A 45-year-old woman presents to her physician complaining of 3 weeks of fevers and pain in her knees and ankles. She also states that she often wakes up during the night drenched in sweat. On examination, her temperature is 38.1°C, blood pressure is 123/56 mmHg, heart rate is 78 beats per minute, and oxygen saturation is 98% on room air. She has 1+ radial pulses, 2+ dorsalis pedis pulses, and mild decreased range of motion in her bilateral knees secondary to pain.
Which of the following is the most appropriate next step in management?
A. MethotrexatePrednisone. The patient’s age and symptoms are consistent with Takayasu arteritis, a large vessel vasculitis defined by granulomatous thickening of the aortic arch and proximal great vessels. Corticosteroids are the preferred treatment. (A) Methotrexate is a treatment for rheumatoid arthritis, which may present with arthritis and low-grade fevers; however, this would not explain the discrepancy between her upper and lower extremity pulses. (C) Endovascular stent placement would be considered if there was concern for coarctation of the aorta. However, coarctation of the aorta (associated with Turner syndrome) has the opposite findings from our patient, showing a decreased blood pressure in the lower extremities with hypertension in the upper extremities. There is also delayed femoral pulses (brachial–femoral delay). (D) Ceftriaxone would be an appropriate treatment for gonococcal arthritis; however, this diagnosis would not produce the difference in upper and lower extremity pulses.