Temporal Arteritis in Emergency Medicine Follow-up

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

Further Inpatient Care

  • Hospital admission for temporal arteritis is unusual but may be indicated depending upon the severity of symptoms and the ability of the patient to provide self-care at home.
Next

Further Outpatient Care

  • Most patients can be treated on an outpatient basis.
  • An adequate quantity of corticosteroids should be prescribed.
  • Follow-up care should be arranged within 72 hours.
  • Symptoms typically improve within 1-3 days.
  • Corticosteroid therapy may last for 1-2 years, depending on the patient’s response.
Previous
Next

Inpatient & Outpatient Medications

  • Nonsteroidal anti-inflammatory drugs can provide pain relief.
  • Methotrexate[6] and azathioprine have been used as both adjuncts and steroid-sparing agents for temporal arteritis, but conclusive evidence regarding their efficacy remains uncertain. These medications should not be prescribed from the emergency department, but they may be added at a later time upon rheumatology follow-up.
  • Long-term steroid use (greater than 3 wk) may require the addition of calcium, vitamin D, and bisphosphonate therapy to prevent steroid-induced osteoporosis.
  • Retrospective data shows that low-dose aspirin has been associated with a lower risk for developing acute vision loss and stroke in patients with temporal arteritis. In the absence of contraindications, low-dose (81 mg) aspirin should be considered along with corticosteroids.[7]
Previous
Next

Transfer

  • Hospital transfer is indicated only if visual disturbance is severe and cannot be adequately evaluated and managed at the current facility.
Previous
Next

Complications

  • Permanent vision loss is the most feared complication of untreated temporal arteritis and can even progress in some cases despite the initiation of corticosteroid therapy. This will tend to occur within the first 5 days of treatment if therapy is going to fail. As an outpatient, corticosteroid doses should be increased until symptoms improve.
  • Approximately 50% of patients with temporal arteritis experience at least one flare-up that requires prolonged corticosteroid therapy.
  • Patients with temporal arteritis are at increased risk for thoracic and abdominal aortic aneurysms compared to age-matched controls.
  • Uncommon complications include CVA, memory loss, myocardial infarction, and peripheral neuropathy.
Previous
Next

Prognosis

  • Generally, temporal arteritis is a self-limiting condition lasting up to 2 years.
  • Treatment with corticosteroids has proven to be effective in most cases, but the lengthy duration of treatment can lead to corticosteroid-induced complications.
Previous
Next

Patient Education

  • Timely follow-up care from the emergency department is critical to accurately diagnose temporal arteritis.
  • Medication compliance and instructions to return to the emergency department if the condition worsens should be emphasized.
  • Patients should be counseled that existing visual loss prior to arrival at the emergency department may not be regained despite initiation of therapy.
Previous
 
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

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. Ball EL, Walsh SR, Tang TY, Gohil R, Clarke JM. Role of ultrasonography in the diagnosis of temporal arteritis. Br J Surg. Dec 2010;97(12):1765-71. [Medline].

  5. [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].

  6. 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].

  7. Nesher G, Berkun Y, Mates M, et al. Low-dose aspirin and prevention of cranial ischemic complications in giant cell arteritis. Arthritis Rheum. Apr 2004;50(4):1332-7. [Medline].

  8. 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].

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

  10. 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].

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

  12. 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].

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

  14. 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].

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

  16. 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].

  17. 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].

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

  19. 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].

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

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

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

  23. 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].

  24. 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].

  25. 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].

  26. 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].

  27. 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].

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

  29. 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].

  30. 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].

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

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

  33. 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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.