A 70-year-old woman with polymyalgia rheumatica on prednisone 15 mg daily develops new-onset left-sided headaches, scalp tenderness, and blurred vision in the left eye over 3 days. ESR is 102 mm/hr. Fundoscopy shows pale disc edema. What is the most urgent next step?
- A Increase prednisone to 15 mg daily and observe
- B Order temporal artery biopsy within 2 weeks and continue current prednisone dose
- C Start intravenous methylprednisolone 1 g daily for 3 days, then high-dose oral prednisone (1 mg/kg/day) ✓
- D Obtain MRI brain with contrast
Correct answer: C. Start intravenous methylprednisolone 1 g daily for 3 days, then high-dose oral prednisone (1 mg/kg/day)
Explanation
This patient has giant cell arteritis with anterior ischemic optic neuropathy, a medical emergency that can cause irreversible blindness. Immediate high-dose corticosteroids (IV methylprednisolone 1 g/day for 3 days, then oral prednisone 1 mg/kg/day) should be started without waiting for biopsy. Biopsy can still be positive for up to 2 weeks after steroids are initiated. Increasing to only 15 mg is grossly inadequate. MRI brain does not diagnose GCA.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.