A 62-year-old woman comes to the emergency department because of severe jaw pain. Over the past day, she has had progressively worsening pain in the right side of her jaw, which occurs predominantly when chewing and talking. A few hours ago, the vision in her right eye "totally blacked out" but returned to normal within a few minutes. She has a history of hypertension and migraines. Her only current medication is losartan. Her temperature is 37.8°C (100°F), pulse is 88/min, respirations are 18/min, and blood pressure is 126/78 mm Hg. Physical examination shows tenderness to palpation along the right jawline and right side of the scalp. Visual acuity is 20/30 bilaterally. Fundoscopic examination shows mild bilateral retinal vein dilation but no other abnormalities. There is no conjunctival injection or lacrimation. Laboratory studies show:Hemoglobin 10 mg/dLMean corpuscular volume 90 µm3Platelet count 500,000/mm3Leukocyte count 9000/mm3Erythrocyte sedimentation rate 92 mm/hWhich of the following is the most appropriate next step in the management of this patient?A. High-dose intravenous methylprednisoloneB. High-dose oral prednisoneC. Intravenous immunoglobulinD. Low-dose oral aspirinE. Low-dose oral prednisoneF. Oral methotrexateShow Explanation
Question
A 62-year-old woman comes to the emergency department because of severe jaw pain. Over the past day, she has had progressively worsening pain in the right side of her jaw, which occurs predominantly when chewing and talking. A few hours ago, the vision in her right eye "totally blacked out" but returned to normal within a few minutes. She has a history of hypertension and migraines. Her only current medication is losartan. Her temperature is 37.8°C (100°F), pulse is 88/min, respirations are 18/min, and blood pressure is 126/78 mm Hg. Physical examination shows tenderness to palpation along the right jawline and right side of the scalp. Visual acuity is 20/30 bilaterally. Fundoscopic examination shows mild bilateral retinal vein dilation but no other abnormalities. There is no conjunctival injection or lacrimation. Laboratory studies show:Hemoglobin 10 mg/dLMean corpuscular volume 90 µm3Platelet count 500,000/mm3Leukocyte count 9000/mm3Erythrocyte sedimentation rate 92 mm/hWhich of the following is the most appropriate next step in the management of this patient?A. High-dose intravenous methylprednisoloneB. High-dose oral prednisoneC. Intravenous immunoglobulinD. Low-dose oral aspirinE. Low-dose oral prednisoneF. Oral methotrexateShow Explanation
Solution
This patient's jaw pain with chewing (jaw claudication), vision changes, and elevated erythrocyte sedimentation rate are concerning for giant cell arteritis (GCA), a vasculitis that most commonly affects the branches of the carotid artery. GCA can cause irreversible blindness due to arteritic anterior ischemic optic neuropathy. Therefore, it is considered a medical emergency. The most appropriate next step in management is to start high-dose glucocorticoids (eg, prednisone, 40-60 mg/day orally or intravenously) immediately to prevent further vision loss. The diagnosis can be confirmed with temporal artery biopsy, but this should not delay treatment.
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