From the Guidelines
The next investigation for a 65-year-old woman with headache and left scalp tenderness should be an erythrocyte sedimentation rate (ESR) to evaluate for giant cell arteritis (temporal arteritis) 1. This is because the patient's symptoms, such as headache and scalp tenderness, are highly suggestive of giant cell arteritis, which is an inflammatory condition affecting medium and large arteries, particularly the temporal arteries.
- The ESR test is a crucial diagnostic tool for giant cell arteritis, as it can help identify inflammation in the body.
- According to the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis, ESR is an important laboratory test for diagnosing giant cell arteritis 1.
- A systematic review and meta-analysis published in JAMA Internal Medicine in 2020 found that ESR had a high sensitivity and specificity for diagnosing giant cell arteritis, making it a useful diagnostic tool 1.
- If the ESR is elevated, the patient should be referred urgently for a temporal artery biopsy to confirm the diagnosis.
- However, empiric treatment with high-dose corticosteroids (typically prednisone 40-60mg daily) should be initiated promptly without waiting for biopsy results if clinical suspicion is high, as delay in treatment could lead to permanent vision loss.
- Additional symptoms to inquire about include jaw claudication, visual disturbances, fever, fatigue, and weight loss, which would further support this diagnosis.
From the Research
Next Investigation for Headache and Left Scalp Tenderness
The patient's symptoms of headache and left scalp tenderness may indicate temporal arteritis, a condition that requires prompt diagnosis and treatment to prevent complications such as vision loss.
- The next investigation to consider would be:
- ESR (Erythrocyte Sedimentation Rate) test, as it is a commonly used marker for inflammation and can help support the diagnosis of temporal arteritis 2, 3, 4, 5
- Other options such as FBC (Full Blood Count), Scalp USS (Ultrasound), EMG (Electromyography), and NCS (Nerve Conduction Study) may not be directly relevant to the diagnosis of temporal arteritis
- It is essential to note that a normal ESR value can make temporal arteritis less likely, but it does not rule out the diagnosis entirely 4
- Temporal artery biopsy is the gold standard for diagnosing temporal arteritis, and it is crucial to perform the biopsy promptly, especially if the patient is started on corticosteroids, as the treatment can affect the biopsy results 6
Clinical Features and Diagnostic Value
- Clinical features such as jaw claudication, diplopia, temporal artery beading, prominence, and tenderness can increase the likelihood of temporal arteritis 4
- The absence of any temporal artery abnormality can modestly reduce the likelihood of disease 4
- The correlation between histopathologic stage of disease and clinical presentation can support the use of temporal artery biopsy to identify patients' risk for complications caused by temporal arteritis 5