Q&A Medicine>>>>>Rheumatology
Question 21#

A 60-year-old woman presents with vision loss in her left eye and worsening headache. The patient has had a “baseline” headache on the left side for the last 3 months, but it has worsened over the past few days. Her past medical history is significant for diabetes, hyperlipidemia, and hypertension. She has a temperature of 37°C, blood pressure of 148/76 mmHg, and heart rate of 76 beats per minute. Physical examination reveals complete loss of vision in her left eye. Laboratory values reveal an ESR of 82 mm/h.

Which of the following is the best next step in management of this patient’s condition?

A. Temporal artery biopsy
B. Low-dose corticosteroids
C. Sumatriptan and supplemental oxygen
D. High-dose corticosteroids

Correct Answer is D

Comment:

High-dose corticosteroids. This patient is presenting with signs, symptoms, and laboratory values consistent with a diagnosis of giant cell arteritis (GCA), also known as temporal arteritis. This is a chronic vasculitis of medium and large vessels that often presents with loss of vision, headaches, and an elevated ESR. Physical examination sometimes reveals diminished pulses and abnormal fundoscopic findings. In order to prevent permanent blindness, a patient with suspected GCA should immediately undergo treatment with high-dose intravenous methylprednisolone as up to 50% of untreated patients will go on to develop blindness. (B) Low-dose oral corticosteroids would be given as a taper over several months following administration of high-dose corticosteroids in the acute setting of GCA. (A) Temporal artery biopsy is certainly indicated here in order to confirm the diagnosis of GCA. However, therapy should not be delayed while waiting for results of the biopsy. (C) Sumatriptan and supplemental oxygen would be indicated in the setting of acute migraine or cluster headache. This patient has a headache, but her associated symptoms and elevated ESR make GCA the likely diagnosis.