Morning Report

Morning Report: Temporal Arteritis

Resident Presenter: Frank Johnston

2.2% of ED visit, 1-3% serious

DDX:

  • Deadly: Meningitis/encephalitis, Intracranial Hemorrhage (ICH), SAH / sentinel bleed, Acute obstructive hydrocephalus, Space occupying lesions, CVA, CO Poisoning, Basilar artery dissection, Preeclampsia, Cerebral venous thrombosis, Hypertensive emergency, Intracranial or Epidural Abscess, infection tumor
  • Important: Acute Glaucoma, Temporal arteritis
  • Idiopathic intracranial hypertension, Acute Glaucoma, Acute sinusitis

History: Infection, Cancer, Immunosuppression, Syncope, Trauma, Altered mental status, Systemic illness (fever, stiff neck, rash) projectile vomiting, Patient on anticoagulation, steroids, HIV

“Red flag” symptoms:

  • Sudden onset or accelerating pattern(SAH 20%)
  • No similar headache in past
  • Age >50yr
  • Occipito nuchal HA(meningitis)
  • Visual disturbances
  • Exertional or post-coital(aneurysm)
  • Family history of SAH or aneurysm
  • Focal neurologic signs
  • Diastolic BP >120
  • Papilledema
  • Jaw claudication(temporal arteritis)
  • Time to maximal onset

Location:

  • Occipital – Cerebellar lesion, muscle spasm, cervical radiculopathy
  • Orbital – Optic neuritis, cavernous sinus thrombosis
  • Facial – Sinusitis, carotid artery dissection

 

PE: Neuro exam, Kernig’s Sign, Brudzinski’s Sign, Palpitation, Jolt test,

Others: 

  • Trigeminal neuralgia
  • TMJ pain
  • Post-lumbar puncture headache
  • Dehydration
  • Analgesia abuse
  • Various ocular and dental problems
  • Herpes zoster ophthalmicus
  • Herpes zoster oticus
  • Cryptococcosis
  • Febrile headache

 

Laboratory Tests

  • If suspect temporal arteritis → ESR
  • If suspect meningitis → CSF studies, CBC to rule-out meningitis
  • Add India Ink, cryptococcal antigen if suspect AIDS-related infection
  • CO poisoning → carboxyhemoglobin level
  • If concern for ICH → non-contrast CT Brain ± Lumbar puncture

Imaging:

  • head CT in patients with: Thunderclap headache, Worst headache of life, Different headache from usual, Meningeal signs, Headache + intractable vomiting, New-onset headache in pts with: Age > 50yrs, Malignancy, HIV
  • Neurological deficits (other than migraine with aura), Consider CXR
  • 50% of pts w/ pneumococcal meningitis have e/o PNA on CXR

The most commonly reported symptoms in patients with GCA are as follows:

  • Headache (initial symptom in 33%, present in 72%)
  • Neck, torso, shoulder, and pelvic girdle pain that is consistent with polymyalgia rheumatica (PMR; initial in 25%, present in 58%)
  • Fatigue and malaise (initial in 20%, present in 56%)
  • Jaw claudication (initial in 4%, present in 40%)
  • Fever (initial in 11%, present in 35%)

 

In this study, the ESR had a sensitivity of 76% to 86%, depending on which of 2 formulas were used, whereas an elevated CRP had a sensitivity of 97.5%. The sensitivity of the ESR and CRP together was 99%. Only 1 of the 119 patients (0.8%) presented with a normal ESR and normal CRP (double false negative); 2 patients (1.7%) had a normal CRP despite an elevated ESR according to both formulas. However, there are some other studies that put the sensitivity at slightly less.  Still  a  very good sensitivity that can be used in most clinical cases.

Learning Points:

  • 50,50,250
  • intravenous (IV) methylprednisolone at doses of 250mg TID
  • Sed Rate and CRP

 

EBM Article:

Parikh M, Miller NR, Lee AG, Savino PJ, Vacarezza MN, Cornblath W, Eggenberger E, Antonio-Santos A, Golnik K, Kardon R, Wall M. Prevalence of a normal C-reactive protein with an elevated erythrocyte sedimentation rate in biopsy-proven giant cell arteritis. Ophthalmology. 2006 Oct;113(10):1842-5. Epub 2006 Aug 1.

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