View Full Version : Arteritis or Not?

Thu 12th June '14, 12:45am

A previously healthy 63-year-old woman presents to her primary care doctor with 4 days of severe stiffness, soreness, and pain in the shoulders, neck, pelvic area, and low back, along with fatigue. Soon thereafter, she developed pain in her right jaw, along with eating, tenderness, and pain in the right scalp and temporal area, but no vision symptoms. The patient's erythrocyte sedimentation rate (ESR) was 7 mm/h, and the C-reactive protein (CRP) level was 3.6 mg/L. Hemoglobin, white blood cell count, and platelet count were normal.

The patient was diagnosed as having polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) and started on 60 mg prednisone 4 days after the onset of symptoms, with rapid improvement. Right temporal artery biopsy was normal. She was referred to a rheumatologist for further treatment.

The patient was seen in the rheumatology clinic 2 weeks after the onset of symptoms. At that point, the patient was found to be asymptomatic and had a normal examination and a normal CRP. Other pertinent negatives: normal temporal artery pulse and no vessel tenderness or nodularity; no peripheral joint synovitis, fever, or weight loss; no respiratory, genitourinary, abdominal, or neurologic symptoms. Despite these findings, the rheumatologist agreed with the diagnosis.

So, how in heaven's name could this patient have PMR/GCA with a normal ESR and a negative temporal artery biopsy?

To answer this, we need to go back to the basic question of how one makes any diagnosis.