elitoki
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a 72 y/o man comes to the emergency department after a 5 min episode of blindness in the right eye. Over the past month, he has had HA and pain in the jaw with chewing. His temp 38.1. Examination shows tender nodular temporal arteries with decreased pulses. His erythrocyte sedimentation rate is 92, Which of the following is the most appropriate immediate step in mangement?
a) carotid USG
b) aspirin
c) cefotaxime
d) corticosteroid
e) temporal artery biopsy
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| dermatology
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E ?????
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| epica
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D?
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| Justice
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e) temporal artery biopsy followed by immediate d) corticosteroid before the results are known
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| maa
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i thought it was low dose corticosteroid then biopsy b/c of blindness. according to uw
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| Justice
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UW says that absence of diagnosis should not delay the treatment. But, steroids can alter histology... Biopsy should be taken first (done in outpatient setting, under local anestesia) and steroids should be given right after that
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| Kamsi
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D
Why not coricosteriod before biopsy? to pervent blindness
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| Kamsi
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NMS says a temporal artery may still be diagnostic up to 1 week after initiation of steriods and that steriods should be started immediately to prevent blindness. So which one should be the next step steriods or biopsy?
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| Justice
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Well, after rereading StepUp, I would agree with starting steroids immediately and then ordering temporal biopsy...
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| elitoki
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What is the dx that are you looking for?
Is it Giant cell arteritis or any thromboembolism that is affecting the circulacion of internal carotid artery?
I understand that Temporal arteritis can cause blindness, but I wonder if that blindness could be just for 5 min as in this Q. or if his blindness comes from thrombolitic lesion of carotid artery that emboli has caused just temporal blindness...
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| radonc
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The transient blindness (amarousis fugax) - I think this is secondary to a vascultic process, the artery closes for 5 minutes, then becomes normal again. I don't think it's embolic.
The answer is corticosteroids, high dose 60mg/day immediately. This is to prevent permanent blindness. Then arrange for temporal artery biopsy - histological changes remain for up to 2 wks after commening treatment.
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| elitoki
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.
Is it possible that amarous fugax be caused by temporal arteritis?
I though that some plaque that loss form carotid artery can produce transient oclusion of retinal artery causing amarous fugax.
Could you help me here?
... and for the answer of this Q. I agree that answer is D. because they are asking about immediate step management. For Temporal arteritis we don't need to confirm the dx to treat pt. Steroid should be given as soon as possible.
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| epica
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Hi Elitoki,
Yes, D.
(I remember this Q from Step 1 notes)
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| radonc
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"For Temporal arteritis we don't need to confirm the dx to treat pt."
This is not correct. Almost all cases of temporal arteritis need to be confirmed with a biopsy, although sometimes the biopsy is negative because the disease affects the artery in segmental fashion. Treatment for this disease requires prednisolone, high-dose for at least 1-2 mths, then tapered to maintenance dose. Most pts need steroids for about 2 yrs because of the risk of relapse. Treatment is highly toxic. You need to confirm the diagnosis!
Elitoki, I am not sure of the exact mechanism of transient loss of vision in temporal arteritis. I thought it was a 'vasculitic process', but you may be right, it may be an embolus causing the amarousis fugax. I am not entirely sure.
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| brutus25
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Clasification criteria 3 of 5 is 93.5%sens and 91.2 spec Arthritis Rheuma 1990 ; 33:1122)
•Age > 50
•New headache
•Temporal artery tendrness or decreased pulsation
•↑ESR
•Biopsy – vasculitis and granulomas
Treatment : steroids ( if vision threatened do not wait path results before starting Rx)
Took those from "The Massachusetts General Hospital Handbook of Internal Medicine"
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