Mrs. Thompson is a 71-year-old female presenting to the ED with several weeks of progressively worsening headaches, jaw pain, and blurry vision.
History of Present Illness
Progressive headaches, particularly those worse in the morning or when lying down, or associated with focal neurological deficits (e.g., visual changes, weakness), are red flags for a potential brain tumor. Mrs. Thompson’s new-onset visual blurring and persistent headaches raise concern for a possible intracranial mass, although her symptoms raise a clinical suspicion for another etiology.
Migraines are often associated with visual disturbances, but the red flag here would be the new onset of such symptoms at an advanced age, or if they are more severe or prolonged than her usual migraines.
While tension-type headaches are typically benign, red flags would include new onset in older age, especially over 50, severe intensity, or an atypical pattern of headache. Mrs. Thompson’s unilateral headache, localized temporal tenderness, and associated jaw pain are not typical of tension-type headaches, suggesting a more concerning secondary cause.
A history of recent head trauma is a red flag for post-traumatic headache. Mrs. Thompson denies any head trauma, making this diagnosis less likely.
This presentation is concerning for temporal arteritis, a condition typically seen in patients over the age of 50 and associated with severe, localized headaches and scalp tenderness, often accompanied by symptoms such as jaw claudication and visual disturbances. Temporal arteritis is an inflammatory disease affecting the large and medium-sized arteries, with the temporal artery being commonly involved. The clinical diagnosis can be supported using criteria that assess systemic inflammation markers such as an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), both of which are typically raised in active cases. In this scenario, Mrs. Thompson presents with an ESR of 70 mm/hr and CRP of 25 mg/L, adding clinical support to the suspicion of temporal arteritis. Immediate consideration for a temporal artery biopsy remains the gold standard for definitive diagnosis, despite the potential risks associated with the procedure. The prompt initiation of corticosteroid therapy is often required to prevent serious complications, including irreversible vision loss.
Important Clues: Mrs. Thompson, aged 71, has been experiencing progressively worsening headaches, primarily localized to her left temple, accompanied by jaw pain and transient episodes of blurred vision. These symptoms, alongside scalp tenderness exacerbated by combing her hair and chewing, raise the suspicion for temporal arteritis. Her recent escalation in headache severity and the visual symptoms are particularly concerning given the risk of irreversible complications such as vision loss associated with this condition.
Approximately six weeks ago, Mrs. Thompson began experiencing intermittent headaches described as severe, throbbing, and localized predominantly over her left temple. Initially, she attributed these headaches to stress and tension and attempted to manage them with over-the-counter analgesics. However, despite these measures, her headaches persisted and gradually increased in intensity and frequency over the subsequent weeks.
Around four weeks ago, Mrs. Thompson began noticing tenderness over the left temporal region, particularly exacerbated by combing her hair or wearing glasses. Concurrently, she developed new-onset jaw pain, characterized as a dull ache exacerbated by chewing, especially during meals. Additionally, she reported experiencing transient episodes of visual blurring in her left eye, lasting for a few minutes at a time and resolving spontaneously. She denies any diplopia, photophobia, or changes in visual field.
Concerned about the persistence and nature of her symptoms, Mrs. Thompson sought medical attention from her primary care physician, who initially suspected tension headaches and prescribed acetaminophen. However, despite adhering to this regimen, her symptoms failed to improve, prompting further evaluation.
Over the past week, Mrs. Thompson’s headaches have become increasingly debilitating, interfering with her daily activities, and significantly impacting her quality of life. She has also noticed a progressive decline in her appetite and energy levels, accompanied by mild nausea but no vomiting. She denies any fevers, night sweats, or unintentional weight loss. There is no history of recent head trauma, scalp lesions, or changes in her usual medication regimen.
In addition to her headaches and jaw pain, Mrs. Thompson reports occasional episodes of fatigue and malaise, which she attributes to her ongoing discomfort and disrupted sleep patterns. She denies any facial weakness, dysarthria, dysphagia, or changes in taste sensation.
