Acutely ill 70 year old man with right temporal headache, fever and malaise

A 70-year-old man presents to the emergency department with a 3-day history of right temporal headache, fever, and profound malaise. He appears acutely ill. His temperature is 39.5°C (103.1°F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 24/min. Tenderness over the right temporal region is appreciated on palpation. The right temporal artery is tender and slightly nodular. Neurologic examination is normal, including funduscopic examination. However, visual acuity is reduced. Laboratory studies show:
Hematocrit 39.0%
Hemoglobin 10.9 g/dL
Leukocytes 8800/µL (neutrophils 68%)
Erythrocyte sedimentation rate 80 mm/hr
Which of the following is the most appropriate next step in management?

  1. Measurement of intraocular pressure
  2. Visual field assessment
  3. Low-dose (10 mg/day) prednisone treatment
  4. High-dose (60 mg/day) prednisone treatment
  5. Temporal artery biopsy

The correct answer is 4. High-dose (60 mg/day) prednisone treatment.

The patient needs urgent treatment with high-dose prednisone for giant cell arteritis (i.e., temporal arteritis). This systemic disease overlaps with polymyalgia rheumatica in approximately 40% of cases. It affects elderly persons who present with fever, malaise, temporal headache, and scalp tenderness. Giant cell arteritis is a frequent cause of fever of unknown origin in the elderly. The leukocyte count may be entirely normal, while the erythrocyte sedimentation rate (ESR) is markedly elevated. This condition may involve arteries other than the superficial temporal artery, including the aortic branches. The most important reason to start prednisone therapy is to prevent blindness secondary to extension of the process to the ophthalmic artery. Prednisone should be administered in high doses (usually 60 mg/day). Measurement of intraocular pressure (choice 1) is appropriate to confirm a diagnosis of acute (narrow-angle) glaucoma. This gives rise to a characteristic acute symptomatology of painful, red eyes, blurred vision, and halos around lights.

Visual field assessment (choice 2) is not indicated in this case.

High-dose prednisone may be slowly tapered to low-dose (10 mg/day) prednisone treatment (choice 3) over a period of 2 months, once the acute phase has resolved. Low-dose prednisone is used for polymyalgia rheumatica.

Temporal artery biopsy (choice 5) is performed routinely in any patient with clinical signs and symptoms of giant cell arteritis. It is positive in up to 80% of cases. It shows the characteristic giant cell-rich granulomatous reaction in the media, with destruction of the elastic lamina. The biopsy should be performed after starting corticosteroid treatment.

Dr. Lawrence Kindo

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This Post Has 2 Comments

  1. touqeer abbas

    really

  2. jan

    GCA with vision problem is a medical emergency and pt is started on high dose asteroid on empirical bases to avoid blindness from otherwise pending ichaemic optic neuropathy

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