An 82-Year-Old Woman With Giant Cell Arteritis and Fatigue

A Case Series in Geriatrics

Mark E. Williams, MD

Disclosures

March 10, 2011

Case Presentation

An 82-year-old, white, female patient presented with a chief complaint of progressive fatigue over several months. The patient also reported loss of appetite and an 8-lb weight loss over the last 5 months. She denied fever, chills, night sweats, gastrointestinal pains, or distress. She noted no melena or hematochezia. Upon further questioning, she admitted to feeling tired on awakening. Her medical history included a glomus tumor of the left tympanic membrane, cystic lesions seen on a spinal MRI for back pain, osteoarthritis in her hips and knees, and a history of chronic kidney disease. The family history was notable for brain tumors in both of her parents. She had no family history of collagen vascular disease, diabetes mellitus, hypertension, stroke, bleeding disorders, anemia, or heart disease.

Upon physical examination the vital signs were normal. The head revealed no areas of scalp tenderness. The areas around her temple arteries were normal and nontender bilaterally. The pupils were equal and round and reacted to light and accommodation. The extraocular movements were full, and there was no nystagmus or ptosis. The optic discs were flat bilaterally. Good venous pulsations were seen. No hemorrhages or exudates were noted. The left tympanic membrane showed a red vascular mass consistent with a paraganglioma. The right tympanic membrane was normal. Thyroid felt normal. Fullness in the left supraclavicular fossa was appreciated. No convincing lymphadenopathy could be found even with the Valsalva maneuver. The lung fields were clear to percussion and auscultation. A grade 2/6 systolic ejection murmur was heard at the left lower sternal border. No abdominal masses were felt.

Laboratory studies showed a mild anemia with a hematocrit of 29.5%, hemoglobin of 9.5 g/dL, and an elevated platelet count of 465,000/mm3. The patient's white blood cell count was 8400/mm3 with a normal differential. These values were slightly lower than the previous year. The patient's erythrocyte sedimentation rate and C-reactive protein concentrations were strikingly elevated, however, at 135 mm/hr and 14.2 mg/L, respectively. Total protein, albumin, and liver and renal function tests were normal.

Upon additional questioning the patient admitted muscle stiffness in the morning and changes in her visual acuity. She denied amaurosis fugax blindness or jaw claudication. The physician made a diagnosis of polymyalgia rheumatica. She was started on a trial of prednisone 10 mg twice daily with instructions to report by the end of the week to monitor her symptoms. There was a remarkable elevation of the erythrocyte sedimentation rate, so a temporal artery biopsy was performed. Biopsy results confirmed giant cell arteritis (GCA). The patient was then given 1 g of methylprednisolone per day intravenously for 3 days and was started on 60 mg/day of oral prednisone.

After being placed on high-dose prednisone, the patient noticed an immediate increase in her energy level and sense of well-being. However, 3 months later the patient returned with complaints of progressive sluggishness and exertional dyspnea for the previous 2 weeks. She also noted midsubsternal chest discomfort early in the morning but no discomfort with exertion or as a part of the breathlessness. She had no paroxysmal nocturnal dyspnea or orthopnea, but did complain of mild swelling of her ankles. At this point she was at 25 mg of prednisone daily with improved inflammatory indices and no active signs of vasculitis. Upon physical examination it was noted that her respiratory rate was 24 breaths per minute. Examination of her hands showed palmar erythema and palmar and antecubital diaphoresis. There was no orbital bruit. Her thyroid was easily felt, and no masses or nodules were appreciated. The cardiac exam revealed no new murmurs and no gallops. There was no hepatojugular reflux, and the spleen and liver were not enlarged. There were trace amounts of pretibial edema. An ECG was performed and was normal with no evidence of ischemia.

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