Mrs. Thompson has attempted various self-care measures, including adequate hydration, rest, and relaxation techniques, but these interventions have provided minimal relief. Concerned about the progressive nature of her symptoms and the impact on her daily functioning, she decided to seek further evaluation and management by a specialist.
Review of Systems
General | Worsening fatigue, malaise, and mild nausea. |
Head |
Headaches localized to temple, worsened with chewing. No positional difference or cervical component. No facial pain or pressure. Positional headaches that improve when lying down are typical of a CSF leak. Additional findings include nausea, and vomiting. Mrs. Thompson does not report any of these symptoms with her headache, which points toward other etiologies. Typical sinusitis would present with facial pain, pressure, and purulent discharge. Mrs. Thompson’s temporal tenderness and visual symptoms are not typical of sinusitis, making this diagnosis less likely. Persistent symptoms despite typical treatment, especially with visual disturbances, are red flags warranting further evaluation. |
Eyes | Transient episodes of blurred vision in the left eye. No auras or other visual disturbances. |
Ears, Nose, Throat | No hearing loss, nasal congestion, rhinorrhea, tearing or sore throat. |
Cardiovascular | No chest pain, palpitations, or shortness of breath. |
Respiratory | No cough, wheezing, or difficulty breathing. |
Gastrointestinal | No nausea, vomiting, or changes in bowel habits. |
Musculoskeletal | No joint pain or swelling. |
Neurological | No numbness, weakness, or difficulty with speech or balance. |
Skin | No rashes or lesions. |
Endocrine | No excessive thirst or urination. |
Psychiatric | No changes in mood or sleep patterns. |
Constitutional |
No night sweats or chills. Clinical Clues: The presentation includes worsening fatigue and malaise, which are suggestive of systemic involvement, common in inflammatory or autoimmune conditions. The localized headaches at the temple, which worsen with chewing, are particularly indicative of temporal arteritis, especially given the specific location and associated symptoms. Furthermore, transient episodes of blurred vision in the left eye raise concerns about ocular involvement, a critical aspect of temporal arteritis that can lead to irreversible vision loss if not promptly addressed. The absence of symptoms such as nasal congestion, rhinorrhea, or sore throat helps rule out sinusitis and other ENT-related conditions, narrowing the differential diagnosis. Additionally, the lack of neurological symptoms like numbness, weakness, or balance issues is crucial in excluding conditions such as strokes or demyelinating diseases. Together, these clues strongly point towards temporal arteritis as a potential diagnosis, underscoring the need for immediate evaluation and management to prevent serious complications. |
Medications and Supplements
Medication Headaches are a common side effect of nitroglycerin and other vasodilators. There’s no mention of Mrs. Thompson using such medications, so this cause is unlikely unless newly prescribed. |
Dosage |
---|---|
Amlodipine | 5 mg daily |
Acetaminophen The chronic use of analgesics leading to headache is a key feature of a medication-overuse headache, but Mrs. Thompson’s history lacks this pattern of chronic medication use, and instead suggests an evolving, severe headache with systemic symptoms. |
325 mg PRN |
Past Medical History
Medical History | Hypertension, managed with Amlodipine 5 mg daily. Osteoarthritis managed with acetaminophen PRN. |
Surgeries | None reported. |
Hospitalizations | None reported. |
Allergies | No known drug allergies reported. |
Screening Tests | Normal colonoscopy at age 68. Normal pap smear at age 65 with negative HPV screening. Normal mammography at age 67. |
Immunizations | Up to date with annual influenza and COVID-19 vaccinations. PCV13 administered at age 65. PPSV23 administered one year after PCV13. Completed two-dose Recombinant Zoster Vaccine (RZV) series at age 60. Most recent Tdap booster at age 70. |
Last Contact | Last seen two months ago for routine evaluation at age 71. |
Family History
Relation | Notes |
---|---|
Father | Deceased at age 75 due to myocardial infarction. |
Mother | Alive, aged 98, with a history of hypertension. |
Siblings | One brother, aged 70, with a history of diabetes mellitus. |
Children | Two adult children, both in good health. |
