MKSAP Quiz: severe head and neck pain
Psychiatric tool adds disorders, guidance to primary care screening
An 82-year-old woman is evaluated for a 2-week history of severe headaches and neck pain. She has stiffness and aching in her shoulders, neck and lower back.
On physical examination, the scalp is diffusely tender to palpation. Funduscopic examination is unremarkable, and she has carotidynia. On musculoskeletal examination, muscle strength testing is limited because of muscle pain. Biceps and triceps reflexes are 2+ and symmetrical.
Laboratory studies
Which of the following is the most appropriate next step in this patient's management?
A. MRI of the head
B. Electromyography
C. Temporal artery biopsy
D. Doppler ultrasonography of the carotid artery
MKSAP Answer and Critique
The correct answer is C) Temporal artery biopsy. This item is available online to MKSAP 14 subscribers in the Rheumatology section, Item 11.
The most appropriate next step in this patient's management is temporal artery biopsy. This patient most likely has giant cell arteritis, which is characterized by inflammation involving the extracranial branches of the carotid artery and typically affects the elderly population. Clinical manifestations of this condition include headaches, optic nerve ischemia, and accompanying polymyalgia rheumatica. Additional features that may occur in giant cell arteritis are scalp tenderness, carotidynia, and jaw claudication. Although the majority of patients with giant cell arteritis have an elevated erythrocyte sedimentation rate, this rate is low or normal in 10% to 24% of these patients.
The gold standard for diagnosing giant cell arteritis is temporal artery biopsy. Whenever possible, temporal artery biopsy should be performed before prednisone therapy is initiated, although some experts delay treatment for a few days until biopsy is obtained if symptoms are mild or there are no ocular manifestations. Nevertheless, immediate initiation of corticosteroid therapy is indicated if any visual symptoms occur. Corticosteroid therapy is less effective at recovering lost vision if treatment is not initiated promptly on the first day that symptoms develop.
Recent studies have shown that administering corticosteroid treatment for up to, and perhaps longer than, 2 weeks before temporal artery biopsy is performed does not affect biopsy results in patients with clinical suspicion for giant cell arteritis. Therefore, some experts recommend that corticosteroid therapy should precede biopsy in this setting.
Neither brain MRI nor ultrasonography of the carotid artery would help to evaluate the cause of this patient's proximal myalgias. This patient does not have muscle weakness or elevated levels of creatine kinase. Therefore, electromyography is not indicated.
Key Point
- The gold standard for diagnosing giant cell arteritis is temporal artery biopsy. The erythrocyte sedimentation rate in patients with giant cell arteritis usually is elevated but may be low or normal in 10% to 24% of patients.