Q1
A 74 yo ♀ presents to the ED, where you are the physician on call. She is concerned about sudden vision loss in her left eye.
What additional history do you want to obtain?
Duration of symptoms? (click to show/hide)
Any history of previous symptoms? (click to show/hide)
Occupation? (click to show/hide)
Associated symptoms? (click to show/hide)
Eye pain? (click to show/hide)
History of cardiovascular disease or cerebrovascular accident? (click to show/hide)
History of trauma? (click to show/hide)
Family history of any eye conditions? (click to show/hide)
Q2
A 74 yo ♀ presents to the ED, where you are the physician on call. She is concerned about sudden vision loss in her left eye. She states that the episode occurred about 4 hours ago.
She has had no symptoms in the right eye. There is no eye pain, but she notes that she has been having headaches for the past 2 weeks.
What is your differential diagnosis? Pick your top four choices.
Acute angle closure glaucoma (click to show/hide)
Central retinal artery occlusion (click to show/hide)
Transient monocular vision loss (click to show/hide)
Dense cataract (click to show/hide)
Giant cell arteritis (click to show/hide)
Herpes simplex keratitis (click to show/hide)
Idiopathic intracranial hypertension (click to show/hide)
Central retinal vein occlusion (click to show/hide)
Q3
You examined this patient’s eyes using a direct ophthalmoscope. The right eye was completely normal to examination. The left eye is pictured below. What is the most likely diagnosis?
Match the fundoscopic change to the pathological condition.
Central retinal artery occlusion (click to show/hide)
Normal retina (click to show/hide)
Central retinal vein occlusion (click to show/hide)
Ischemic optic neuropathy (as occures in GCA) (click to show/hide)
Retinal detachment (click to show/hide)
Q4
You suspect she has giant cell arteritis based on her associated headaches which were located in the temporal region on both sides.
Which other symptoms would you expect her to have if she did?
Pain & weakness in arms and shoulders (click to show/hide)
Rash on her cheeks (click to show/hide)
Loss of hair in patches (click to show/hide)
Pain with chewing (click to show/hide)
Dry eyes and mouth (click to show/hide)
Q5
What diagnostic tests would confirm a diagnosis of giant cell arteritis?
Anti-nuclear antibody (click to show/hide)
Temporal artery biopsy (click to show/hide)
C-reactive protein (click to show/hide)
Complete blood count (click to show/hide)
Eryhrocyte sedimentation rate (click to show/hide)
Anti-neutrophil cytoplasm antibody (click to show/hide)
Q6
In the ED, her ESR and CRP come back elevated at 100 mm/hr and 12 ng/mL respectively. Temporal artery biopsy is not available for the next two days as your surgeon is on vacation.
What is the next best step in the management of this patient?
Wait until the temporal artery is biopsied in two days, then start high dose prednisone (40-60 mg/day) (click to show/hide)
Wait until the temporal artery is biopsied in two days, then start low dose prednisone (5-10 mg/day) (click to show/hide)
Start broad spectrum antibiotics – ciprofloxacin, piperacillin/tazobactam, and vancomycin now, wait until the temporal artery is biopsied, then start high dose prednisone (40-60 mg/day) (click to show/hide)
Start broad spectrum antibiotics – ciprofloxacin, piperacillin/tazobactam, and vancomycin now, wait until the temporal artery is biopsied, then start low dose prednisone (5-10 mg/day) (click to show/hide)
Start high dose prednisone now (40-60 mg/day) (click to show/hide)
Start low dose prednisone now (5-10 mg/day) (click to show/hide)
Summary
Giant cell arteritis (GCA) is a granulomatous vasculitis of medium sized blood vessels. It occurs most commonly in females than males with a ratio of about 3:1, and occurs most commonly at around age 70.
Symptoms include headache and scalp tenderness, usually in the temporal region, jaw claudication, amaurosis fugax (transient monocular loss of vision in one eye), and polymyalgia rheumatica (weakness in proximal muscle groups of upper and lower limbs).
The gold standard for diagnosis is temporal artery biopsy (need at least 3 cm sample). Histology reveals non-caseating granulomas in the vessel walls. Lesions are not continuous, so a negative biopsy does not guarantee that disease is not present. Other lab tests include markedly elevated ESR and CRP, along with mildly elevated alkaline phosphatase and platelets.
Treatment should be started immediately as the possible sequelae of untreated GCA include irreversible monocular blindness secondary to ischemic optic neuropathy. High dose prednisone (40-60 mg prednisone daily) should be started immediately, and the results of the temporal artery biopsy will not be affected for the first three days of therapy.