82 Rheumatology
Q4: How would you initially manage the case? A4 Having assessed the extent of involvement, treatment typically involves an induction phase designed to arrest inflammation and a longer-term treatment phase aimed at maintaining disease suppression. Drugs commonly used are steroids, immunosuppressants and cytotoxics. Co-trimoxazole is prescribed for those patients with Staphylococcus aureus in their noses, because it is believed to reduce relapses of the condition when used in combination with other immunosuppressants.
Q5: What are the principles of long-term management? A5 In this patient with renal involvement, potential renal failure needs to be assessed. The lung involvement can progress to fibrosis. Involvement of the upper airways can produce aggressive local damage, even eroding through the floor of the anterior skull. Untreated eye involvement can lead to blindness. Secondary infection is a constant threat as a result of the condition and/or treatment. Flare-ups are not uncommon, often requiring temporary increases in treatment.
Q6: What is the prognosis? A6 A medical cure is not possible. Long-term follow-up with careful multi-system assessment is essential to maximize the success of treatment. The prognosis is adversely affected by renal involvement; overall the 10-year survival rate is about 80 per cent.
CASE 3. 9 – An elderly woman with aching shoulders and thighs, a painful temporal headache and a sudden onset of sight loss in her right eye.
Q1: What is the likely differential diagnosis? A1 The history of polymyalgic symptoms, temporal headache and sudden onset of blindness strongly suggest a diagnosis of temporal arteritis.
Q2: How would you investigate this case? A2 This is a rare example of a rheumatological emergency. Consideration should be given to whether ordering tests will delay the introduction of prednisolone. After just 48 hours of prednisolone therapy the typical blood findings of a highly raised