An 82-year-old woman schedules an appointment to see you for neck and back pain. At age 50, she had an L4-L5 diskectomy and laminectomy. She also has long-standing hypothyroidism for which she takes levothyroxine 0.1 mg daily. Over the past few months, she has become more fatigued and describes pain in both of her arms, her low back, and the front of her thighs. She notes that the tops of her shoulders are also achy. She decided to call for an appointment because of worsening headache. She tells you that she has an appointment later this afternoon with her ophthalmologist, because she noticed some flickering of the vision in her left eye. Upon further questioning, she does acknowledge that she has cut her telephone conversation short with her daughter because her jaw begins to ache if she talks too long. Physical examination shows that she has normal vital signs. She has diffuse scalp tenderness. The oral mucosa is normal without aphthous ulcers and the salivary pool is normal. Her pupils are equal, round, and reactive to light and accommodation, and extraocular muscles are intact. The funduscopic examination appears normal for her age. Neck motion is slightly reduced to lateral flexion and rotation. Her trapezii are tender to palpation, but there is no significant loss of range of motion in her shoulders. Her supraspinatus and infraspinatus tendons appear intact. Her quadriceps are mildly tender, but her gastrocnemius muscles are normal. Her strength is normal for age. Her reflexes are normal and symmetrical.
Which of the following should be done next?
- start 80 mg prednisone daily
- start ibuprofen and refer for a temporal artery biopsy
- trigger point injections of triamcinolone in the trapezius muscles
- stat MRI/MRA of the head
- no treatment until after she is evaluated by the ophthalmologist and a rheumatologist
Answer(s): A
Explanation:
The diagnosis is almost certainly temporal arteritis. Age over 70, headache with scalp tenderness, jaw claudication, and visual disturbance would suggest the diagnosis even if the sedimentation rate came back within the normal range. Since the patient's supraspinatus and infraspinatus strength are normal, complete rotator cuff tear seems unlikely. Rotator cuff tears would also not explain the leg component. Osteoarthritis of the neck and back could explain many of her clinical features, particularly if spinal stenosis is present, but would not account for the jaw claudication or the headaches with scalp tenderness. Many patients with temporal arteritis have features of polymyalgia rheumatica, but in this case, temporal arteritis is the best working diagnosis.
Temporal arteritis is one of the few unequivocal rheumatic disease emergencies. The patient should be given large doses of prednisone immediately. An ESR should be obtained, but as noted above, even a normal study would not prevent the prednisone from being prescribed at this point. You should also contact the ophthalmologist because there can be retinal clues not picked up on standard office funduscopy. In addition, many ophthalmologists now will do the temporal artery biopsy in their patients. This is a very reasonable next step for the patient and will unequivocally establish the diagnosis.
Temporal arteritis may have skip lesions, and thus, a fairly significant length of the temporal artery should be taken by the surgeon. MRI of the brain, even with MRA, will not help establish a diagnosis of temporal arteritis and will needlessly delay diagnosis, possibly causing the patient to lose vision.