Grandparents | Limited information available; maternal grandmother had a history of stroke. |
Social History
Occupation | Retired schoolteacher. Currently volunteers at the local library twice a week, helping with reading programs for children. |
Education | Bachelor’s degree in education. |
Alcohol | Occasional drinker, usually when attending social gatherings or events. |
Smoking |
Never smoked. Mrs. Thompson has never smoked, which makes nicotine-related headaches less likely. However, exposure to other stimulants could still be a concern if there were any in her environment. |
Drugs |
Denies any illicit drug use. Since there is no indication of opioid use in Mrs. Thompson’s history, opioid withdrawal is unlikely. However, if she were taking opioids for pain management and abruptly stopped, headaches could be a withdrawal symptom. |
Caffine |
Enjoys one cup of tea in the morning. Headaches that develop after stopping or reducing caffeine intake could indicate caffeine withdrawal. Mrs. Thompson enjoys one cup of tea daily; if she had recently stopped or decreased her caffeine intake, and her headaches coincided with this change, it would be more consistent with caffeine withdrawal as the diagnosis. |
Diet | Balanced diet with three meals a day, emphasizing fruits, vegetables, and lean proteins. |
Exercise | Regular walks in the neighborhood, averaging 30 minutes per day. |
Hobbies | Enjoys reading, gardening, and attending book club meetings. |
Stress | Minimal stress reported, with retirement providing a more relaxed lifestyle. |
Travel | No recent travel. |
Sexual | Married for 40 years; in a monogamous relationship with her husband. |
Insurance Status |
Primary Insurance: Medicare Part B, Prescription Coverage: Medicare Part D for prescription medications. Under Original Medicare, beneficiaries have the flexibility to see any specialist without network restrictions, which is crucial for timely diagnosis and treatment. With supplemental Medigap insurance, out-of-pocket costs can be minimized, as it covers the 20% coinsurance and additional expenses for diagnostics and medications. |
Physical Exam
General | Appears well-nourished and in no acute distress. |
Head and Neck |
Tenderness noted over the left temple with palpation. Temporal prominence appreciated. No scalp lesions or erythema. No cervical lymphadenopathy or nuchal rigidity noted. Fever, neck stiffness, and altered mental status are classic red flags for meningitis. Mrs. Thompson denies fevers and nuchal rigidity, and there is no mention of altered mental status, making this diagnosis less likely. However, any sudden worsening of symptoms or development of these signs would warrant immediate investigation. |
Ophthalmologic Exam | Visual acuity decreased in the left eye, noted as 20/100, compared to normal limits in the right eye. No conjunctival injection or discharge. Fundoscopic examination reveals a mild optic disc edema in the left eye without evidence of hemorrhages or exudates. Extraocular movements intact, no nystagmus or ptosis observed. |
Cardiovascular | No carotid bruits appreciated bilaterally. No jugular venous distention. Heart sounds normal, no murmurs, rubs, or gallops appreciated. |
Respiratory | Normal respiratory effort, no accessory muscle use. Clear breath sounds bilaterally, no wheezing, crackles, or rhonchi appreciated. Symmetric chest expansion. |
Abdominal | Abdomen soft and non-tender to palpation. No hepatosplenomegaly appreciated. Bowel sounds present in all quadrants. |
Neurological |
Cranial nerves II-XII intact. Normal tone and strength in all extremities. Sensation intact to light touch and proprioception. No focal neurological deficits appreciated. Given Mrs. Thompson’s symptoms and presentation, it is unlikely that she is experiencing an intracranial hemorrhage. Her symptoms are progressive and localized, such as headaches at the temple and jaw pain, are not characteristic of intracranial hemorrhages, which usually present suddenly and with severe “thunderclap” headaches. Furthermore, she lacks acute neurological deficits like altered mental status or focal weaknesses, commonly seen in hemorrhagic events. The absence of sudden onset, coupled with her specific visual disturbances and lack of relevant risk factors such as recent head trauma or anticoagulation use, further diminishes the likelihood of an intracranial hemorrhage. |
What is your differential at this point?
What else could be on your differential?
