eMedicine Specialties > Emergency Medicine > Rheumatology

Temporal Arteritis: Differential Diagnoses & Workup

Author: Christopher H Lee, MD, Clinical Instructor, Section of EMS, Department of Emergency Medicine, Yale University School of Medicine
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
Contributor Information and Disclosures

Updated: Sep 8, 2009

Differential Diagnoses

Glaucoma, Acute Angle-Closure
Stroke, Ischemic
Headache, Migraine
Temporal Arteritis
Iritis and Uveitis
Transient Ischemic Attack
Orbital Infections
Ultraviolet Keratitis
Polymyalgia Rheumatica
Retinal Artery Occlusion
Retinal Vein Occlusion

Workup

Laboratory Studies

  • Erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation. It is the most commonly used laboratory test in diagnosing temporal arteritis. Most patients with temporal arteritis have an ESR greater than 80 mm/h. However, up to 20% of patients with temporal arteritis may have a normal or low ESR, and thus a normal ESR level can not exclude a diagnosis of temporal arteritis.  
    • Normal ESR levels vary according to a patient’s age and sex. A general guide for estimating normal ESR values uses the following formulas:
      • Males: (0.5 X age)
      • Females: (0.5 X age) + 5      
  • C-reactive protein (CRP) is an acute-phase protein released by hepatocytes in inflammatory states. 8CRP has been found to be elevated (>2.45 mg/dL) in patients with temporal arteritis, even in patients with a normal ESR. An advantage to CRP is that the normal value range does not vary with age or sex. A normal CRP is less than 0.5 mg/dL. An elevated CRP may help to make the diagnosis when taken under consideration with a normal ESR.
  • Complete blood cell count (CBC) may reveal leukocytosis, anemia, or thrombocytosis. Several studies have documented an association between an elevated platelet count >400 X 103/L and temporal arteritis. However, this test is not sufficiently sensitive or specific to be useful in the diagnosis of temporal arteritis.
  • Elevated liver function test (LFT) results, particularly alkaline phosphatase, are obtained in about one half of patients with temporal arteritis

Imaging Studies

  • Color duplex sonography of temporal arteries can be used prior to biopsy for optimal results.3  A sonographic halo sign around temporal arteries may be pathognomonic for temporal arteritis. However, whether ultrasonographic imaging can replace temporal artery biopsy as the definitive diagnostic procedure remains to be seen.

Procedures

  • Definitive diagnosis relies on temporal artery biopsy. Biopsy should be performed as an outpatient procedure within 1 week after the initiation of corticosteroid therapy in the emergency department. Although prompt follow-up is optimal, biopsy results have been useful even 3-4 weeks after the initiation of steroid therapy. Since affected areas of vessels can be patchy or segmental, multiple biopsy sites may be required. If clinical suspicion remains high after an initial negative biopsy result, bilateral biopsies may be required.


Hematoxylin and eosin stained superficial tempora...

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.

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Hematoxylin and eosin stained superficial tempora...

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.

More on Temporal Arteritis

Overview: Temporal Arteritis
Differential Diagnoses & Workup: Temporal Arteritis
Treatment & Medication: Temporal Arteritis
Follow-up: Temporal Arteritis
Multimedia: Temporal Arteritis
References
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References

  1. Wiszniewska M, Devuyst G, Bogousslavsky J. Giant cell arteritis as a cause of first-ever stroke. Cerebrovasc Dis. 2007;24(2-3):226-30. [Medline].

  2. Hunder GG, Bloch DA, Michel BA, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. Aug 1990;33(8):1122-8. [Medline].

  3. Karahaliou M, Vaiopoulos G, Papaspyrou S, et al. Colour duplex sonography of temporal arteries before decision for biopsy: a prospective study in 55 patients with suspected giant cell arteritis. Arthritis Res Ther. 2006;8(4):R116. [Medline].

  4. [Best Evidence] Mazlumzadeh M, Hunder GG, Easley KA, et al. Treatment of giant cell arteritis using induction therapy with high-dose glucocorticoids: a double-blind, placebo-controlled, randomized prospective clinical trial. Arthritis Rheum. Oct 2006;54(10):3310-8. [Medline].

  5. Mahr AD, Jover JA, Spiera RF, et al. Adjunctive methotrexate for treatment of giant cell arteritis: an individual patient data meta-analysis. Arthritis Rheum. Aug 2007;56(8):2789-97. [Medline].

  6. Barrier J, Bignon JD, Soulillou JP, et al. Increased prevalence of HLA-DR4 in giant-cell arteritis. N Engl J Med. Jul 9 1981;305(2):104-5. [Medline].

  7. Bongartz T, Matteson EL. Large-vessel involvement in giant cell arteritis. Curr Opin Rheumatol. Jan 2006;18(1):10-7. [Medline].

  8. Cantini F, Niccoli L, Storri L, et al. Are polymyalgia rheumatica and giant cell arteritis the same disease?. Semin Arthritis Rheum. Apr 2004;33(5):294-301. [Medline].

  9. Carroll SC, Gaskin BJ, Danesh-Meyer HV. Giant cell arteritis. Clin Experiment Ophthalmol. Mar 2006;34(2):159-73; quiz 194. [Medline].

