Temporal Arteritis in Emergency Medicine Clinical Presentation

  • Author: Christopher H Lee, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 15, 2011
 

History

Headache is the most common chief complaint and presents in over two thirds of patients with temporal arteritis. The headache tends to be new or different in character than previous headaches and is typically sudden in onset, localizing to the temporal region. However, pain with temporal arteritis can occur diffusely through the occipital, frontal, or parietal regions as well. Therefore, any new headache in patients older than 50 years warrants a consideration of temporal arteritis.

Because temporal arteritis tends to affect the branches of the carotid artery, clinical manifestations vary depending on the distribution of the ischemic vessel. For example, superficial temporal artery involvement can lead to severe scalp tenderness during such simple acts as resting the head on a pillow, combing hair, or wearing hats and eyeglasses. Patients may also present with visible areas of scalp necrosis. Similarly, jaw claudication while speaking or chewing is observed in patients with involvement of the maxillary artery, which can occur in half of patients with temporal arteritis.

Visual loss may also be a presenting symptom and can be sudden and painless. Initial visual symptoms are usually transient and intermittent, typically manifesting as unilateral visual loss or occasionally diplopia. However, if left untreated, permanent blindness frequently results.

Constitutional symptoms due to systemic inflammation are common. These nonspecific symptoms include fever, malaise, memory impairment, anorexia, weight loss, fatigue, and depression. Additionally, polymyalgia rheumatica symptoms are present in about half of all cases of temporal arteritis and may be the initial complaint in many patients.

Based on the 1990 American College of Rheumatology criteria for classification of temporal arteritis, at least 3 of the following 5 items must be present (sensitivity 93.5%, specificity 91.2%)[2] :

  1. Age of onset older than 50 years
  2. New-onset headache or localized head pain
  3. Temporal artery tenderness to palpation or reduced pulsation
  4. Erythrocyte sedimentation rate (ESR) greater than 50 mm/h
  5. Abnormal arterial biopsy (necrotizing vasculitis with granulomatous proliferation and infiltration)
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Physical

A thorough physical and neurological examination should be performed to exclude other possible causes of headache and visual disturbances.

The head and face should be examined for inflamed and thickened arteries, tenderness to palpation, tender scalp nodules, or necrotic areas of the scalp. Inflamed vessels may be tender and warm. They may also appear thickened and dilated, such that the examiner may be able to roll the artery between the fingers and the skull. Cranial nerve palsies, particularly of the sixth nerve, should also be noted.

A complete eye examination should be performed, including visual acuity, visual field check, and funduscopic as well as a slit lamp examinations. Special attention should be paid to the retinal vessels, as other causes of loss of vision such as central retinal artery or vein occlusion can cause a markedly abnormal funduscopic examination result. In temporal arteritis, the funduscopic examination result may be normal or can show dilated retinal veins.

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Contributor Information and Disclosures
Author

Christopher H Lee, MD  Clinical Instructor, Section of EMS, Department of Emergency Medicine, Yale University School of Medicine

Christopher H Lee, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Jean Marie Hammel, MD  Assistant Professor, Associate Residency Director of Emergency Medicine Residency Program, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine

Jean Marie Hammel, MD is a member of the following medical societies: Alpha Omega Alpha and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard S Krause, MD  Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Gino A Farina, MD, FACEP, FAAEM  Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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Hematoxylin and eosin stained superficial temporal artery biopsy specimen, cross section. The hallmark histologic features of giant cell arteritis shown here include intimal thickening with luminal stenosis, mononuclear inflammatory cell infiltrate with media invasion and necrosis, and giant cell formation in the media.
Lumbar angiogram showing stenosis and occlusion of femoral artery branches due to vasculitis in the same patient whose temporal artery biopsy specimen is shown in the previous image.
Hematoxylin and eosin stained femoral artery branch, cross section, taken from a lower limb amputation specimen. Mononuclear cell invasion and necrosis in the media of this large artery can be observed. Extensive lower limb vasculitis from giant cell arteritis resulted in ischemic necrosis of the lower limb, necessitating amputation.
 
 
 
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