Giant cell arteritis as a cause of intermittent claudication

Abstract

A 57-year-old lady who works in the post office presented initially in May 1994 with a 5- month history of left calf claudication at 50 yards. Six months previously she had also complained to her GP of joint pain, tiredness, and muscle aches. Rheumatoid factor was negative and erythrocyte sedimentation rate was elevated at 102. A diagnosis of polymyalgia rheumatica was made and she commenced a course of low-dose steroids, from which she gained dramatic relief. However, the pain in her legs continued and 6 months after the onset it caused sufficient handicap to interfere with her lifestyle. At presentation to the vascular clinic, she was no longer on steroids. She smoked ten cigarettes per day and had no other atherosclerotic risk factors. On examination she had palpable femorals with no pulses distally. An arteriogram was arranged, which showed bilateral femoropopliteal occlusions with both popliteal arteries being patent above the knee, with poor run off. A diagnosis of peripheral vascular disease was made and confirmed by ankle:brachial pressure indices of 0.7 and 0.76 for the dorsalis pedis arteries on the right and left side respectively. She was advised to stop smoking and was put on an exercise regime. An outpatient review was to be carried out in 2 months time. Her joint and muscle symptoms returned, so she was referred to the rheumatologist. A temporal artery biopsy was arranged. This showed multi-nucleated histiocytes consistent with giant cell arteritis. She was subsequently started on prednisolone 60 mg and methotrexate 10 mg. Three weeks after commencement of treatment she made a dramatic improvement in her symptoms of joint pains and muscle aches. Unexpectedly, the claudication disappeared, despite the continuance of her smoking habit. Her claudication symptoms were therefore attributed entirely to large vessel vasculitis as a result of giant cell arteritis. Her ankle:brachial pressure indices improved to 0.89 and 0.92 for the right and left side respectively.