What are the physical symptoms of giant cell arteritis?

Physical Symptoms of Giant Cell Arteritis

Giant cell arteritis presents with a constellation of cranial, systemic, and vascular manifestations that include headache, jaw claudication, temporal artery abnormalities, visual symptoms, constitutional features, and large vessel involvement—with no single symptom sufficient to confirm or exclude the diagnosis. 1, 2

Cranial Manifestations

Temporal Artery Abnormalities

• Temporal artery thickening is one of the strongest physical findings (positive LR 4.70), presenting as a cord-like, palpable vessel 1, 2
• Loss of temporal artery pulse occurs with a positive LR of 3.25, indicating significant diagnostic value 1, 2
• Temporal artery tenderness has a positive LR of 3.14 and is commonly present on palpation 1, 2
• Any temporal artery abnormality (thickening, nodularity, tenderness, reduced pulse, or pulselessness) collectively has a positive LR of 3.14 1

Headache and Scalp Symptoms

• New-onset headache is the most common presenting symptom, though it has limited diagnostic accuracy when considered alone (LR not statistically significant) 1, 2
• Scalp tenderness occurs frequently with a positive LR of 3.14, though it is not specific enough to rule in disease independently 1, 2

Jaw and Oral Symptoms

• Jaw claudication is one of the strongest clinical predictors with a positive LR of 4.90, manifesting as pain with chewing or prolonged talking 1, 2

Visual Manifestations

Ocular Complications

• Permanent visual loss occurs in 14-18% of patients and represents the most feared complication 3, 2, 4
• Anterior ischemic optic neuropathy (AION) has a positive LR of 2.15 and is the most common cause of vision loss 1
• Transient visual symptoms including diplopia (positive LR 1.72), blurred vision, and amaurosis fugax may herald permanent vision loss 1, 4
• Relative afferent pupillary defect (RAPD) may be present on examination 1
• Central retinal artery occlusion occurs less commonly (positive LR 1.49) 1

Less Common Ischemic Complications

• Stroke, cranial nerve palsy, and scalp necrosis can occur as ischemic complications 3

Systemic and Constitutional Symptoms

General Features

• Constitutional symptoms including fever/pyrexia, malaise, weight loss, and night sweats are common but have limited diagnostic specificity 1, 5
• Fever has a positive LR of only 1.29, making it poorly discriminatory 1

Musculoskeletal Manifestations

• Polymyalgia rheumatica (PMR) symptoms occur frequently, with previous PMR diagnosis having a positive LR of 2.07 1, 2
• Proximal muscle pain and stiffness characteristic of PMR may be the presenting symptom 6, 5

Large Vessel Involvement

Peripheral Vascular Manifestations

• Limb claudication has the highest positive LR of 6.01, making it the strongest clinical predictor when present 1, 2
• Absent or diminished peripheral pulses indicate large vessel involvement 1, 2
• Arterial stenosis, aneurysms, and dilatation can occur in the aorta and its branches 1, 3

Laboratory Abnormalities as Physical Correlates

Inflammatory Markers

• ESR >100 mm/h has a positive LR of 3.11 1, 2
• ESR >40 mm/h is present in >95% of cases, with absence having a negative LR of 0.18 1, 2
• CRP ≥2.5 mg/dL is elevated in most cases, with absence having a negative LR of 0.38 1, 2
• Platelet count >400 × 10³/μL has a positive LR of 3.75 1, 3, 2
• Anemia is common with a positive LR of 1.27 1

Respiratory Manifestations (Uncommon)

• Chronic cough occurs in <10% of cases, typically harsh and nonproductive 3, 7
• May relate to isolated small airways disease, lung nodules, or vasculitis of pulmonary arteries 7

Critical Clinical Pitfalls

The absence of classic cranial features does not exclude GCA—diagnosis can be delayed in patients without headache or temporal artery abnormalities 1. Headache and scalp tenderness, despite being considered "classic" features, have limited diagnostic utility because they occur commonly in both GCA and non-GCA patients 1. No single clinical or laboratory feature is sufficient to rule in or rule out the disease; combinations of symptoms must guide the decision to pursue further investigation with vascular imaging or temporal artery biopsy 1. The presence of jaw claudication or limb claudication should prompt immediate evaluation given their high positive likelihood ratios 1, 2.