The presentation of headaches can be quite variable, and as such the differential can be extensive. Based on the diverse symptoms and potential causes, the etiology could be vascular, neurological, infectious/inflammatory or related to substance use or withdrawal. Other than temporal arteritis, other key diagnoses to consider include:
- Tension-type headache
- Migraine
- Cluster headache
- Medication-overuse headache
- Sinusitis
- Intracranial hemorrhage
- Meningitis
- Brain tumor
- Hypertension
- Cervicogenic headache
- Post-traumatic headache
- Cerebrospinal Fluid (CSF) Leak
- Alcohol use
- Sympathomimetics (e.g., nicotine)
- Caffeine withdrawal headache
- Opioid withdrawal
- Nitroglycerin
Ordering Diagnostics
Order Name |
---|
Lab Results
Lab | Result | Normal Range |
---|---|---|
ESR |
70 mm/hr |
0-25 mm/hr |
CRP Erythrocyte Sedimentation Rate (ESR) and C-reactive Protein (CRP) are essential but relatively nonspecific markers of inflammation, playing a crucial role in the diagnostic workup for Temporal Arteritis (TA). According to the 2022 American College of Rheumatology/EULAR classification criteria for TA, an ESR greater than 50 mm/hr or a CRP level of 10 mg/L or higher contributes significantly to the diagnosis, adding a score of +3. Elevated levels of ESR and CRP support the clinical suspicion of TA and help differentiate it from other potential causes of headache and systemic inflammation. Although these markers are nonspecific, their elevated levels are valuable in building a case for TA, especially when combined with other clinical findings. Conversely, normal levels of ESR and CRP are highly sensitive markers; one study (Parikh et al.) found that ESR in conjunction with CRP was 99% sensitive and can sometimes be used to rule out TA, particularly when clinical symptoms are ambiguous. The widespread availability, quick administration, and cost-effectiveness of ESR and CRP tests make them practical for initial screening and a critical part of the diagnostic process in suspected cases of temporal arteritis. |
25 mg/L |
< 10 mg/L |
CBC The Complete Blood Count (CBC), particularly with a focus on anemia, is an important tool in the diagnosis and management of Temporal Arteritis (TA). While TA itself is an inflammatory vasculitis, it is commonly associated with normochromic, normocytic anemia due to chronic inflammation. Monitoring the CBC can help identify anemia, which supports the clinical suspicion of TA when combined with other symptoms such as headaches, jaw claudication, and elevated inflammatory markers like ESR and CRP. |
WBC: 8.5 thousand/mm3 Hemoglobin: 11.0 g/dL Hematocrit: 34% Platelets: 400 thousand/mm3 |
WBC: 4-10 thousand/mm3 Hemoglobin: 13.2-16.6 g/dL for men, 11.6-15 g/dL for women Hematocrit: 41-50% for men, 36-44% for women Platelets: 140-370 thousand/mm3 |
CMP The Comprehensive Metabolic Panel (CMP) plays an important role in the diagnosis and management of Temporal Arteritis (TA), particularly when considering treatment options like tocilizumab. While CMP is not directly used to diagnose TA, it is crucial for assessing the overall health and organ function of the patient, which is especially important before initiating treatments that can have systemic effects. Tocilizumab, an IL-6 inhibitor, has been shown to be effective in reducing inflammation and the required dosage of corticosteroids in TA patients, but it also carries potential risks for liver toxicity and alterations in kidney function. Monitoring liver enzymes, renal function, and electrolyte levels through CMP is essential before and during tocilizumab treatment to ensure that the patient can safely tolerate the medication. Additionally, abnormalities detected in the CMP may indicate underlying conditions that could affect the management of TA, guiding clinicians to tailor treatment plans that minimize risk and optimize outcomes. |
Sodium: 140 mmol/L Potassium: 4.0 mmol/L Chloride: 102 mmol/L Bicarbonate: 25 mmol/L BUN: 15 mg/dL Creatinine: 0.9 mg/dL Glucose: 85 mg/dL Calcium: 9.2 mg/dL AST: 30 U/L ALT: 28 U/L Alkaline phosphatase: 85 U/L Total bilirubin: 0.8 mg/dL Total protein: 7.0 g/dL Albumin: 4.0 g/dL |
Sodium: 136-145 mmol/L Potassium: 3.5-5.1 mmol/L Chloride: 98-107 mmol/L Bicarbonate: 22-29 mmol/L BUN: 6-20 mg/dL Creatinine: 0.67-1.17 mg/dL Glucose: 70-99 mg/dL Calcium: 8.5-10.6 mg/dL AST: 0-40 U/L ALT: 0-41 U/L Alkaline phosphatase: 40-129 U/L Total bilirubin: <1.2 mg/dL Total protein: 6-8 g/dL Albumin: 3.5-5.2 g/dL |
