Review Question - QID 103085

This elderly woman with headache and visual changes has a presentation concerning for giant cell arteritis. Patients with suspected giant cell arteritis should be treated immediately with high dose steroids to prevent further visual loss.

Giant cell (also referred to as temporal) arteritis is a subacute granulomatous inflammation of large vessels, most commonly, the branches of the external carotid artery. Inflammation of these vessels may lead to partial or complete occlusion. Involvement of the ophthalmic artery is common and can lead to visual changes and eventual blindness. A minority of patients with giant cell arteritis also have involvement of the aortic arch and are at increased risk for thoracic aortic aneurysm. It is most common in women older than 50 years of age. Giant cell arteritis is associated with polymyalgia rheumatica, which is characterized by proximal muscle pain and stiffness as seen in this woman. Inflammatory markers such as the ESR and C reactive protien are elevated in these patients, characteristically with ESR greater than 100 mm/hr. Temporal artery biopsy should be obtained urgently if giant cell arteritis is suspected. However, temporal artery biopsy should not delay the administration of high dose steroids. Treatment for suspected giant cell arteritis must be initiated prior to confirmation with biopsy.

Ciofalo et. al review the pathophysiology, diagnosis, and management of giant cell arteritis. They discuss the features that distinguish giant cell arteritis from other causes of headache, and recommend that patients with suspected giant cell arteritis be treated immediately with high dose steroids prior to biopsy.

Incorrect Answers:
Answer 1: Ibuprofen would be appropriate for a patient with a suspected tension or migraine type headache. However, this patient's history of joint pain and stiffness, visual changes and elevated inflammatory markers make giant cell arteritis a more likely diagnosis.

Answer 3: Non-contrast CT scan of the head would be appropriate if subarachnoid hemorrhage was suspected as the cause of this patient's headache. However, a headache that is sudden in onset with associated neck stiffness would be expected.

Answer 4: Supplemental oxygen and sumatriptan would be appropriate for management of a suspected cluster headache. These headaches are typically located in the periorbital region with associated lacrimation or rhinorrhea, and are more common in younger male patients who smoke.

Answer 5: Temporal artery biopsy would be indicated in this patient to confirm the diagnosis of giant cell arteritis. However, biopsy should not delay the administration of steroids, as this condition can result in blindness if not treated promptly.

Bullet Summary:
Patients with confirmed or suspected giant cell arteritis should be treated with high dose steroids prior to confirmation of the diagnosis with temporal artery biopsy.