Temporal arteritis: Clinical sciences

Temporal arteritis, also known as giant cell arteritis, is an inflammatory vasculitis of medium and large arteries. In temporal arteritis, there’s inflammation and thickening of the vessel wall, which eventually can result in ischemia and complications, such as vision loss. Now, as the same suggests, the temporal artery is the most common vessel involved. But don’t let the name fool you! Other intracranial and extracranial vessels can be affected as well, especially the vertebrobasilar arterial system. More remote sites of vascular involvement include the aorta and its proximal branches, like the carotid, subclavian, axillary, and brachial arteries.

Okay, if a patient presents with a chief concern suggesting temporal arteritis, first perform a focused history and physical exam, and order labs, including an erythrocyte sedimentation rate, or ESR, C-reactive protein or CRP, and complete blood cell count, or CBC.

Your patient will generally be older than 50, and likely report a new onset of localized headache, typically described as unilateral pain in the temporal region that worsens over time. These symptoms are often associated with scalp pain; as well as systemic symptoms like fatigue, malaise, fever, and unintentional weight loss. In more severe cases, you might notice symptoms suggestive of ischemia, including sudden vision changes ranging from diplopia to complete vision loss. There might also be pain with chewing, known as jaw claudication.

Here’s a high-yield fact! Temporal arteritis is closely associated with polymyalgia rheumatica, another inflammatory disorder that primarily affects the shoulders and hips. These patients typically report morning pain and stiffness in the muscles of the neck, shoulders, and hips. So, if you have clinical suspicion of polymyalgia rheumatica, be sure to evaluate your patient for temporal arteritis too!

Moving on physical exam findings, these may reveal an abnormal temporal artery exam, such as tenderness to palpation, ropiness, nodularity, and even decreased quality of pulse. Additionally, fundoscopic examination might show optic disc pallor and edema early in the disease, and in more advanced cases, you may even find optic disc atrophy. Finally, labs typically reveal elevated inflammatory markers, such as ESR and CRP, with CBC showing thrombocytosis and anemia.

If your patient presents with these signs and symptoms, you should suspect temporal arteritis. Next, assess your patient for vision changes. If your patient is experiencing any vision changes, this is considered an ophthalmologic emergency! Do not delay treatment, as this can lead to permanent vision loss. So, even if you haven’t confirmed the diagnosis, start the patient on high-dose intravenous glucocorticoids immediately, and obtain an emergent ophthalmology consultation.

On the other hand, if your patient is not experiencing any vision changes, start high-dose oral glucocorticoids instead, which may help prevent further vascular inflammation that could ultimately lead to vision loss. In addition, request a routine ophthalmology consultation. The key point is that glucocorticoids should not be delayed while confirming the diagnosis!

Alright, now that you’ve started glucocorticoids and requested an ophthalmology consultation, your next step is to confirm the diagnosis by obtaining a temporal artery biopsy, preferably on the symptomatic side.