eMedicine Specialties > Emergency Medicine > Rheumatology

Temporal Arteritis: Follow-up

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

Follow-up

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.

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.

Inpatient & Outpatient Medications

  • Nonsteroidal anti-inflammatory drugs can provide pain relief.
  • Methotrexate5 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.

Transfer

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

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.

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.

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.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the diagnosis in elderly patients, especially with an elevated ESR
  • Failure to consider other causes of systemic illness with an elevated ESR, such as malignancy or chronic infections
  • Failure to promptly initiate corticosteroid therapy
  • Failure to administer corticosteroids pending results of temporal artery biopsy
  • Failure to arrange timely follow-up care

Special Concerns

  • Emergency physicians should suspect temporal arteritis as a possible diagnosis in any older patient who presents with a new headache, jaw claudication, or symptoms of polymyalgia rheumatica, particularly those with an elevated ESR, CRP, or thrombocytosis.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Ann G Egland, MD, and Leslie W Jackson, MD, to the development and writing of this article.



More on Temporal Arteritis

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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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