Temporal arteritis is large vessel vasculitis which overlaps with polymyalgia rheumatica (PMR). Histology shows changes that characteristically 'skips' certain sections of the affected artery whilst damaging others.

PC

• typically patient > 60 years old
• usually rapid onset (e.g. < 1 month)
• headache (found in 85%)
• jaw claudication (65%)
• visual disturbances
  • amaurosis fugax
  • blurring
  • double vision
  • vision testing is a key investigation in patients with suspected temporal arteritis
  • secondary to anterior ischemic optic neuropathy
• tender, palpable temporal artery
• around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness)
• also lethargy, depression, low-grade fever, anorexia, night sweats

Investigations

• raised inflammatory markers
  • ESR > 50 mm/hr (note ESR < 30 in 10% of patients)
  • CRP may also be elevated
• temporal artery biopsy
  • skip lesions may be present
• note creatine kinase and EMG normal

Management

• urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy
  • if there is no visual loss then high-dose prednisolone is used
  • if there is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone
  • there should be a dramatic response, if not the diagnosis should be reconsidered
  • Biopsy: skip lesions can occur which may show a normal biopsy - therefore steroids should not be discontinued based on a negative biopsy result
• urgent ophthalmology review
  • patients with visual symptoms should be seen the same-day by an ophthalmologist
  • visual damage is often irreversible