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Question 14#

A 75-year-old man complains of headache. On one occasion he transiently lost vision in his right eye. He also complains of aching in the shoulders and neck. There are no focal neurologic findings. Carotid pulses are normal without bruits. Laboratory data show a mild anemia. Erythrocyte sedimentation rate (ESR) is 85. Which of the following is the best approach to management?

A) Begin glucocorticoid therapy and arrange for temporal artery biopsy
B) Schedule temporal artery biopsy and begin corticosteroids based on biopsy results and clinical course
C) Schedule carotid angiography
D) Follow ESR and consider further studies if it remains elevated
E) Start aspirin and defer any invasive studies unless further symptoms develop

Correct Answer is A

Comment:

Headache and transient unilateral visual loss (amaurosis fugax) in this elderly patient with polymyalgia rheumatica (PMR) symptoms suggest a diagnosis of temporal arteritis. The erythrocyte sedimentation rate is high in almost all cases. Temporal arteritis occurs most commonly in patients older than 55 and is highly associated with polymyalgia rheumatica. However, only about 25% of patients with PMR have giant cell arteritis. Older patients who complain of diffuse myalgias and joint stiffness, particularly of the shoulders and hips, should be evaluated for PMR with an ESR. Unilateral visual changes or even permanent visual loss may occur abruptly in patients with temporal arteritis. Biopsy results should not delay initiation of corticosteroid therapy. Biopsies may show vasculitis even after 14 days of glucocorticoid therapy. Delay risks permanent loss of sight. Once an episode of loss of vision occurs, workup must proceed as quickly as possible. Treatment for temporal arteritis requires relatively high doses of steroids, beginning with prednisone at 40 to 60 mg per day for about 1 month with subsequent tapering. Aspirin should be added because it decreases the risks of vascular occlusions but is not sufficient alone. The treatment for polymyalgia rheumatica without concomitant temporal arteritis requires much lower doses of steroids, in the range of 10 to 20 mg per day of prednisone. Carotid disease can cause amaurosis fugax but would not account for the headache, polymyalgia rheumatica, or the elevated sedimentation rate.