Shmerling proposed an algorithm for the diagnosis and management of a patient with possible temporal arteritis. The author is from Beth Israel Deaconess Medical Center in Boston.
Patient selection: presence of clinical findings suggestive of temporal arteritis
Parameters:
(1) clinical suspicion based on history, physical examination and laboratory testing
(2) vision
(3) findings on temporal artery biopsy
Suspicion |
Vision |
Initial Management |
---|---|---|
none |
NA |
evaluate for an alternative diagnosis |
low |
NA |
perform temporal artery biopsy |
moderate or high |
unaffected |
start oral corticosteroid therapy; perform temporal artery biopsy |
moderate or high |
affected |
start intravenous corticosteroid therapy; perform temporal artery biopsy |
where:
• If the suspicion is low and vision is affected, then the suspicion is bumped up to moderate in the implementation.
Oral corticosteroid therapy: prednisone 1 mg/kg per day or equivalent
IV corticosteroid therapy: methylprednisolone 80 mg per 8 hours
Suspicion |
Initial Biopsy |
Additional Management |
---|---|---|
low |
negative for TA |
evaluate for an alternative diagnosis |
low |
positive for TA |
start oral corticosteroid therapy (as above) |
moderate |
negative for TA |
consider biopsy of contralateral temporal artery |
moderate |
positive for TA |
continue therapy as listed above |
high |
negative for TA |
perform a biopsy of contralateral temporal artery |
high |
positive for TA |
continue therapy as listed above |
Suspicion |
Contralateral Biopsy |
Additional Management |
---|---|---|
moderate |
negative or not done |
discontinue steroid therapy; consider alternative diagnosis |
moderate |
positive |
continue therapy as listed above |
high |
negative |
consider continued corticosteroid therapy while looking for an alternative diagnosis |
high |
positive |
continue therapy as listed above |
Purpose: To evaluate a patient with possible temporal arteritis using the algorithm of Shmerling.
Specialty: Immunology/Rheumatology
Objective: options
ICD-10: M31.5, M31.6,