B. Temporal arteritis
Temporal arteritis, also called giant cell arteritis, is a medium-to large-sized vessel vasculitis that can be vision-threatening. It is a disease seen exclusively in patients over 50 years of age and is linked to polymyalgia rheumatica. Important history elements include headache and jaw claudication, both of which this patient described. Additional history can be variable, including fever, a variety of visual complaints and nonspecific musculoskeletal concerns. While the physical findings are also variable in cases of temporal arteritis, a thorough examination is essential in patients presenting with a chief complaint of head-ache because the differential diagnosis is so broad, ranging from benign and self-limited conditions like tension-type headache to a life-threatening problem such as subarachnoid hemorrhage or meningitis. Patients with temporal arteritis can present with tenderness or prominence of a temporal artery, ischemic changes to the optic disc, bruits, and diminished pulses. Laboratory findings that support a clinical suspicion for temporal arteritis include an elevated ESR and CRP, which are often markedly elevated. The gold standard for diagnosis is a temporal artery biopsy with typical histologic features, although numerous imaging tests like magnetic resonance angiography can also be helpful.
This patient was admitted to the hospital and started on glucocorticoid therapy. Vascular surgery was consulted to perform an urgent right temporal artery biopsy. The pathology specimens revealed classic findings to support the diagnosis of temporal arteritis, including intimal thickening with edema, granulomatous inflammation, lymphocytic infiltration, and giant cells associated with destruction of the internal elastic lamina. The patient experienced clinical improvement on steroids and was discharged with follow-up in rheumatology clinic where her steroids were tapered. This case illustrates the importance of considering temporal arteritis on the differential diagnosis for headache and the timely initiation of steroids if other causes of headache have been deemed less likely based on history, physical examination and laboratory testing.