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Focal granulomatous inflammation
81%
150/185
Granulomatous, necrotizing inflammation with eosinophilia
5%
9/185
IgA immune complex deposition
0%
0/185
Non-granulomatous, necrotizing inflammation
4%
8/185
“Onion-skin” appearance of the arteriolar wall
3%
5/185
Select Answer to see Preferred Response
This elderly female patient with unilateral headache, jaw claudication, and painless transient vision loss most likely has temporal giant cell arteritis, which features focal granulomatous inflammation on pathology. Temporal giant cell arteritis is a large-vessel vasculitis that is typically seen in female patients over 50 years of age and presents with headache in the temporal region, jaw claudication, and occasionally visual symptoms, such as amaurosis fugax (transient vision loss). Giant cell arteritis should always be considered in the differential diagnosis of a patient with new-onset headache in elderly patients with an elevated erythrocyte sedimentation rate (ESR). Diagnosis is confirmed with a temporal artery biopsy, which shows hallmark histological features of vessel thickening with a narrowed lumen, granulomatous inflammation, and presence of giant cells (Illustration A). Permanent vision loss may occur in up to 20% of patients if prompt initiation of treatment with corticosteroids is not performed. Illustration A shows a temporal artery biopsy specimen from a patient with giant cell arteritis, with the arrow pointing to a giant cell. Incorrect Answers: Answer 2: Granulomatous, necrotizing inflammation of the arterial wall with eosinophilia is characteristic of eosinophilic granulomatosis with polyangiitis, a small-vessel vasculitis that presents with asthma, sinusitis, skin nodules or purpura, and peripheral neuropathy. Answer 3: IgA immune complex deposition in the arterial wall is characteristic of IgA vasculitis, which is most commonly seen in children and presents with a triad of skin findings (palpable purpura), arthralgias, and abdominal pain. Answer 4: Non-granulomatous, necrotizing inflammation of the arterial wall is characteristic of microscopic polyangiitis, a vasculitis which commonly involves the lung, kidneys, and skin. Answer 5: “Onion-skin” appearance of the arterial wall is characteristic of hyperplastic arteriosclerosis, a condition most commonly associated with hypertensive emergency. Bullet Summary: Focal granulomatous inflammation with giant cells is seen on pathology in giant cell arteritis.
4.4
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