Name:
An 84-Year-Old with Severe Headaches
Description:
An 84-Year-Old with Severe Headaches
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T00H04M46S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener,
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine.
CATHY: Welcome to Episode 29: An 84-Year-Old with Severe Headaches.
CHARLIE: Here's the question: an 84-year-old woman is seen by her primary care physician for evaluation of severe headaches. She noted these several weeks ago, and they have been getting worse. She's having at least one episode each day, with no obvious provocation. Although she has not had any visual aura, she is concerned that she's been having intermittent loss of vision in her left eye, just for the last few days. She denies new weakness or numbness, but she does report jaw pain with eating.
CHARLIE: Her past medical history includes coronary artery disease requiring a bypass graft, ten years ago, diabetes mellitus, hyperlipidemia, and mild depression. Her full review of systems is notable for night sweats and mild low-back pain, particularly prominent in the morning, and these have occurred around the same times as these headaches.
CATHY: In Episode 11, we talk about the differential diagnosis of headaches and when to be concerned, and this patient is presenting with some worrisome findings. So, the findings that are of note here are: the worsening over the course of weeks; neurologic symptoms-- he or she describes intermittent loss of vision and jaw pain with eating. And that constellation of symptoms in someone who's 84 years old must make you think of giant cell arteritis, which I think is a do-not-miss diagnosis.
CHARLIE: What do you mean by a do-not-miss diagnosis?
CATHY: By that I mean a diagnosis where a treatment can be started empirically, because if you don't there could be serious, irreversible consequences for the patient.
CHARLIE: Okay. So, what is giant cell arteritis?
CATHY: It's inflammation of the medium- and large-sized arteries, and characteristically involves one or more branches of the carotid artery, particularly the temporal artery. With involvement of the ophthalmic artery, it can lead to blindness. An empiric treatment with glucocorticoids, though, is effective in preventing this complication if it's caught early.
CHARLIE: Do the other symptoms described in this case help you at all with the diagnosis of GCA?
CATHY: The night sweats and back pain that are worse in the morning make me think that this is rheumatologic, and the back pain may be polymyalgia rheumatica. This can be seen in 40-50% of patients with giant cell arteritis, and about 10-20% of patients who initially present with features of isolated polymyalgia rheumatica can go on later to develop giant cell arteritis. So, this constellation of symptoms really points me in the direction of GCA.
CHARLIE: Okay, so the question asks: which of the following is the next most appropriate step? Option A says, aspirin, 975 mg orally every day; option B says, measurement of the erythrocyte sedimentation rate; option C says, immediate initiation of glucocorticoid therapy; option D says, referral for a temporal artery biopsy; and option E says, referral for an ultrasound of the temporal artery.
CATHY: I would go with immediate initiation of glucocorticoids. So, I mentioned before about steroids as an option for treatment, but the other reason starting steroids may be helpful is because if you see a dramatic response it lends further support to the diagnosis, as well.
CHARLIE: Would the other options be helpful at all?
CATHY: So, option A asks about aspirin, and that may help with pain but it's really not therapeutic or diagnostic, so that I would say is not helpful. Option B mentions ESR, and that's almost universally elevated, but it's not specific for the diagnosis. And the same is true for CRP, so neither of those would be particularly helpful. Option D mentions the temporal artery biopsy, and that can definitely be part of the diagnostic workup, but it shouldn't delay the treatment with steroids, given the threat of visual loss.
CATHY: Option E mentions temporal artery ultrasound, and that could also be suggestive, but it's not diagnostic.
CHARLIE: So, what would you start?
CATHY: So, the primary therapy is prednisone at 40-60 mg daily for one month with gradual tapering after that. You should do this in conjunction with rheumatology, and if someone's going to be on steroids for a long period of time, remember appropriate prophylaxis. So, that includes PCP prophylaxis, and calcium and vitamin D supplementation. And in this patient, she also has a history of diabetes, so, you'll need to monitor her glucoses closely while she's on steroids.
CHARLIE: Okay, so the teaching point in this case-- that in an elderly patient with new-onset headaches, systemic findings, and visual symptoms, suspect giant cell arteritis, and immediate steroids may prevent complications such as blindness.
CATHY: And to read more, you can check out Harrison's chapter on Vasculitis Syndromes within the section on Rheumatology and Immunology. ♪ (music) ♪