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?
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.
A 37-year-old man presents with low back pain. He also endorses morning stiffness of his lower back. Both the pain and the stiffness improve with exercise. The patient has also noted bloody diarrhea over the past 2 weeks, but his friend told him that since he often weight-lifts, it is most likely secondary to hemorrhoids. Physical examination reveals pain on palpation over the sacroiliac joints. Dermatologic examination confirms several discrete violaceous nodules that are painful to palpation over the bilateral shins. Fecal occult blood test is positive and laboratory values reveal a hemoglobin level of 10.1 g/dL and high p-ANCA titers.
Which of the following is the most likely underlying disease contributing to this patient’s symptoms?
Ulcerative colitis. This patient is presenting with signs and symptoms consistent with an underlying inflammatory bowel disease (IBD), most likely ulcerative colitis. The acute onset of bloody diarrhea in combination with anemia and positive fecal occult blood testing in the setting of his relatively young age lend credence to the diagnosis. This patient is also demonstrating extraintestinal manifestations of ulcerative colitis, including erythema nodosum and arthritis (similar in presentation to ankylosis spondylitis). p-ANCA is positive in high titers in ulcerative colitis, as seen with this patient. (A) Celiac disease is an autoimmune disease typified by malabsorption. Testing reveals anti-endomysial antibodies and anti-transglutaminase antibodies. Skin findings include dermatitis herpetiformis. (B) Reactive arthritis is characterized by nongonococcal urethritis, conjunctivitis, and arthritis. (D) Giardia lamblia infection causes a foul-smelling steatorrhea secondary to malabsorption. Bloody diarrhea is not present.
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