
Yes |
Yes |
Yes |
Yes |
No |
Codeine |
Patient died |
|
|
|
|
|
|
|
|
before |
|
|
|
|
|
|
|
|
treatment |
Yes
Yes
Yes
Yes
Yes administration , while one patient died before receiving steroids ( Table 1 ). There have been many purported mechanisms for the causes of these mental status changes in GCA patients . One mechanism is that intracranial or meningeal vasculitis induces mild global ischemia due to decreased blood flow . 9 A global , systemic , inflammatory effect cannot be ruled out as another possible cause . While subacute dementia is not considered a possible manifestation of temporal arteritis , this case demonstrates that GCA can be detected by examining the patient for signs and symptoms of depression , confusion , delirium , hallucinations , etc . Our patient exhibited significant altered mental status that manifested as progressive cognitive decline , loss of memory , disorientation to self and others , and increased irritability . GCA should be considered in the differential diagnosis for altered mental status in elderly patients , especially since it is treatable and can lead to significant improvement in function .
Of note , our patient had multiple nutritional and vitamin deficiencies . We found the patient suffered from Folate , B3 , B6 , and Zinc deficiency related to poor oral consumption . After ruling out other etiologies of diarrhea , we also attributed his diarrhea and dementia to a pellagra-like reaction caused by niacin deficiency . His lack of photosensitive dermatitis on presentation may be due to confinement to his house , nursing home , and hospital over several months prior to admission .
On supplementation of vitamins and minerals , we observed an improvement in both diarrhea and cognition . Literature review is limited on vitamin deficiencies and GCA prior to steroid treatment ; however , it has been shown that homocysteine levels can be elevated in autoimmune disorders such as GCA . The most frequent causes of elevated homocysteine levels are due to deficiencies in folic acid or vitamin B12 , which was seen in our patient . Hyperhomocysteinemia is an independent risk factor for ischemic optic neuropathy , silent brain infarction , and stroke . Martinez , et al ., found a slight association between elevated homocysteine levels in a small sample of patients with GCA and increased ischemic events , which he predicts to be greater with increased sample size . 10 After supplementation with B9 / B12 , levels of homocysteine were significantly decreased in GCA patients , possibly decreasing their risk for future ischemic complications . Though this may have been a potential cause of AMS in our patient as he had low B6 and folate , there was no evidence of acute vascular injury on imaging .
Conclusion
In conclusion , altered mental status secondary to GCA and pellagra is a rare phenomenon ; however , the sequelae can lead to severe morbidity . Expansion of diagnostic criteria for GCA is the key to improving patient outcomes . Biopsy is a critical component in diagnosis and treatment should focus on steroids and nutrient replenishment .
References
1 . Pradeep S , Smith JH . Giant Cell Arteritis : Practical Pearls and Updates . Current Pain and Headache Reports . 2018 ; 22 ( 1 ): 2 . doi : 10.1007 / s11916- 018-0655-y
2 . Andrews JM . Giant-cell (“ temporal ”) arteritis . A disease with variable clinical manifestations . Neurology . 1966 ; 16 ( 10 ): 963-971 . doi : 10.1212 / wnl . 16.10.963
3 . Lahaye C , Sanchez M , Rouet A , et al . A curable pseudo-dementia related to an atypical presentation of giant cell arteritis . Age and Ageing . 2020 ; 49 ( 3 ): 487-489 . doi : 10.1093 / ageing / afaa010
4 . Maharaj M , Shimon L , Brake D . Confusion in Giant Cell Arteritis - A Diagnostic Challenge . Can J Neurol Sci . 2014 ; 41 ( 4 ): 535-537 . doi : 10.1017 / S0317167100018667
5 . Pascuzzi RM , Roos KL , Davis TE . Mental status abnormalities in temporal arteritis : a treatable cause of dementia in the elderly . Arthritis Rheum . 1989 ; 32 ( 10 ): 1308-1311 . doi : 10.1002 / anr . 1780321017
6 . Cochran JW , Fox JH , Kelly MP . Reversible mental symptoms in temporal arteritis . J Nerv Ment Dis . 1978 ; 166 ( 6 ): 446-447 . doi : 10.1097 / 00005053-197806000- 00010
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Volume 117 • Number 12 june 2021 • 277