HEADACHE, LETHARGY AND BLURRED VISION
A 76-year-old man presents to his general practitioner (GP) with a 2-day history of headache and blurred vision. He describes general lethargy and muscle aching over the last 3–4 days.On further questioning, he reports that when brushing his hair he experiences pain on the same side of his forehead as the headache. His GP has recently started a statin for raised
cholesterol and he takes bendroflumethiazide 2.5 mg once daily for hypertension.
His general examination is unremarkable, blood pressure 136/86 mmHg and pulse 78/min.
• What is the likely diagnosis?
• What should the initial management involve?
The most likely diagnosis is temporal arteritis. This condition predominantly affects the elderly population. Temporal arteritis is usually a clinical diagnosis, which is suggested by its unilateral features (bilateral presentation is rare), typically of pain affecting the temporal region, and can be associated visual disturbance. Palpation of the affected artery may reveal
tenderness, warmth, and pulselessness. The inflamed artery may be dilated and thickened,allowing the vessel to be rolled between the fingers and skull. Jaw claudication may occurwhen the patient is chewing or talking and is seen in approximately 65 per cent of patientswith temporal arteritis. Constitutional symptoms include anorexia, weight loss, fever, sweats
and malaise. The ESR is characteristically over 100 mm/h.
The importance of making the diagnosis is that without high-dose oral steroids the patient can permanently lose vision on the affected side. Oral steroid treatment usually results in an improvement in symptoms within 48h, and such a response further supports the diagnosis.
The length of the treatment course is 12–18 months.
To confirm the diagnosis, a temporal artery biopsy can be performed. This should ideally be performed within 2 weeks of commencing treatment. It is important to note that a negative biopsy does not rule out the presence of temporal arteritis as the areas of inflammation affecting the temporal artery may not be uniform and can skip regions.
• The importance of making the diagnosis is that without high-dose oral steroids the patient can permanently lose vision on the affected side.