TSH |
2.5 mIU/L |
0.4-4.0 mIU/L |
Free T4 Thyroid function tests are not indicated for diagnosing Temporal Arteritis (TA) since TA is unrelated to thyroid dysfunction. While these tests pose minimal physical risk, they add unnecessary costs without contributing valuable diagnostic information for TA. |
1.2 ng/dL | 0.8-1.8 ng/dL |
Lipid panel In Temporal Arteritis (TA), a lipid profile, which includes measurements of total cholesterol, LDL, HDL, and triglycerides, typically remains unaffected by the condition itself. TA is a systemic vasculitis that impacts large and medium-sized arteries but does not directly alter lipid metabolism. Therefore, lipid profile values usually stay within the patient’s baseline range and do not provide diagnostic information for TA. |
Total cholesterol: 160 mg/dL LDL: 110 mg/dL HDL: 50 mg/dL Triglycerides: 120 mg/dL |
Total cholesterol: < 200 mg/dL LDL: < 100 mg/dL HDL: > 40 mg/dL Triglycerides: 150 mg/dL |
ANA Ordering an autoimmune panel, which includes tests for conditions like systemic lupus erythematosus or rheumatoid arthritis, is not indicated in the diagnosis of Temporal Arteritis (TA) and could potentially cause harm by leading to diagnostic confusion. Although TA is an autoimmune condition, the markers assessed in an autoimmune panel, such as antinuclear antibodies (ANA) or rheumatoid factor (RF), are not relevant to the inflammatory processes involved in TA. |
Negative (1:20) | Negative (< 1:40) |
RF | Negative (10 U/mL) | Negative (< 15 IU/mL) |
Anti-CCP | Negative (5 U/mL) | Negative (< 20 U/mL) |
Anti-Smith | Negative | Negative |
Anti-Ro/SSA | Negative | Negative |
Anti-La/SSB | Negative | Negative |
Anti-dsDNA | Negative | Negative |
Anti-Scl-70 | Negative | Negative |
Anti-Jo-1 | Negative | Negative |
Imaging Results
Image/Procedure | Result |
---|---|
Temporal artery biopsy Temporal artery biopsy (TAB) remains a critical component in the diagnosis of Giant Cell Arteritis (GCA), as outlined in the 2022 American College of Rheumatology/EULAR classification criteria for GCA. These criteria emphasize the importance of specific clinical and laboratory findings in establishing a diagnosis, with TAB being one of the key diagnostic tools. The biopsy provides definitive histopathological evidence of vasculitis, essential for confirming the diagnosis and guiding appropriate treatment. |
Positive for inflammation and giant cells |
Temporal artery ultrasound Temporal artery ultrasound is emerging as a viable diagnostic alternative for Temporal Arteritis (TA), particularly useful in settings where temporal artery biopsy (TAB) might be delayed or inaccessible. According to the 2022 American College of Rheumatology/EULAR classification criteria for TA, a positive temporal artery ultrasound showing a halo sign contributes significantly to the diagnosis, adding a score of +5, which reflects its potential to expedite the diagnostic process in a non-invasive manner. |
Positive for halo sign |
CT head Neuroimaging techniques such as CT, MRI, and PET scans, while valuable in certain contexts, are generally not recommended as first-line diagnostic tools for Temporal Arteritis (TA). According to the 2022 American College of Rheumatology/EULAR classification criteria, these imaging modalities are not specifically highlighted for the initial diagnosis of TA. Although PET scans, for example, can detect FDG-PET activity throughout the aorta and other large vessels, contributing a score of +2 to the diagnostic criteria, they are more suited for assessing the extent of vascular involvement rather than for primary diagnosis. |
Normal (no acute findings) |
MRI brain | Normal (no acute findings) |
PET scan | FDG uptake in large arteries |
Lumbar puncture A lumbar puncture can be a valuable diagnostic tool in confirming certain types of headaches, particularly when conditions like meningitis, subarachnoid hemorrhage, or increased intracranial pressure are suspected. In these cases, analyzing the cerebrospinal fluid (CSF) can provide crucial information, such as the presence of infection, bleeding, or abnormal pressure, which directly guides diagnosis and treatment. |
Opening pressure: 10 cm H2O (normal: < 20 cm) Color: clear Cell count: 2 cells/ µL (normal: 0-5 cells/ µL) Protein: 24 mg/dL (normal: < 45 mg/dL) CSF:serum glucose: 0.6 (normal > 0.6) |
How did you do?
