MKSAP: 82-year-old woman with left-sided headaches

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

An 82-year-old woman is evaluated for a 2-week history of left-sided headaches with pain on chewing, accompanied by achiness in the shoulders and hips. She has no other pertinent personal or family history. She takes no medications.

On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 132/86 mm Hg, pulse rate is 88/min, and respiration rate is 18/min. BMI is 25. Eye examination is normal. There are tenderness and swelling over the left temporal area. Moderate to severe pain on range of motion of the shoulders and hips is noted. There is no pain over the temporomandibular joints on palpation.

Laboratory studies, including basic metabolic panel, complete blood count, and liver chemistries, are normal; erythrocyte sedimentation rate is 85 mm/h.

Which of the following is the most appropriate immediate next step in management?

A. Initiate prednisone, 15 mg/d
B. Initiate prednisone, 60 mg/d
C. Obtain MRI of the head
D. Obtain temporal artery biopsy

MKSAP Answer and Critique

The correct answer is B: Initiate prednisone, 60 mg/d.

Treatment with prednisone, 60 mg/d (or 1 mg/kg/d), is indicated immediately for this patient.

She has temporal artery pain and tenderness, along with jaw claudication in the setting of low-grade fever and a very high erythrocyte sedimentation rate. Given her age, these findings are most consistent with giant cell arteritis (GCA). The presence of shoulder and hip symptoms is consistent with polymyalgia rheumatica (PMR), which commonly co-occurs in patients with GCA (approximately 50% of cases). Despite a lack of visual symptoms to date, the patient is at risk of acute and potentially catastrophic visual loss. Immediate treatment is therefore warranted, the standard regimen being prednisone at a dose of 60 mg/d. (In the setting of severe visual loss, high-dose pulse glucocorticoids might be considered.) The addition of low-dose aspirin has been shown in limited studies to further reduce the risk of visual loss in patients with GCA already receiving prednisone and is favored by some experts.

Low-dose prednisone in the range of 10 to 20 mg/d is generally adequate treatment for isolated PMR but has not been shown to adequately treat GCA or to prevent visual complications.

MRI of the head permits the visualization of structures that could potentially be associated with headache and/or visual symptoms, including tumors, hydrocephalus, and/or large aneurysms. However, the presence of jaw claudication, as well as the presence of PMR symptoms, is not consistent with an intracranial lesion.

A temporal artery biopsy should be obtained as rapidly as possible to confirm the GCA diagnosis and to help direct long-term management; however, the histopathology of the disease will still be readable up to 1 to 2 weeks after initiation of treatment, and treatment should not be deferred pending biopsy.

Key Point

  • Immediate treatment with prednisone, 60 mg/d (or 1 mg/kg/d), is indicated for patients with suspected giant cell arteritis to prevent visual complications.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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