Headache case 2

Headache case 2

A 70-year-old woman of Scandinavian descent consults a physician because she has been having numerous headaches for the past several months. These headaches began abruptly and increased in severity and duration over a several week period. They are sometimes accompanied by facial pain on the lateral aspect of her forehead. During the period when the headaches first began, she experienced malaise and fever. Physical examination is notable for a tender, thickened blood vessel running cranially along her lateral temple anterior to and above her ear.
Q 1
The involved blood vessel is most likely which of the following?
/ A. Facial artery
/ B. Lingual artery
/ C. Occipital artery
/ D. Posterior auricular artery
/ E. Superficial temporal artery

Q 2
The involved blood vessel is a branch arising directly from which of the following blood vessels?
/ A. Basilar artery
/ B. Common carotid artery
/ C. External carotid artery
/ D. Internal carotid artery
/ E. Vertebral artery


Q 3
Biopsy of the involved blood vessel would be most likely to show which of the following?
/ A. Arteriolosclerosis
/ B. Giant cell arteritis
/ C. Polyarteritis nodosa
/ D. Takayasu arteritis
/ E. Wegener granulomatosis


Q 4
Which of the following is the most serious complication of this disease process?
/ A. Blindness
/ B. Face and neck pain
/ C. Jaw claudication
/ D. Skin necrosis
/ E. Widespread vessel tenderness


Q 5
The patient has also been experiencing severe morning stiffness, which causes her to have to "roll" out of bed in the morning. Her shoulder girdle and pelvic girdle are most strikingly involved. She experiences the pain as "muscle pain," but later serum studies show no elevation of the muscle marker creatine kinase. Physical examination for arthritis-related findings is unremarkable, but her erythrocyte sedimentation rate is found to be markedly high. Which of the following is the most likely diagnosis?
/ A. Gout
/ B. Osteoarthritis
/ C. Polymyalgia rheumatica
/ D. Rheumatoid arthritis
/ E. Still disease


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Headache case 2 answers

A1
The correct answer is E. The artery is the superficial temporal artery, which is often just called the temporal artery. It runs from the parotid gland upward in front of the tragus of the ear together with the auriculotemporal nerve, and divides into anterior and posterior branches that supply the temporal area of the scalp.
The facial artery (choice A) arises below the corner of the jaw and then crosses the mandible to run diagonally toward the nose.
The lingual artery (choice B) arises below the corner of the jaw and supplies the tongue.
The occipital artery (choice C) and the posterior auricular artery (choice D) both course backward behind the ear.

A2
The correct answer is C. The temporal artery is a terminal branch (together with the posterior auricular artery) of the external carotid artery. The external carotid artery supplies the external aspect of the face and head, and its branches include the lingual artery, the facial artery, the superficial temporal artery, the posterior auricular artery, and the occipital artery.
The basilar artery (choice A) arises from the union of the two paired vertebral arteries (choice E); both supply the brainstem and the rest of the brain through the Circle of Willis.
The common carotid artery (choice B) gives rise to the internal and external carotid arteries.
The internal carotid artery (choice D) supplies the brain via the Circle of Willis.

A3
The correct answer is B. The most likely diagnosis is giant cell arteritis, which is characterized microscopically by granulomatous destruction, with giant cell formation, of the wall of the vessel. The condition is also commonly known as temporal arteritis, although this term is presently being discouraged because the inflammatory process may involve many other similar sized arteries both within and outside of the head. The clinical presentation illustrated in the case summary is typical. The condition is fairly uncommon (18 cases per 100,000 in the population aged 50 years or more), and so will be suspected more often than proved. The diagnosis is established by biopsy of a fairly long segment (2 cm or more) of the temporal artery, since the lesion is spotty and may be missed with smaller biopsies. (There is enough collateral blood supply to the scalp that distal infarction of scalp tissues does not occur.)
Arteriolosclerosis (choice A) involves arterioles rather than larger vessels, and is most commonly diagnosed in the kidney.
Polyarteritis nodosa (choice C) produces localized inflammation of blood vessels in many sites in the body, and while it might possibly involve the temporal artery, it does not have a particular predilection for doing so.
Takayasu arteritis (choice D) is a granulomatous involvement of the aorta and its branches, and is most common in Asia or in people of Asian descent.
Wegener granulomatosus (choice E) would characteristically also produce prominent lung involvement.

A4
The correct answer is A. Visual symptoms that can be seen in giant cell arteritis include blurred vision, diplopia, visual hallucinations, and transient or permanent blindness. These symptoms are thought to be related to the involvement of the ciliary arteries and/or the central retinal artery. In large part, because of the fear of recurrence with the possibility of permanent blindness, temporal arteritis is treated with a prolonged steroid course that may run for a year or longer. The conditions listed in the other choices can also occur, but are not usually as serious as the risk of blindness.

A5
The correct answer is C. There is a known association between giant cell arteritis and polymyalgia rheumatica, and in fact, some authors claim that the two conditions are actually different ends of the same disease spectrum. The clinical description given in the question is typical. Polymyalgia rheumatica appears to be much more common than giant cell arteritis, so patients with giant cell arteritis are much more likely to have coexisting polymyalgia rheumatica than vice versa.
Gout (choice A) usually appears clinically quite different, with obvious involvement of one or a small number of joints.
While polymyalgia rheumatica is often misdiagnosed as osteoarthritis (choice B), rheumatoid arthritis (choice D), or adult-onset Still disease (the adult form of juvenile rheumatoid arthritis, choice E), the prominence of the muscle complaints, the absence of obvious joint deformity, and the predilection for involvement of shoulder and pelvic girdles should suggest the correct diagnosis.