A Case of Temporal Arteritis

KEY LEARNING POINTSFROM A MEDICAL HISTORY OBTAINED BY FOUR THIRD-YEAR MEDICAL

STUDENTS FROM A PATIENT WITH NEUROLOGICAL SIGNS

THE CASE. 80 YEAR OLD WOMANo 2 years ago: began to experience severe episodes of persistent headaches not relieved by over-the-counter and

prescribed analgesics, that occurred recurrently and for several hours at a time

Headaches were described as a crushing pain that radiated from her neck, over her head, and into her face

Associated with loss of appetite, jaw pain, and photosensitivity

No other abnormal neurological signs were present, no true visual loss, and no identifiable triggers

An in-hospital diagnosis of temporal arteritis was made on an especially acute episode of the headache, and steroidal treatment immediately commenced

On a daily dosage of prednisolone (3.5 mg); self-administration is increased on episodic flares Low-dosage aspirin, omeprazole, a supplementary medication for her joints, as adjuncts in her steroidal treatment

Levothyroxine prescribed for hypothyroidism prior to diagnosis of temporal arteritis

Has otherwise been of normal health and fitness over the course of her life Nothing of note on systematic enquiry

Previous hospitalisation has been for childbirthNo apparently significant family history

Personally believes her headaches may have been triggered by stressful, financially-related, life events; her relationship with her husband is a positive one and he was highlighted as a significant source of psychosocial support

LEARNING

POINT 1

LEARNING POINT 2

LEARNING POINT 3

WEAKNESSES IN THE HISTORY Information that would have been useful to obtain in retrospect:

▪ What were the precise time distributions of her headaches, in terms of their onset and how long they lasted? This could have been undertaken in more detail, and is essential to a differential diagnosis.

▪ What were the precise dosages of the NSAIDs prescribed? This is of particular significance on revelation of the patient’s diagnosis. Temporal arteritis is an inflammatory condition, and given the anti-inflammatory mechanism of NSAIDs, pain relief should have been obtained. However, an inadequate dosage in light of the severity of the diagnosis may explain why this was not the case.

▪ Given her appetite loss, did she experience any degree of weight loss over the course of her headaches? This might suggest involvement of the Temporalis. If mastication becomes associated with pain, one might naturally expect lower food intake over time.

What it looks like

Left: Normal Aorta

Right: Giant-Cell Arteritis

LEARNING POINT 1. It’s

A CHALLENGING DIAGNOSIS• May be complicated by features of other neurological conditions

• Headaches are a common presentation in a geriatric population, with tension-type headaches being the most frequently occurring – there are multiple overlapping features

• Irreversible vision loss is a consequence, and therefore, treatment must be immediately commenced on clinical suspicion

CLINICAL DIAGNOSIS: internal and external carotid artery involvement

Jaw claudication

Headache; temporal

pain

Scalp tenderness

Acute onset of visual

disturbance

Abnormal temporal artery

on gross examination

ACUTE PHASE REACTANT MARKERS

✓ Elevated ESR: erythrocyte sedimentation rate – high specificity

✓ Elevated CRP – also a marker of ‘disease activity’

TEMPORAL ARTERY BIOPSY

◆ Classification by vessel wall involvement e.g. small periadventitial, up to transmural

◆ Identification of no. of white blood cells

◆ Presence of thromboses and necroses

◆ A wide histiologic spectrum of inflammatory lesions in temporal artery biopsy VASCULAR IMAGING

Delineation of vascular anatomy features such as luminal narrowing, occlusion, and calcification

MULTIDISCIPLINARY INVOLVEMENT Rheumatologists play a role So does the ophthalmologist, as ocular symptoms are crucial and common clinical manifestations