CL is a 78-year-old woman who presented with a 2-month history of malaise, poor appetite with weight loss, and generalized weakness. For 2 weeks she had also had frequent vertex headaches that were often severe and kept her from sleeping. In fact, she also had trouble combing her hair in the morning because it caused pain in the scalp.
She consulted her dentist because chewing caused pain in the mandibular area, but he could find no dental cause for this. On further questioning she specified that the pain in her jaw would start a few seconds after she began to chew solid food and grow in severity over another 10 to 20 seconds to the point that she would have to stop chewing, after which the pain would subside over another 5 to 15 seconds. She was also having pain in the hips and stiffness of the legs that made walking difficult.
On the day of her office visit she had experienced a brief episode of visual loss in her left eye that she described as a "shade being pulled down" over the upper half of the visual field. For about 20 seconds she lost all vision in the left eye, and then sight returned first in the lower half of the field and then the upper half, with full return of vision within 1 to 2 minutes. No pain was associated with this episode.
Examination revealed a frail-looking elderly woman in some distress. There was evidence of recent weight loss, and she had trouble rising from the waiting room chair to enter the office. Her gait appeared painful and stiff, and she held her head rigidly in the straight-ahead position as she walked. When asked to bend her neck forward or back or to turn her head to either side she winced with pain. The examiner was able to move her head and neck in all directions passively, but it required slow steady movement to avoid causing pain.
Blood pressure was 180/95 taken from her right arm and 140/80 from the left arm. There was a loud left subclavian bruit. An ulcer was noted in the buccal mucosa next to the left lower teeth.
There were no localizing findings on neurologic examination. Active and passive flexion of either leg caused pain in the hips and upper thighs. Visual acuity was 20/30 either eye, and there was no subjective red desaturation either eye on viewing a red bottle cap with either eye singly. Visual fields were full to confrontation testing (finger counting in each quadrant).
Complete blood count revealed moderate normochromic, normocytic anemia, and the Westergren erythrocyte sedimentation rate was 89 in the first hour. Carotid Duplex blood flow examination showed insignificant stenosis on either side, but ocular plethysmography showed reduced pulse amplitude in both eyes. Left temporal artery biopsy was performed, and methylprednisolone 1 gram was infused intravenously immediately afterward. She was instructed to return for an additional infusion of intravenous methylprednisolone 1 gram for the next 2 days, after which she was placed on oral prednisone at a dose of 80 mg each morning.
Microscopic examination of the temporal artery tissue revealed areas of intimal proliferation, fragmentation of the internal elastic lamina, and adjacent to disrupted segments of the elastic lamina, the media was infiltrated with lymphocytes, plasma cells, epithelioid cells, and multinucleated giant cells.
Within 48 hours of treatment onset she was free of pain, and within 2 weeks her body weight and strength had returned to premorbid status. After 3 weeks the prednisone dosage was gradually tapered in decrements of 5 mg/day each month.