A 79 year old woman presents with headache and blurry vision in the left eye for 1 week. She was healthy until recently, reporting that she has “not been feeling her normal way.” Her visual acuity were 20/40 OD, 20/400 OS and the rest of her exam was normal except for the findings shown below:
Labs reveal elevated ESR and CRP levels. What is the most appropriate next step in managing this patient?
A. Schedule a temporal artery biopsy
B. Obtain a brain MRI
C. High-dose PO prednisone
D. High-dose IV methylprednisolone
Correct Answer: D
This patient has giant cell arteritis (GCA) with a highly progressive loss of vision in the left eye within 1 week. While prednisone PO has been recommended in older protocols, it is now highly recommended to administer higher dose IV steroids such as methylprednisolone (solumedrol) immediately, usually before labs such as ESR and CRP are even secured. A brain MRI should only be ordered with the suspicion of intracranial pathology and/or if papilledema is present. While a temporal artery biopsy can definitively confirm the diagnosis of GCA, the most appropriate next step in management of this patient requires administration of high-dose steroids.
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