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Difficulty: MediumRheumatology and Immunology

A 72-year-old woman comes to the emergency department due to a severe right-sided headache, jaw pain when chewing food, and generalized aching in her shoulders and hips that has progressively worsened over the past 2 weeks. This morning, she experienced a 10-minute episode of painless, transient vision loss in her right eye that has since resolved. Her temperature is 37.8°C (100.0°F), blood pressure is 138/82 mm Hg, and pulse is 88/min. Physical examination reveals a tender, thickened, and non-pulsatile right temporal artery. She has limited active range of motion of her shoulders due to pain, but her muscle strength is normal. Laboratory studies show an erythrocyte sedimentation rate of 98 mm/hr. Which of the following is the most appropriate next step in management?

  1. Administration of high-dose intravenous methylprednisoloneAnswer
  2. B
    Administration of high-dose oral prednisone
  3. C
    Performance of a temporal artery biopsy
  4. D
    Carotid duplex ultrasonography
  5. E
    Initiation of intravenous vancomycin and ceftriaxone

Answer

Administration of high-dose intravenous methylprednisolone
This patient's presentation of a new right-sided headache, jaw claudication, polymyalgia rheumatica symptoms (shoulder and hip aching), and a significantly elevated erythrocyte sedimentation rate is classic for giant cell arteritis (GCA). The episode of amaurosis fugax (transient, painless vision loss) is a true medical emergency indicating threatened anterior ischemic optic neuropathy. To prevent permanent and irreversible blindness, immediate treatment with high-dose intravenous methylprednisolone is required. While a temporal artery biopsy is needed to confirm the diagnosis, treatment must never be delayed while waiting for the biopsy to be performed, as the biopsy will still yield accurate results for up to two weeks after initiating corticosteroid therapy.

Step-by-Step Solution

1
Identify the patient's underlying syndrome based on the clinical presentation.
The combination of new-onset localized headache, jaw claudication, thickened temporal artery, shoulder/hip stiffness (polymyalgia rheumatica), and highly elevated ESR in an older adult points definitively to giant cell arteritis (GCA).
Recognizing the systemic vasculitis is the first step to determining the urgency of intervention.
2
Evaluate for the presence of severe complications.
The patient reports a transient episode of painless vision loss (amaurosis fugax) in her right eye.
Visual symptoms in GCA indicate severe end-organ ischemia (anterior ischemic optic neuropathy) and drastically change the acute management strategy.
3
Select the appropriate pharmacotherapy based on complication status.
High-dose intravenous methylprednisolone must be administered immediately.
While oral prednisone is acceptable for GCA without ischemic complications, the presence of visual symptoms requires immediate intravenous therapy to prevent permanent and irreversible blindness. This must occur before any confirmatory testing.

Key Concept

Patients with suspected giant cell arteritis presenting with visual symptoms require immediate high-dose intravenous glucocorticoids to prevent irreversible vision loss; this treatment must precede definitive diagnosis via temporal artery biopsy.
Estimated Time:1m 30s
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Topics

Rheumatology and Immunology

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