An 81-Year-Old Woman With Temporal Arteritis

DR SHIP: Mrs V has been generally in good health. About 7 days before her presentation, she developed an atypical headache. She also noticed difficulty opening her mouth, pain behind her eye, and some unusual lumps on her head. She recalls upper respiratory infection symptoms in the week before her headache. Her symptoms were intermittent. She had no fever or chills, no joint pain or weakness, and no systemic symptoms. She took no medications for her symptoms. She then woke with a booming headache and sought care. Her physician was concerned about her symptom complex; she started taking prednisone and a temporal artery biopsy was scheduled for the next day. Her past medical history is significant for hypertension, a right heel fracture, a right ankle fracture, toxic multinodular goiter, lichen planus, and allergic rhinitis. Her current medications include 180 mg of verapamil twice daily, 160 mg of valsartan twice daily, 20 mg of furosemide once a day, 1 mg of clonidine in transdermal patch once weekly, 15 mg of propylthiouracil a day, 40 mg of desloratadine once a day, and a spray of fluticasone in each nostril daily. She has no known drug allergies. Mrs V has been widowed for 7 years. She lives alone and works 3 mornings a week. She does not smoke and drinks alcohol rarely. On physical examination at the time of her presentation to her physician she appeared well. Her blood pressure was elevated at 170/90 mm Hg, and her pulse was 66/min. Her head was normal; no lumps or lesions were appreciated. There was mild tenderness to palpation at the temporal area bilaterally. She had no temporomandibular joint tenderness, and she was able to open her mouth easily. Her physical examination was otherwise normal. Her laboratory studies included an erythrocyte sedimentation rate (ESR) of 46 mm/hr. Hematocrit was 41.8%. White blood cell count was 11.5 10/L, with 82.8% neutrophils and 11% lymphocytes. Platelets were normal, electrolytes were normal. Creatinine was 0.7 mg/dL (53.37 mmol/L). A biopsy of her left temporal artery showed active giant cell arteritis with intimal edema. MRS V: HER VIEW In the beginning it felt like a tight helmet. And shortly after that, I was out to lunch, I think the next day, and my jaw wouldn’t open as well as it should, and I couldn’t eat my sandwich. A day later, I had a lump on the right side of my head, and then above my eyes, the bone ached. Behind my ears, the bone ached, and my grandson noticed on my temporal lobe I had a big egg. This was over a weekend. And Monday morning I got up with a booming, booming headache. It was mostly on the left side except the lump on the right was sore. I never get headaches, and I thought at first maybe it was a stroke. But I took my blood pressure and it was higher than usual, but not high enough for a stroke. When I got these strange symptoms, I knew it was something very different and something I should see the doctor about, which I did. She said, it might be nothing, but it might be something so serious that we’ll have to give you a treatment before we can diagnose it fully. She told me what she thought it was. She put me on prednisone, 60 mg a day. And the next day, they did a biopsy on the temporal artery. I noticed a lift as soon as I took the prednisone. But I don’t feel like myself with taking the prednisone. I feel as though I have a bunch of pills sitting in my stomach all the time. But it’s not intolerable. When I first took it, I was like a crazy woman. I couldn’t get enough food into me. And I thought, boy, I’ve got to stop this. But it’s settled down now. It’s fine. But you just crave food. I’m still on it, and I’m taking the 60 mg for a month. Then, I’ll have a sedimentation test, and she might be able to lower it. And I’ll be on it for about a year. Otherwise they said it might come back. I’d like to ask Dr Shmerling how long this could have been developing before I got it. They did tell me that temporal arteritis is not uncommon. I had never heard of it before.