A 67-year-old man comes to the office due to a persistent headache and pain in the jaw when chewing food. For the past 2 months, he has been unable to eat "tough foods like steak because the pain makes it take too long to chew them." Medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Blood pressure is 130/70 mm Hg, and pulse is 76/min and regular. Physical examination is unremarkable. Appropriate therapy is immediately started, and an arterial biopsy is performed. Histopathology shows multinuclear giant cells and internal elastic membrane fragmentation. Prompt institution of therapy in this patient most likely reduces the risk of which of the following complications?

Question

A 67-year-old man comes to the office due to a persistent headache and pain in the jaw when chewing food.  For the past 2 months, he has been unable to eat "tough foods like steak because the pain makes it take too long to chew them."  Medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia.  Blood pressure is 130/70 mm Hg, and pulse is 76/min and regular.  Physical examination is unremarkable.  Appropriate therapy is immediately started, and an arterial biopsy is performed.  Histopathology shows multinuclear giant cells and internal elastic membrane fragmentation.  Prompt institution of therapy in this patient most likely reduces the risk of which of the following complications?

Quizplus · Accepted Answer

11ec160b_3a59_d5be_9249_93501400f2ac_MD0001_00 This patient with headache and jaw claudication has typical symptoms of giant cell (temporal) arteritis (GCA). GCA occurs almost exclusively in individuals age >50 and is characterized by granulomatous inflammation of the media with fragmentation of the internal elastic lamina, primarily in the arteries of the head and neck. About half of patients with GCA also have polymyalgia rheumatica, which presents with pain and stiffness in the shoulders and hips. Inflammatory markers (ie, erythrocyte sedimentation rate, C-reactive protein) have high sensitivity for GCA, but there are no specific serologic tests. The diagnosis is confirmed by temporal artery biopsy. GCA can cause severe ischemic optic neuropathy due to ophthalmic artery occlusion, which can lead to blindness if not treated promptly. Other optic complications of GCA include amaurosis fugax, central or branch retinal artery occlusion, and cerebral infarction leading to central visual field defects. GCA is therefore considered a medical emergency, and physicians should not wait for biopsy before starting glucocorticoid therapy (eg, prednisone, methylprednisolone). (Choice A) Acute angle-closure glaucoma causes vision loss associated with ocular pain, headache, and nausea. Examination findings include conjunctival erythema, corneal opacity, and a fixed, mid-dilated pupil. Risk factors include farsightedness (ie, hyperopia), anticholinergic drugs, and adrenergic agonists. (Choice C) Proliferative retinopathy (ie, neovascularization of the retina) is most commonly due to longstanding, uncontrolled diabetes. Although treatment of GCA with systemic glucocorticoids can raise blood glucose, untreated GCA does not cause proliferative retinopathy. (Choice D) Retinal detachment presents with floaters, flashing lights (photopsia), and progressive monocular vision loss. Risk factors for retinal detachment include prior eye trauma or surgery, nearsightedness (ie, myopia), age-related macular degeneration, and diabetic retinopathy. (Choice E) Retinal vein occlusion (RVO) presents with painless blurring of vision in a limited visual field (branch RVO) or entire eye (central RVO). Major risk factors include diabetes, hypertension, atherosclerotic disease, glaucoma, smoking, and obesity. (Choice F) Vitreous hemorrhage causes variable-severity monocular vision loss; examination shows loss of the red reflex and obscuration of the retina. Major causes include ocular injury, anticoagulation, diabetic retinopathy, and intraocular tumors. Educational objective: Giant cell arteritis (GCA) is characterized by granulomatous inflammation of the media with fragmentation of the internal elastic lamina most often affecting the medium and small branches of the carotid artery. Ischemic optic neuropathy with irreversible blindness is a potential complication of GCA; therefore, patients with suspected GCA require immediate glucocorticoid therapy. __________ References: Pathology of ischemic optic neuropathy. (http://www.ncbi.nlm.nih.gov/pubmed/28029908)

A 67-Year-Old Man Comes to the Office Due to a Persistent