You spent a total of $
Those that are absolutely indicated to manage and treat the clinical scenario:
Labs | Imaging |
---|---|
ESR | Temporal artery biopsy |
CRP | |
CBC | |
CMP |
Those that are not indicated and would not change management but have minimal harm to patient:
Labs | Imaging |
---|---|
TSH | Temporal artery ultrasound |
Free T4 | |
Lipid panel |
Labs | Imaging |
---|---|
ANA | CT head |
RF | MRI brain |
Anti-CCP | PET scan |
Anti-Smith | Lumbar puncture |
Anti-Ro/SSA | |
Anti-La/SSB | |
Anti-dsDNA | |
Anti-Scl-70 | |
Anti-Jo-1 |
Takeaways
Temporal arteritis—also known as giant cell arteritis—is a critical condition primarily affecting older adults, characterized by inflammation of the large and medium arteries, notably the temporal arteries. is the most common form of systemic vasculitis in adults over the age of 50, with a higher prevalence in populations of Northern European descent. The overall prevalence of TA varies geographically, ranging from approximately 15 to 30 cases per 100,000 people aged 50 and older in the United States and Europe. Women are more commonly affected than men, with a female-to-male ratio of about 2:1. The morbidity associated with TA is significant, particularly due to its potential to cause irreversible vision loss. Up to 15-20% of patients with untreated TA may experience blindness, making early and accurate diagnosis crucial. The most feared complication is ischemic optic neuropathy, leading to sudden, painless vision loss, which can be permanent. Mortality in TA is generally low with timely treatment. This condition can lead to serious complications, such as irreversible vision loss, if not promptly diagnosed and treated. Temporal arteritis is not only a medical emergency but also a significant healthcare concern due to its potential for causing long-term disability.
Accurate diagnosis is essential for effective management and is typically confirmed through elevated inflammatory markers like ESR and CRP, as well as a temporal artery biopsy, which, according to the 2022 American College of Rheumatology/EULAR classification criteria, adds a significant diagnostic score when positive. Early intervention with corticosteroids remains the cornerstone of treatment, significantly reducing the risk of complications and improving outcomes. Newer treatments like tocilizumab, an IL-6 inhibitor, have also shown promise in managing symptoms and reducing the required dosage of corticosteroids, potentially decreasing side effects. In terms of high-value care, managing temporal arteritis effectively requires considering the cost and accessibility of treatments, including understanding insurance coverage, which can significantly impact patient access to medications like tocilizumab (which costs up to 360$ per dose). The cost of untreated temporal arteritis, both in terms of patient quality of life and potential for severe complications, underscores the importance of timely, evidence-based interventions. Balancing these factors requires thoughtful consideration of both traditional and newer therapeutic options, keeping in mind the financial implications for the healthcare system and the patient. Practitioners must consider patient preferences, insurance coverage, and quality of life, ensuring decisions are tailored to individual clinical scenarios and patient needs. This approach emphasizes the importance of evidence-based practice and resource-conscious care to optimize both outcomes and expenditures, striving for the most effective yet cost-efficient treatment pathway.