  10. Cid MC, Font C, Oristrell J, et al. Association between strong inflammatory response and low risk of developing visual loss and other cranial ischemic complications in giant cell (temporal) arteritis. Arthritis Rheum. Jan 1998;41(1):26-32. [Medline].

  11. Cornblath WT, Eggenberger ER. Progressive visual loss from giant cell arteritis despite high-dose intravenous methylprednisolone. Ophthalmology. May 1997;104(5):854-8. [Medline].

  12. De Silva M, Hazleman BL. Azathioprine in giant cell arteritis/polymyalgia rheumatica: a double-blind study. Ann Rheum Dis. Feb 1986;45(2):136-8. [Medline].

  13. Eberhardt RT, Dhadly M. Giant cell arteritis: diagnosis, management, and cardiovascular implications. Cardiol Rev. Mar-Apr 2007;15(2):55-61. [Medline].

  14. Fardet L, Flahault A, Kettaneh A, et al. Corticosteroid-induced clinical adverse events: frequency, risk factors and patient's opinion. Br J Dermatol. Jul 2007;157(1):142-8. [Medline].

  15. Gabriel SE, Espy M, Erdman DD, et al. The role of parvovirus B19 in the pathogenesis of giant cell arteritis: a preliminary evaluation. Arthritis Rheum. Jun 1999;42(6):1255-8. [Medline].

  16. Gonzalez-Gay MA. Genetic epidemiology. Giant cell arteritis and polymyalgia rheumatica. Arthritis Res. 2001;3(3):154-7. [Medline].

  17. Haugeberg G, Bie R, Nordbo SA. Temporal arteritis associated with Chlamydia pneumoniae DNA detected in an artery specimen. J Rheumatol. Jul 2001;28(7):1738-9. [Medline].

  18. Hellmann DB. Temporal arteritis: a cough, toothache, and tongue infarction. JAMA. Jun 12 2002;287(22):2996-3000. [Medline].

  19. Horton BT, et al. Arteritis of temporal vessels: report of 7 cases. Proc Staff Meet Mayo Clin. 1937;12:548-53.

  20. Hunder GG. Giant cell arteritis and polymyalgia rheumatica. Med Clin North Am. Jan 1997;81(1):195-219. [Medline].

  21. Imrich R, Bosak V, Rovensky J. Polymyalgia rheumatica and temporal arteritis: the endocrine relations and the pathogenesis. Review. Endocr Regul. Sep 2006;40(3):83-9. [Medline].

  22. Parikh M, Miller NR, Lee AG, et al. Prevalence of a normal C-reactive protein with an elevated erythrocyte sedimentation rate in biopsy-proven giant cell arteritis. Ophthalmology. Oct 2006;113(10):1842-5. [Medline].

  23. Regan MJ, Wood BJ, Hsieh YH, et al. Temporal arteritis and Chlamydia pneumoniae: failure to detect the organism by polymerase chain reaction in ninety cases and ninety controls. Arthritis Rheum. Apr 2002;46(4):1056-60. [Medline].

  24. Rodriguez-Pla A, Bosch-Gil JA, Echevarria-Mayo JE, et al. No detection of parvovirus B19 or herpesvirus DNA in giant cell arteritis. J Clin Virol. Sep 2004;31(1):11-5. [Medline].

  25. Salvarani C, Cantini F, Boiardi L, et al. Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med. Jul 25 2002;347(4):261-71. [Medline].

  26. Unwin B, Williams CM, Gilliland W. Polymyalgia rheumatica and giant cell arteritis. Am Fam Physician. Nov 1 2006;74(9):1547-54. [Medline].

  27. Wagner AD, Wittkop U, Prahst A, et al. Dendritic cells co-localize with activated CD4+ T cells in giant cell arteritis. Clin Exp Rheumatol. Mar-Apr 2003;21(2):185-92. [Medline].

  28. Watts RA, Gonzalez-Gay MA, Lane SE, et al. Geoepidemiology of systemic vasculitis: comparison of the incidence in two regions of Europe. Ann Rheum Dis. Feb 2001;60(2):170-2. [Medline].

  29. Weyand CM, Goronzy JJ. Arterial wall injury in giant cell arteritis. Arthritis Rheum. May 1999;42(5):844-53. [Medline].

  30. Weyand CM, Goronzy JJ. Medium- and large-vessel vasculitis. N Engl J Med. Jul 10 2003;349(2):160-9. [Medline].

  31. Weyand CM, Hicok KC, Hunder GG, et al. The HLA-DRB1 locus as a genetic component in giant cell arteritis. Mapping of a disease-linked sequence motif to the antigen binding site of the HLA-DR molecule. J Clin Invest. Dec 1992;90(6):2355-61. [Medline].

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Further Reading

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Keywords

TA, temporal arteritis, GCA, giant cell arteritis, cranial arteritis, vasculitis, systemic vasculopathy, temporal-located headaches, ischemic optic neuritis, headache, cephalgia, impaired vision, vision loss, jaw claudication, sixth nerve palsy, afferent pupillary defect, temporalarteritis, ophthalmic emergency, blindness, arteritic ischemic optic neuropathy 

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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.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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

CME Editor

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, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
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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