Giant Cell Arteritis Manifesting as Area Postrema Syndrome: A Case Report

A 76-year-old man presenting with intractable nausea, vomiting and hiccoughs was found to have multiple watershed cerebellar strokes and a medullary stroke involving the area postrema. Imaging revealed extensive segmental stenoses involving the bilateral V2-V3 portions of the vertebral arteries. Mildly elevated inflammatory markers raised the possibility of giant cell arteritis (GCA). While the patient exhibited multiple neurological deficits, it was his intractable nausea, vomiting and hiccoughs - manifestations of area postrema syndrome (APS) - that prolonged his admission to a total of 81 days, limiting his ability to engage with rehabilitation. The diagnosis was confirmed with positron emission tomography (PET) imaging. Treatment with corticosteroids was initiated, followed by the introduction of weekly subcutaneous tocilizumab, an IL-6 inhibitor, ultimately resolving both his APS and its underlying cause, giant cell arteritis. To our limited knowledge, this is only the second case of area postrema syndrome caused by GCA in the literature.