What are the symptoms and treatment of temporal arteritis?

Temporal Arteritis: Symptoms and Treatment

High-dose glucocorticoid therapy (40-60 mg/day prednisone) should be initiated immediately for active temporal arteritis, with urgent referral for specialist evaluation, especially in patients with visual symptoms to prevent permanent vision loss. 1, 2

Key Symptoms and Clinical Findings

Common Symptoms

• Headache: New-onset persistent localized headache, often in temporal area 1, 2
• Constitutional symptoms: Weight loss >2kg, low-grade fever, fatigue, night sweats 1, 3
• Jaw claudication: Pain when chewing 1, 4
• Visual disturbances: Amaurosis fugax (temporary vision loss), diplopia, permanent vision loss 1, 5
• Scalp tenderness 1
• Polymyalgia rheumatica symptoms: Proximal muscle pain and stiffness 2, 3
• Respiratory symptoms: Chronic harsh, nonproductive cough (in <10% of cases) 1

Key Physical Examination Findings

• Tenderness and/or thickening of the superficial temporal arteries 1, 2
• Reduced pulsation of temporal arteries 1
• Bruits (particularly in the axilla) 1
• Reduced pulses/blood pressure in upper limbs 1
• Ophthalmologic findings: Anterior ischemic optic neuropathy, cranial nerve palsies 1, 5

Diagnostic Approach

1. Laboratory Tests:

   • Erythrocyte sedimentation rate (ESR) - typically elevated (>50 mm/h) 2
   • C-reactive protein (CRP) - usually elevated 1
   • Complete blood count - may show thrombocytosis (>400 × 10³/μL) 2

2. Confirmatory Testing:

   • Temporal artery biopsy - gold standard for diagnosis 2, 3
   • Imaging options if biopsy is negative but clinical suspicion remains high:
     • Temporal artery ultrasound 6
     • MRI/MRA of cranial arteries
     • CT angiography
     • FDG-PET/CT 2

Treatment Algorithm

Immediate Management

1. For patients with visual symptoms:

   • Start high-dose glucocorticoids immediately before specialist appointment 1
   • Consider IV methylprednisolone 500-1000 mg/day for threatened vision loss 2

2. For all patients with suspected temporal arteritis:

   • Initiate oral prednisone 40-60 mg/day 1, 2
   • Urgent referral to specialist center for further workup 1, 2
   • Perform diagnostic tests regardless of pre-emptive therapy duration 1

Long-term Management

1. Glucocorticoid Tapering:

   • Taper to 15-20 mg/day within 2-3 months
   • Taper to ≤5 mg/day after 1 year 1

2. Adjunctive Therapy:

   • Consider tocilizumab to reduce glucocorticoid requirements and prevent relapses 2
   • Low-dose aspirin (75-150 mg/day) for cardiovascular and cerebrovascular protection 2

3. Monitoring:

   • Regular assessment of clinical symptoms
   • Monitor inflammatory markers (ESR, CRP)
   • Watch for relapses (occur in 34-62% of patients) 2

4. Prevention of Glucocorticoid-Induced Side Effects:

   • Bone protection therapy
   • Blood pressure and glucose monitoring
   • Regular screening for cataracts and other complications 2

Important Considerations

• Time-sensitive emergency: Delay in treatment when visual symptoms are present is the strongest risk factor for permanent blindness 1, 5
• Age consideration: Temporal arteritis typically affects patients over 50 years 2, 3
• Diagnostic challenges: Symptoms can mimic other conditions including angle-closure glaucoma, hypertension, migraine, and trigeminal neuralgia 7
• Biopsy timing: Temporal artery biopsy can still show features of GCA even weeks after starting glucocorticoid therapy 1

Pitfalls to Avoid

• Delayed treatment: Never wait for biopsy results before starting treatment when temporal arteritis is strongly suspected, especially with visual symptoms 1, 5
• Inadequate initial dosing: Underdosing glucocorticoids initially can lead to treatment failure and complications 2
• Premature discontinuation: Only 15-20% of patients achieve sustained remission with glucocorticoids alone; most require prolonged therapy 2
• Missing atypical presentations: Respiratory symptoms like chronic cough can be the presenting feature in some cases 1
• Inadequate monitoring: Failure to monitor for relapses and glucocorticoid side effects 2