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Vasculitis, GCA and PMR
Vasculitis is classified by vessel size — large (GCA, Takayasu), medium (PAN) and small (ANCA, IgA, cryoglobulinaemia); and when GCA is suspected, steroids are given at once, before the biopsy, to save sight.
Why it matters in the exam
The classic question presents a patient over 50 with a new headache, scalp tenderness, jaw pain on chewing and falling vision, with a high ESR and CRP — giant cell arteritis. The candidate must choose immediate prednisone 40–60 mg (and intravenous methylprednisolone if vision is lost), with temporal artery biopsy or ultrasound only afterwards, since these stay diagnostic after a few days of treatment. GCA is linked to PMR: pain and stiffness of the shoulder and hip girdles over age 50 with a high ESR and a dramatic response to prednisone 12.5–25 mg.
Beyond the large vessels, patterns must be recognised: Takayasu in a young woman with a blood-pressure difference between the arms, absent pulses and arm pain on effort; PAN with hepatitis B, hypertension, mononeuritis multiplex and renal artery aneurysms, without lung involvement and without ANCA; and small-vessel ANCA vasculitis (GPA, MPA, EGPA), covered in the glomerulonephritis chapter. Behçet disease, common in our region, presents with oral and genital ulcers, eye inflammation (uveitis) and a pathergy reaction. Tocilizumab is used as a steroid-sparing drug in GCA.
Key points
- GCA: over 50, headache, jaw pain, vision; prednisone 40–60 mg at once.
- PMR: shoulder and hip girdle stiffness, prednisone 12.5–25 mg.
- Takayasu: young woman, absent pulse.
- PAN: hepatitis B, mononeuritis, no lungs and no ANCA.
- Behçet: oral and genital ulcers, uveitis, pathergy.
Summary table
| Vessel size | Disease | Clinical clue | Treatment |
|---|---|---|---|
| Large | GCA | Over 50, headache, jaw pain, falling vision, high ESR | Prednisone 40–60 mg at once; tocilizumab as steroid-sparing |
| Large | Takayasu | Young woman, absent pulse, arm blood-pressure difference | Steroids ± immunosuppressants |
| — | PMR | Over 50, shoulder and hip girdle stiffness, high ESR | Prednisone 12.5–25 mg; rapid response |
| Medium | PAN | Hepatitis B, mononeuritis, renal aneurysms; no ANCA | Steroids ± cyclophosphamide; treat HBV |
| Small | ANCA (GPA, MPA, EGPA) | Sinusitis, lung haemorrhage, glomerulonephritis, asthma | Steroids + rituximab |
| Variable | Behçet | Oral and genital ulcers, uveitis, pathergy | Colchicine, apremilast; anti-TNF in severe disease |
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Sources
- EULAR recommendations for the management of large vessel vasculitis, 2018 — Giant cell arteritis and Takayasu arteritis
- ACR/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis, 2021 — Glucocorticoids, tocilizumab and temporal artery biopsy
- Harrison's Principles of Internal Medicine, 21st edition (2022) — The Vasculitis Syndromes; Polymyalgia Rheumatica
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.