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References
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Monti S, Schäfer VS, Muratore F, Salvarani C, Montecucco C, Luqmani R. Updates on the diagnosis and monitoring of giant cell arteritis. Front Med (Lausanne). 2023 Feb 23;10:1125141. doi: 10.3389/fmed.2023.1125141. PMID: 36910481; PMCID: PMC9995793.
Zarrin B, Pineles, SL, Kozak A, Al-Zubidi N, March de Ribot F, Ing EB, Barmettler A, Marcet MM, Wilson MW, Burkat CN. Giant Cell Arteritis. EyeWiki. 2024 Oct 1. URL: www.eyewiki.org/Giant_Cell_Arteritis. Accessed 16 October 2024.
Kawasaki A, Purvin V. Giant cell arteritis: an updated review. Acta Ophthalmol. 2009 Feb;87(1):13-32. doi: 10.1111/j.1755-3768.2008.01314.x. Epub 2008 Oct 7. PMID: 18937808.
Gordon LK, Levin LA. Visual loss in giant cell arteritis. JAMA. 1998 Jul 22-29;280(4):385-6. doi: 10.1001/jama.280.4.385. PMID: 9686559.
Miller NR. Visual manifestations of temporal arteritis. Rheum Dis Clin North Am. 2001 Nov;27(4):781-97, vi. doi: 10.1016/s0889-857x(05)70235-0. PMID: 11723764.
American College of Rheumatology. Giant Cell Arteritis. URL: https://rheumatology.org/patients/giant-cell-arteritis. Accessed 16 October 2024.
Salvarani C, Muratore F. Treatment of giant cell arteritis. UpToDate. 2024 Jan 17. URL: https://www.uptodate.com/contents/treatment-of-giant-cell-arteritis. Accessed 16 October 2024.
Fraser JA, Weyand CM, Newman NJ, Biousse V. The treatment of giant cell arteritis. Rev Neurol Dis. 2008 Summer;5(3):140-52. PMID: 18838954; PMCID: PMC3014829.
Régent A, Mouthon L. Treatment of Giant Cell Arteritis (GCA). J Clin Med. 2022 Mar 24;11(7):1799. doi: 10.3390/jcm11071799. PMID: 35407411; PMCID: PMC8999932.
Ponte C, Grayson PC, Robson JC, Suppiah R, Gribbons KB, Judge A, Craven A, Khalid S, Hutchings A, Watts RA, Merkel PA, Luqmani RA; DCVAS Study Group. 2022 American College of Rheumatology/EULAR classification criteria for giant cell arteritis. Ann Rheum Dis. 2022 Dec;81(12):1647-1653. doi: 10.1136/ard-2022-223480. Epub 2022 Nov 9. Erratum in: Ann Rheum Dis. 2023 Feb;82(2):e52. doi: 10.1136/annrheumdis-2022-223480corr1. PMID: 36351706.
Parikh M, Miller NR, Lee AG, Savino PJ, Vacarezza MN, Cornblath W, Eggenberger E, Antonio-Santos A, Golnik K, Kardon R, Wall M. Prevalence of a normal C-reactive protein with an elevated erythrocyte sedimentation rate in biopsy-proven giant cell arteritis. Ophthalmology. 2006 Oct;113(10):1842-5. doi: 10.1016/j.ophtha.2006.05.020. Epub 2006 Aug 1. PMID: 16884778.
This case was created by Umut Akova (Emory School of Medicine), Emma Williams (UCSD School of Medicine), and Dr. Amit Pahwa (Johns Hopkins University). Expert guidance was provided by Dr. Susan Lee (UCSD).
Disclaimer: This case is intended to be used for educational purposes only. Medical science is continuously evolving, and we try to keep up by reviewing our cases on a regular basis. This case was last reviewed in October 2024. If you notice an error or inconsistency with current guidelines, please let us know through the feedback function.
T
P
126/90
A new or severe headache associated with elevated blood pressure can be concerning for hypertensive emergency (usually >180/120). Mrs. Thompson’s blood pressure is mildly elevated but not in the range typically associated with hypertensive crises. However, continued monitoring is advised.
RR
O2 Sat