Clinical Vignette XIII

• Which of the following diagnoses is best characterized by the following set of clinical findings, signs, and symptoms in a 51-year-old female with a medical history notable for hyperlipidemia being treated with maximum dose simvastatin and a family history significant for two older sisters diagnosed with Hashimoto’s thyroiditis?

• Vital signs are normal
• Little to no muscle fatigue
• Bilateral muscle pain and stiffness
• Little to no muscle weakness
• Remainder of physical exam normal
• WBC: 2                                                                Normal Range:  4.0-10.5 K/uL
• Hemoglobin: 6 (L)                                          Normal Range:  12-17.5 g/dL
• Hematocrit: 2 (L)                                            Normal Range:  36-46%
• Platelet: 143 (L)                                            Normal Range:  150-400 K/uL
• Total creatine kinase level: 117                      Normal Range:  32-182 U/L     
• Erythrocyte Sed. Rate (ESR): 74 (H)         Normal Range:  0-16 mm/hr
• C-reactive protein (CRP): 13 (H)                Normal Range:  < 0.60 mg/dL
• Rheumatoid factor (RF): 12                           Normal Range:  < 14 IU/mL
• Anti-Cyclic Citrullinated Peptide: 18           Normal Range:  < 20 Units                                         

Which of the following is the most appropriate next step in management of this patient?

The now 56-year-old woman is evaluated in the Medtigo Medical Center Emergency Department for an episode of acute and transient loss of vision in her left eye earlier today while watching television. She describes the transient vision loss “seemed as if a dark curtain was coming down in front of my left eye.” She then states, “I was just watching the news one moment and everything was fine until I suddenly couldn’t see anything out of my left eye. It was like someone had dropped a dark curtain in front of my left eye without telling me and within moments I couldn’t see anything out of that eye. I thought maybe I just closed my left eyelid but that clearly wasn’t the case. I panicked and didn’t know what to do so I called my daughter to drive me to the emergency department. By the time she arrived to pick me up about 15 minutes later, the vision in my left eye just spontaneously came back. I was so scared that I was having a stroke when I couldn’t see anything out of my left eye but I guess I was wrong since my vision came back so fast. Just to be safe, I had my daughter drive me here anyways. Have you ever had any patients with similar eye issues like mine? Do you have any idea what could have caused something like this to happen?”

After listening attentively to the patient’s story, the clinician proceeds to ask her a series of medically-directed questions. From the brief series of questions, the clinician was able to learn a significant amount of highly-relevant information about the patient. She was diagnosed with polymyalgia rheumatica about 16 months ago and was treated with low-dose prednisone which was titrated over the course of 8 months until her symptoms essentially resolved. Since completing her prednisone treatment 8 months ago, she hasn’t had any flares and has been able to enjoy a much better quality of life. That is until 3 day ago when she started experiencing daily fevers, night sweats, and recurring early symptoms of prolonged morning stiffness and muscle aches and pain in her neck, shoulders, and thighs. She also has a 3-day history of new-onset and persistent headache localized to the left temporal region as well as mild pain in her jaw when she chews solid food. The rest of her medical history is notable for hyperlipidemia. Her current medications include maximum dose simvastatin and a daily women’s multivitamin. She does not drink alcohol, smoke cigarettes, chew tobacco, or use recreational drugs. Her family history is notable for two older sisters diagnosed with Hashimoto’s thyroiditis, one daughter diagnosed with systemic lupus erythematosus, and one son diagnosed with rheumatoid arthritis. The rest of the patient’s medical history, social history, and family history is non-contributory.

On physical examination, temperature is 100.6°F (38.1°C), blood pressure is 117/62 mm Hg, pulse rate is 81 beats/min, respiration rate is 14/min, and oxygen saturation is 97% breathing ambient air. Body mass index is 23.3 kg/m². Cardiovascular exam reveals a normal S1 and S2 with a grade 2/6 aortic regurgitation murmur. Pulmonary exam is clear to auscultation bilaterally. There is mild tenderness to palpation of the left temporal region. Ophthalmologic exam is unremarkable. Neurologic exam including visual testing is unremarkable. The remainder of the physical examination is unremarkable.