Should an in-office steroid injection be given to an elderly female patient with new onset bilateral temporal headaches and a tooth infection, while awaiting lab results for Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Comprehensive Metabolic Panel (CMP), and Complete Blood Count (CBC), and CT scans of the head and face?

Should Steroids Be Given While Awaiting Workup Results?

No, do not give an in-office steroid injection while awaiting lab and imaging results in this patient—the recent bilateral hip cortisone injections 3-4 weeks ago already provide systemic steroid exposure that could mask giant cell arteritis (GCA) symptoms and confound diagnostic testing, and the presence of a tooth infection as an alternative explanation for temporal headaches makes empiric steroid treatment premature and potentially harmful. 1

Critical Reasoning Against Immediate Steroid Administration

Recent Steroid Exposure Complicates the Clinical Picture

• The patient received bilateral cortisone hip injections 3-4 weeks ago, which can provide systemic absorption and anti-inflammatory effects that may already be suppressing inflammatory markers and symptoms 1
• Systemic corticosteroids can suppress late-phase inflammatory responses for 3 days to 2 weeks after administration, depending on dose and formulation 1
• Adding additional steroids now would further confound interpretation of both laboratory results (ESR/CRP) and clinical response, making it impossible to determine if symptom improvement is from treating GCA versus treating the dental infection 1

The Tooth Infection Provides a Competing Diagnosis

• Dental infections commonly cause temporal and facial pain that can mimic GCA, and the patient's headache pattern (bilateral temples, sometimes one side or the other) is consistent with referred pain from odontogenic infection 1, 2
• Sphenoid sinus and dental infections can present with temporal headache and elevated ESR, and premature steroid treatment in such cases can worsen infection and lead to serious complications including intracranial extension 2
• The ordered CT of face and head will help differentiate between dental/sinus pathology and vascular inflammation 1

What Makes GCA Less Likely in This Case (But Not Excluded)

Missing Key Clinical Features

• The patient denies temporal artery tenderness and scalp tenderness, which are common findings in GCA 1, 3
• No fevers are reported, though this is not always present in GCA 1
• The absence of jaw claudication is notable—this symptom has 9.1 times greater odds of positive temporal artery biopsy and is one of the most important indicators of GCA 4
• No visual symptoms are mentioned, though these can develop suddenly and represent an ophthalmologic emergency 1, 5

Critical Caveat About "Normal" Labs

• GCA can occur with normal ESR and CRP—case reports document biopsy-proven GCA with both markers in normal range 5, 6
• However, when ESR is markedly elevated (>100 mm/h), it has 92.2% specificity for GCA 3
• The combination of ESR and CRP together has 99% sensitivity for GCA, with only 0.8% of biopsy-proven cases showing both normal 7
• An elevated ESR with normal CRP occurs in 1.7% of biopsy-proven GCA cases 7

The Correct Management Algorithm

Immediate Actions (Before Lab Results)

• Perform temporal artery ultrasound urgently if available—this can show the "halo sign" and help establish diagnosis without waiting for biopsy 1
• Complete detailed symptom assessment specifically asking about:
  • Visual changes (blurred vision, diplopia, transient vision loss) 1, 5
  • Jaw claudication (pain in jaw muscles while chewing) 1, 4
  • Constitutional symptoms (malaise, weight loss, fever) 1, 3
  • Polymyalgia rheumatica symptoms (bilateral shoulder/hip pain, morning stiffness >45 minutes) 3
• Examine temporal arteries for tenderness, decreased pulsation, or nodularity 1
• Assess the dental infection severity and initiate appropriate antibiotic therapy 1

When Lab Results Return

If ESR >100 mm/h and/or markedly elevated CRP with compatible symptoms:

• Initiate high-dose oral glucocorticoids immediately (prednisone 40-60 mg daily or equivalent) without waiting for biopsy 1
• The American Heart Association/American Stroke Association recommends immediate initiation of oral high-dose glucocorticoids within the first 24 hours for suspected GCA to reduce risk of permanent blindness 1
• Arrange temporal artery biopsy within 1-2 weeks—biopsy can remain positive for up to 2 weeks after starting steroids 1
• Biopsy confirmation should not delay treatment when clinical suspicion is high 1

If ESR/CRP mildly elevated or normal:

• Continue monitoring and complete imaging workup 3
• Consider alternative diagnoses including dental infection, sinusitis, tension headache 1, 2
• Repeat inflammatory markers in 2-4 weeks if symptoms persist 3

Red Flags Requiring Same-Day Ophthalmology/Rheumatology Referral

• New visual symptoms (even transient) 1, 3, 5
• Jaw claudication 1, 4
• ESR >100 mm/h with compatible symptoms 3
• Sudden worsening of headache or new neurologic symptoms 1

Why Waiting Is the Safer Approach

• Steroid treatment can mask serious infections including the patient's known tooth infection and potential complications like sinus or intracranial extension 2
• Recent steroid exposure already complicates diagnosis—adding more steroids now provides no additional diagnostic or therapeutic benefit 1
• The 24-48 hour wait for lab results will not significantly increase risk of vision loss if GCA is present, as the disease typically progresses over days to weeks 1
• Premature steroid treatment without confirmed diagnosis commits the patient to prolonged immunosuppression with associated risks (diabetes, osteoporosis, infection) 6

The appropriate course is to await the ordered laboratory and imaging results, treat the dental infection, and initiate high-dose steroids only if diagnostic testing supports GCA or if acute visual symptoms develop. 1, 3