A 76-year-old man is brought to the emergency department due to intermittent blurry vision for the past 3 days. Today he feels as though "a curtain is falling in front" of his right eye. Family members have been worried about a decline in his general health over the past month as he has been eating less and has been less socially active. The patient has "felt down" for several weeks and has had headaches, a decreased appetite, and difficulty eating solid foods due to pain while chewing.
Medical history is notable for hypertension, intermittent atrial fibrillation, mild dementia, and a transient ischemic episode 6 months ago. A carotid ultrasonogram performed 6 months ago showed 40% stenosis in the carotid arteries bilaterally. Current medications include triamterene, hydrochlorothiazide, dabigatran, atorvastatin, and aspirin. The patient retired from coal mining 20 years ago and lives alone in an apartment. He does not use tobacco but drinks alcohol on social occasions.
Blood pressure is 142/78 mm Hg, and pulse is 78/min and regular. On physical examination, the pupils are reactive to light. Visual acuity is 20/40 in the left eye and 20/100 in the right eye. There is no scalp tenderness. The oropharyngeal mucosa is dry and no lymph nodes are palpable. Cardiopulmonary examination is unremarkable. The abdomen is soft and there is no organomegaly. Upper and lower limb deep tendon reflexes are 2+ bilaterally. Muscle power is 5/5 in all extremities.
Laboratory results are as follows:
Chest x-ray reveals no abnormalities.
Which of the following is the most appropriate next step in management of this patient's condition?

Question

A 76-year-old man is brought to the emergency department due to intermittent blurry vision for the past 3 days.  Today he feels as though "a curtain is falling in front" of his right eye.  Family members have been worried about a decline in his general health over the past month as he has been eating less and has been less socially active.  The patient has "felt down" for several weeks and has had headaches, a decreased appetite, and difficulty eating solid foods due to pain while chewing.
Medical history is notable for hypertension, intermittent atrial fibrillation, mild dementia, and a transient ischemic episode 6 months ago.  A carotid ultrasonogram performed 6 months ago showed 40% stenosis in the carotid arteries bilaterally.  Current medications include triamterene, hydrochlorothiazide, dabigatran, atorvastatin, and aspirin.  The patient retired from coal mining 20 years ago and lives alone in an apartment.  He does not use tobacco but drinks alcohol on social occasions.
Blood pressure is 142/78 mm Hg, and pulse is 78/min and regular.  On physical examination, the pupils are reactive to light.  Visual acuity is 20/40 in the left eye and 20/100 in the right eye.  There is no scalp tenderness.  The oropharyngeal mucosa is dry and no lymph nodes are palpable.  Cardiopulmonary examination is unremarkable.  The abdomen is soft and there is no organomegaly.  Upper and lower limb deep tendon reflexes are 2+ bilaterally.  Muscle power is 5/5 in all extremities.
Laboratory results are as follows:
 Chest x-ray reveals no abnormalities.
Which of the following is the most appropriate next step in management of this patient's condition?

Quizplus · Accepted Answer

11ec193a_9663_72af_853d_f1140917d117_MD0002_00 This patient's presentation is highly concerning for giant cell arteritis (GCA) given his systemic symptoms (fatigue, loss of appetite), headaches, jaw claudication, amaurosis fugax (acute unilateral vision loss), normocytic anemia, and elevated erythrocyte sedimentation rate (ESR). Ophthalmology consultation and a temporal artery biopsy, which confirms the diagnosis, are required; however, high-dose systemic glucocorticoids (eg, prednisone) should be given immediately to prevent complications (eg, optic neuropathy causing blindness) while awaiting biopsy results. Low-dose aspirin is also recommended to reduce risk of cranial ischemic complications (eg, stroke). Early symptoms of GCA are often nonspecific, and elderly patients may not come for evaluation until visual symptoms develop. Jaw claudication (eg, pain with chewing), seen in up to 50% of cases, has high specificity for GCA; temporal artery swelling and tenderness are helpful findings, but many patients have no scalp tenderness. Although ESR elevation increases the likelihood of diagnosis, GCA and polymyalgia rheumatica (shoulder/neck/hip girdle aching and morning stiffness) can occur with a normal ESR (up to 20% of cases in some series). Conversely, although these conditions do not cause a rise in muscle enzyme (eg, creatine kinase) levels, elderly patients frequently have comorbid diagnoses or medications (eg, statins) causing elevations in these enzymes; therefore, a mildly elevated creatine kinase cannot be used to rule out GCA. (Choice A) If patients develop a thrombotic stroke while on aspirin, dipyridamole can be added. (Choices B and C) This patient has known carotid atherosclerosis and a recent transient ischemic attack. MR angiography is helpful in diagnosing carotid dissection and carotid stenosis, and carotid endarterectomy would be considered in a symptomatic man with >50% stenosis. Although carotid atherosclerosis can cause amaurosis fugax, this patient's constitutional symptoms, elevated ESR, and jaw claudication are more consistent with GCA; empiric glucocorticoid therapy is the most appropriate next step. (Choice E) Heparin would be beneficial for ophthalmic circulation in embolic stroke; however, this patient is already anticoagulated on dabigatran, and the systemic symptoms and jaw pain make GCA more likely than stroke. Educational objective: Clinical features of giant cell arteritis include systemic symptoms, headaches, jaw claudication, and amaurosis fugax. Inflammatory markers (eg, erythrocyte sedimentation rate) are usually elevated. Temporal artery biopsy is the preferred confirmatory test, but patients should be started on immediate high-dose glucocorticoids to prevent vision loss while awaiting biopsy results. __________ References: Low-dose aspirin and prevention of cranial ischemic complications in giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/15077317) Initiation of glucocorticoid therapy: before or after temporal artery biopsy? (http://www.ncbi.nlm.nih.gov/pubmed/15065613) Polymyalgia rheumatica and giant-cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/18640460)

A 76-Year-Old Man Is Brought to the Emergency Department Due