A 76-year-old woman comes to the office due to headache. For the last week, she has had a dull, right-sided headache associated with malaise; her symptoms are unlike any headache she has had in the past. Medical history includes type 2 diabetes mellitus, hypertension, and coronary artery disease. The patient smokes 2 packs of cigarettes a day and does not drink alcohol. Vital signs are normal. Examination shows normal extraocular movement and funduscopic inspection. There is normal, pain-free range of motion at the cervical spine and no focal cervical or cranial tenderness. Cranial nerve examination is normal. Cardiac examination is also normal, and the feet are warm and dry. Erythrocyte sedimentation rate is 55 mm/hr (normal: ≤29). Which of the following is the most appropriate next step in management of this patient?

Question

A 76-year-old woman comes to the office due to headache.  For the last week, she has had a dull, right-sided headache associated with malaise; her symptoms are unlike any headache she has had in the past.  Medical history includes type 2 diabetes mellitus, hypertension, and coronary artery disease.  The patient smokes 2 packs of cigarettes a day and does not drink alcohol.  Vital signs are normal.  Examination shows normal extraocular movement and funduscopic inspection.  There is normal, pain-free range of motion at the cervical spine and no focal cervical or cranial tenderness.  Cranial nerve examination is normal.  Cardiac examination is also normal, and the feet are warm and dry.  Erythrocyte sedimentation rate is 55 mm/hr (normal: ≤29).  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d558_3f9f_bc81_693cd6b0cdba_MD0003_00 This patient has clinical features that strongly suggest giant cell (temporal) arteritis (GCA), including age ≥50, a new headache associated with malaise, and an elevated erythrocyte sedimentation rate (ESR). Other common features include fever, jaw claudication, and tenderness over the temporal artery. GCA is frequently associated with polymyalgia rheumatica, which is characterized by achy pain and stiffness in the proximal shoulder and hip girdles; however, this is absent in approximately half of patients. Untreated GCA can rapidly lead to permanent vision loss due to ischemic optic neuropathy (ION). Standard initial treatment includes intermediate- to high-dose oral glucocorticoids (eg, prednisone 40-60 mg daily); patients with early ocular symptoms (eg, amaurosis fugax, vision blurring) should be admitted to the hospital urgently for pulse-dose parenteral glucocorticoids (eg, methylprednisolone 500-1,000 mg daily). Because patients with GCA require long-term (ie, >1-year) glucocorticoid therapy, which itself carries significant risks, the diagnosis should be confirmed as soon as possible with temporal artery biopsy. However, to minimize the risk of ION, treatment should be initiated immediately and should not be delayed while awaiting biopsy results (Choice A). Biopsy findings remain detectable up to 30 days after the start of treatment. (Choice B) Noncontrast head CT scan is indicated for assessment of intracranial bleeding (eg, subarachnoid hemorrhage, subdural hematoma). Subarachnoid hemorrhage presents with a severe thunderclap headache, whereas subdural or epidural hematomas usually occur in the setting of trauma. Subacute headache with malaise and elevated ESR is most consistent with GCA. (Choice C) Nonsteroidal anti-inflammatory drugs are not effective for GCA and should not be considered an alternative to glucocorticoid therapy. (Choice E) Isolated polymyalgia rheumatica with no features of GCA (eg, headache, temporal artery tenderness) can be diagnosed with laboratory inflammatory markers (ie, ESR, C-reactive protein) and treated with glucocorticoids without further workup. However, this patient's presentation with headache is concerning for GCA and warrants temporal artery biopsy. Educational objective: Giant cell arteritis is characterized by new headache and elevated inflammatory markers in patients age ≥50; complications include permanent vision loss. Definitive diagnosis can be obtained with temporal artery biopsy; however, to reduce the risk of blindness, treatment with systemic glucocorticoids should not be delayed while awaiting biopsy results. References: Primary care vasculitis: polymyalgia rheumatica and giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/29759126)

A 76-Year-Old Woman Comes to the Office Due to Headache